- 03:22 COVID Crisis as an Outpatient and Advance Care Planning (ACP)
- 08:06 The virtual visit
- 12:44 Vital Talk Mnemonic: “CALMER”
- 22:03 Challenges to Outpatient COVID Care
- 26:03 Parting Thoughts
COVID advance care planning conversations as an outpatient:
- Nuanced ACP conversations with more branch points, as patients may think of a “COVID goals of care” vs. goals in non-COVID times
- Higher likelihood of high-risk patients getting sick
- Who to prioritize? One approach is to focus on elderly (age >80 years); comorbidities like obesity, hypertension, diabetes; other chronic conditions (metastatic cancer, renal disease on dialysis); and those with poor social support or who may not be in a situation to isolate.
Roadmap for outpatient ACP conversation
- Potentially more access to patients and their support system through virtual visits during lockdown
- If possible, use video to get closer and build rapport. Opportunity to contextualize patients in their own environment, akin to a home visit.
- Bring healthcare proxy or family members into the conversation
- Framework: CALMER (from VitalTalk)
- Check in: get the emotional temperature of the conversation
- “How are you doing with this whole pandemic?”
- Ask about COVID: request permission to dive into discussion on serious illness
- “Would it be okay if we talked more about what would happen if you were to get sick from this disease?”
- Lay out the issues: share your concerns about the patient’s risk factors that could contribute to poorer outcomes from COVID19
- Use language of hope and worry: “I hope that we can keep can keep you healthy and safe and out of the hospital, and I worry that if you got so sick that you needed a ventilator or CPR, your chances of leaving the hospital and getting back to how you’re feeling now would be low.”
- Motivate patient to explore goals and take steps
- Identify health care proxy and alternate
- Document phone numbers for these individuals in the chart
- Provide tools for patients to complete an Advance Directive
- Identify health care proxy and alternate
- Expect emotion
- Give a space for patients and families to process and to be vulnerable
- “I’m sorry, I know this can be hard to think about.”
- Record the conversation: documentation is key!
- Identify healthcare proxy, document code status if discussed, and highlight any specific considerations or language patients use
- The hidden “M”: Make a recommendation
- Use shared decision making by offering a medical plan that fits the patient’s values (see Inpatient GOC episode for more advice on making recommendations)
- Asking permission to do so: “Would it be okay if I make a recommendation based on what I am hearing?”
- Check in: get the emotional temperature of the conversation
Documents to discuss with patients and help them fill out:
- Advance Directive: Legal document signed by patients that lists wishes regarding acceptable quality of life and specific medical care preferences during serious illness or end-of-life situation (e.g., feeding tubes, mechanical ventilation).
- POLST (Portable Order for Life Sustaining Treatment): Medical order signed by a clinician that conveys the same information in a direct way, including code status, hospitalization, etc. Physical piece of paper housed with patients and used in emergency situations. Should also scan a copy into the EMR, if available.
Additional challenges of outpatient ACP conversations with COVID19
- Patient resistance to having these conversations
- Remember, these can be ongoing discussions
- It is not our job to convince patients
- How to support patients whose goal is to remain out of hospital at all costs?
- See Center for the Advancement of Palliative Care (CAPC) COVID19 Response Resources Toolkit for medication guide for COVID19 symptom management at home
Conclusion: These conversations are tough, especially when we care so much about our patients and worry for them. We are all human, and things may not go perfectly despite our best intentions. Hopefully, we can find meaning in our work of supporting patients through this difficult time.
Mariah: There’s this feeling in the outpatient world right now of like, wow, things are very, they’re slowing down. Um, because we had to do this weird transition a lot to telemedicine if you’re a full time outpatient provider, you’re kind of like, what’s my role right now?
Jafar: That’s Dr. Mariah Roberston, a geriatrics fellow at Johns Hopkins and Harvard Macy Scholar. She, like many outpatient clinicians, is focusing more and more on advance care planning with her patients.
Mariah: As someone who’s doing mostly virtual visits right now, um, you know, I’m like I’m not on the front lines in the hospital with PPE on my face and like sweating and stressed and trying not to get sick and also have this conversation, you know, so like part of me is like, this is my, this is my gift. Like what I can give back to help others in the healthcare field that are working so hard right now. And so part of it is that too. It’s like, come on, help me get, like, help me hope these people so that they’re not dealing with this later when things are like, you know, really scary. Um, and also, I mean, at the end of this, is like the patient not having to go through that either alone without their family or confused, you know?
Jafar: Advance care planning – the process of helping patients plan out their healthcare if they get sicker – is really hard: it takes time and effort and practice and skill. So it’s no wonder it falls behind in our normal day to day clinic world. But that’s not the world we live in any more. Sickness and even death are now a looming possibility for anyone, and we as clinicians must help prepare our patients for it. So how can we do so effectively, practically, and sensitively?
Jafar: Hi guys, this Dr. Jafar Al-Mondhiry, typically a co-host with our At The Bedside series, with you here for a special episode on outpatient advance care planning during COVID-19.
Amrapali: Hey everyone I’m Dr. Amrapali Maitra. Thanks so much for having me on, Jafar!
Jafar: Awesome to have you Amrapali! I wasn’t gonna let you and Shreya have all the fun with the inpatient goals of care episode so I’ve muscled myself in here. I think a lot of us are used to participating in these types of discussions with patients in the hospital, but we wanted to walk through tips and challenges on advance care planning as an outpatient clinician. So today we will cover 1) why COVID creates a new urgency for proactive advance care planning conversations, and how to identify our high-risk patients.
Amrapali: 2) how to approach these conversations using the CALMER framework from VitalTalk as well as how to make recommendations.
Jafar: and 3) some of the unique challenges to outpatient care during COVID and tips for addressing them. Amrapali: To do this, we sat down with Dr. Mariah Robertson, who has been thinking a lot about advance care planning or, as you might hear in this episode, ACP.
Mariah: This has been a passion of mine for a while. I had my whole fellowship kind of dedicated to this being my education project for trainees to learn how to do better advance care planning talking about the bad before things get bad. And then a pandemic happened. And so my entire mindset shifted around how we think about this because things got bad really fast.
Amrapali: I love the way Dr. Robertson puts it– that advance care planning is “talking about the bad before things get bad.” And unfortunately, we’re seeing more of the “bad” than we’re used to right now, so it’s an important time to have these honest conversations.
COVID advance care planning conversations as an outpatient
Jafar: So first and foremost, I gotta say that Advance Care Planning is appropriate for ALL patients at ALL stages of illness. I actually filled out an Advance Directive for myself just this past month. If we’re being honest though, under normal conditions, we may not have the time or bandwidth to help patients go through this – given all the other things we need to address with them in clinic – unless we think they’re at risk for getting sicker in the near future. But COVID has expanded the range of patients we worry about, and with a special urgency:
Mariah: I am in geriatrics and so in particular, this pandemic is impacting our patient panel and our patient population, um, disproportionately. And so my conversations have changed whereas before I had the time and the luxury of kind of saying, okay, we’ll come back to this – and I still do on the outpatient side, even during the pandemic – now there feels like an urgency to have these conversations with everyone preemptively, whether they’re comfortable or not. It’s amazing we have people in their eighties who are so functional. But yet we see the data showing that people over 85 uniformly across all the places that we’ve looked, U.S., China, Italy are at a significantly higher risk if they get intubated or they go to the ICU of mortality. And so I have to have that conversation, which is an odd conversation with someone who normally we’d be like, ah, you know, it’s okay for us to continue being full code if that’s what you want. I don’t, I can’t say that you wouldn’t do well. Now I have to say we have to be a little bit more aggressive and have a conversation about this even if it feels odd.
Jafar: And the urgency to bring up COVID isn’t just about how likely the patient is to get seriously ill–it’s also about how radically different it is to be hospitalized during a viral pandemic. And this is something to address directly when you’re having these conversations:
Mariah: I think that the key thing there is really highlighting the unique aspects of this pandemic, not just that it’s impacting older adults, but that when you go to the hospital, you might die alone… and that’s maybe not something you would want. Or you may not have visitors while you’re sick, um, or you may have to make some tough decisions without the people you love the most being next to you in the hospital. And that’s things we would never have in a normal ACP conversation in primary care, but right now feel very important to talk about.
Amrapali: With all these new challenges of physical distancing and hospital policies, it may change the way patients think about the care they would want during this pandemic.
Mariah: There is a COVID goals of care, and then there’s a … what my goals of care would be if I weren’t in the middle of a pandemic impacting older adults or you know, frailer individuals. And so we’ve even found ourselves having two goals of care conversations. One for right now in the pandemic, and one that might be more applicable when we’re through it.
Amrapali: That’s something I hadn’t thought about before: that some patients may be saying, “I would want to be DNR/DNI if I were to get COVID. But if I survive the pandemic and then get sick with something else, like a run-of-the-mill pneumonia, I might want more aggressive measures.” The level of nuance and branch points in these ACP conversations is new.
Mariah: For example, I talked with a patient who, um, was like, yeah, you know, I’ve heard that they won’t even offer me a ventilator if I wanted it when I’m in the hospital. So, you know, like some of these, these kind of like real talk conversation pieces where, um, they already kind of have heard the worst case scenario with rationing of care and that, that helps me, you know, to kind of guide where they would want things to go from there. And, and I’ve, I’ve even had patients say like, you know, I, I would normally say like, code me, intubate me. Um, I want to try to get through this and see how I do and if all the resources are there, um, I still want that. But if you were to call me and say looking like the resources are poor or that if I went to the ED, I might just die in ED and they wouldn’t offer me an ICU bed, then I wanna, you know, then I’d want to stay home. So there’s like some really interesting nuances that arise in having these conversations when I get to the part about if they got seriously ill.
Amrapali: It’s interesting to think how much our patients are exposed to the language of healthcare in the media, and say things like, “I hear they wont give me vent!” So now more than ever, we have to navigate what patients are hearing and their beliefs about COVID.
Jafar: And along with the specific details that patients may be aware of, the rapid rate of change during the pandemic means goals of care may change just as fast. Thankfully our health system hasn’t yet hit that tipping point that so many of us have worried about with rationing of care like ventilators. But if it does get close to that, we can continue to use the outpatient setting to address goals of care that match what the health system can offer. Ok ok, we hope we’ve convinced you how important it is, now more than ever to have advance care planning conversations with patients. But how do you decide who to prioritize? You could argue it’s everyone, but you gotta start somewhere. Dr. Robertsen shared her panel management strategy:
Mariah: So we decided to start with our oldest and our folks with the most comorbid conditions, or the ones that we worry the most about from a social isolation perspective or um, some of their social determinants, some of their risk factors for being sick or being at higher risk. And so that was how we started, when we were thinking about who we call first, people that we worried the most about or people that we also didn’t feel we had the best defined goals from. So some people, we’ve had this conversation many times over. We try to do it every year as part of Medicare wellness visits. But some patients, you’ve really, the tougher conversations are the ones that we prioritize because we knew we needed to have these conversations. I know we’ve sort of put it off over time, but we really need to now like have it. So that was how we really started picking people first.
Amrapali: So despite prioritizing by age which makes a lot of sense, it’s hard to know– there are so many stories of younger patients right now who are also getting very sick, including our otherwise relatively healthy patients with obesity, hypertension or diabetes.
Jafar: Dr. Robertson also mentions patients who are socially vulnerable, and there’s a HUGE intersection of COVID19 with social determinants of health and health equity, so stay tuned for an upcoming Core IM episode tackling this!
How to Approach as an Outpatient
Jafar: Ok, so now you’ve figured out who you need to have this serious talk with. But how do we begin? Hopefully, the lockdown is making it a LITTLE easier for you to start your virtual visit…
Mariah: The nice thing about physical distancing is most people are home. So there’s not this, like I can’t catch them on their phone or I can’t catch them on a video and check in with them. The phone in particular.
Jafar: If you are able to use video conferencing, you can even use it as an opportunity get closer with patients, in ways that might put you both at more ease:
Mariah: It’s like they’re inviting you into their home. And I tried to think about it like that. And as someone interested in home-based medicine, it especially resonates. But I try to kind of like, Oh, let’s look at it, you know, can you, would you mind showing me a couple of pictures? Or just kind of like engaging their environment in them or my kids are often in the background and so I’ll be like, Oh, this is my son. You know, he’ll pop in. And so there’s a little bit of that just to kind of say, Hey, this is weird, but also cool. You’ll never get to see them in clinic normally. Um, and I don’t get to see your dog. And so that’s sort of how I kind of get things to like a more, kind of calm and comfortable place.
Jafar: Another advantage to doing a virtual visit is that we can bring in loved ones who might not otherwise make it into the clinic, and allow them to take part in these conversations too, so everyone is on the same page.
Mariah: If we can, and we need to bring family into the conversations. lot of times with older adults, there’s like an adult child that they’re staying with and so the child will ask to come in if they’re an important person to the conversation. And then if it’s a telephone conversation, we are looping them in or we’re rescheduling for a time when we can all be on the same call. And so we do make that a very important part of, of both… like making sure they’re, they’re doing well in that we’re giving the same tips to the family about physical distancing. But also that, you know, the people that are important are hearing those goals.
Amrapali: That really resonates! Because yesterday I was doing a virtual visit over the phone for a 60 yo patient with many comorbidities who was getting a little confused; we got her sister on the phone who’s at home with her right now, and the three of us talked on speakerphone and that really helped! But to be honest, I also have faced many challenges with virtual visits, like not being able to see a patient’s face if we are on the phone, not being able to use helpful nonverbal clues to figure out how the conversation is making them feel. Also, I’m just a big nodder and smiler to show I’m listening–how will my patients be able to get that over the phone? It can be awkward, even downright difficult, to have conversations remotely.
Jafar: Totally–I’m big on that in-person connection with patients, so losing that is tough. The main reason to take this on is so you can have an intimate conversation BEFORE the stress of serious illness:
Mariah: I think the approach is different when you are the primary provider for someone than it might be if you’re meeting them for the first time in the hospital, and having also to have these conversations when things are, um, more tense or more, um, serious.
Amrapali: As a general roadmap for how to guide the conversation, we really like the mnemonic “CALMER”, developed by the folks at Vital Talk — you know, the same folks who gave us SPIKES for breaking bad news. The first, C, stands for “Check in”, which means starting by taking the emotional temperature of the situation–for the patient AND for yourself:
Mariah: The approach I start with is always finding out where they are with things, kind of how they’re feeling about this whole crazy pandemic. And that’s something we can all relate to and kind of share, share our feelings around. And so that helps us get to a common place and also helps me understand any misinformation they might have or anything that might be increasing their risks generally for getting sick. Um, and it also helps me to find out how they’re preparing.
Amrapali: Once things get rolling a bit, you move on to, A, which stands for “Ask about COVID.” Basically, this means asking permission to do a deeper dive into the topic–and asking permission is a powerful tool in any serious illness communication:
Mariah: And then I say, would it be okay if we kind of talk a little bit more about that? We dig a little deeper and I tell you what I, I feel or think about some of those things. So I always open the door with it with that.
Jafar: The next step, L, is for Lay out the issues. Basically, this is where you can share your concern about the patient’s specific risk factors, like advanced age, obesity or diabetes, that may make you more worried about bad outcomes from COVID19. On our end as clinicians, we should be aware of some sobering statistics: patients with an out of hospital cardiac arrest have only about 12% chance of survival to discharge (and not necessarily discharge home), about half of whom will have some form of neurologic impairment.
When you think about older, frailer, or sicker patients, this number rapidly drops down, with the survival of Nursing Home residents only being about 3%. When counseling patients, I like to stick to the kind of HOPE–WORRY statements we mentioned in previous episodes on inpatient goals of care and prognosis. Something like this: “I HOPE we can keep can keep you healthy and safe and out of the hospital, but I WORRY that if you ever got so sick that you needed a ventilator or CPR, your chances of ever leaving the hospital, and back to how your feeling now would be close to zero. I really care about what you see as an acceptable Quality of Life, so I wanted to bring these things up now”
Amrapali: Love those I-statements, Jafar… So once you’ve laid out your concerns, the next step, M, stands for Motivate: motivate the patient to explore their goals of care, and take some next steps! At a minimum, help them name their healthcare proxy – ideally with an alternate proxy as well. Don’t make the rookie mistake of forgetting to get working phone numbers and putting them into the chart. Then, go one step further and ask your patient, “Hey, does your proxy actually know your wishes?” Because here’s the thing: paperwork, like an Advance Directive, can only provide guidance (and a lot of people forget this). Ultimately in a crisis it will come down to a discussion between that proxy and the clinicians. So its important that the proxy can actually speak for the patient.
Mariah: The other thing that that scares me is that geriatric patients present very differently and they, and there’s a lot of delirium. There’s a lot of confusion that happens when people get really sick with this across the board, but especially your older adults. And so God forbid, like you, you don’t make the decision now and then you get really confused and you’re alone in the hospital and they’re going to have to do whatever it is that is documented, you know?
Jafar: I think there’s actually another, hidden M here that’s worth talking about in its own right–”Make a recommendation.” Something we tried to highlight in our inpatient goals of care episode. Too often, patients are left overwhelmed and I would argue even abandoned to make decisions, with us on the medical side operating under the concept that this is what it means to have patient autonomy–to be given choices without the influence of the clinician. A more nuanced and appropriate balance of responsibilities comes through Shared Decision Making, which means we use our medical expertise to recommend a plan. Dr. Robertson gave us a great example of this:
Mariah: Today I had a patient when we spoke with that, um, multiple people are coming in and out of the home. They live in a place where there’s not a lot of like ability to isolate themselves from others and they also are in their eighties, and they also have a lot of comorbid conditions including bad lungs. And their wish, off the bat when we were talking was, well, I think I’d want, I want you to send me to the hospital. I want you to try to do whatever, you know, whatever they need to do. And then I was like, okay, do you mind if I give some recommendations on my part? You know, some real talk here in some almost informing, we’re doing a little bit of informed assent, not necessarily quite to that point, but just saying I have some recommendations… and I had to talk a little about the fact that with their lungs the way they are and what we’re seeing with this disease process … I wouldn’t recommend getting intubated, wouldn’t recommend getting coded because it would be probably futile for them at their age, late eighties, with their comorbid conditions. And so, while I said I’d, I’d be hopeful that things would go well, I think as your primary care doctor, it’s really important that I say that I don’t have confidence that this would go well for you. And that actually was received reasonably well, although, you know, with some pushback, just because of the fact that it’s tough to hear. But, I think, with honesty, we were able to reach a point in the conversation where we decided that the Coronavirus, at least the Coronavirus goals would be that we would not be that aggressive with the care. We would not get intubated, we would not be coded and we would try to manage everything at home with primary care support.
Amrapali: And that brings us to our next letter, E, which stands for Expect Emotion. As Dr. Roberston was just explaining, this stuff is tough to hear! I mean, it’s our own mortality we’re talking about! I like to name that with patients by saying, you know, “I’m sorry, I know this can be hard to think about.” And then pause or give a little space for patients or families to process and be vulnerable–instead of jumping right to the plan as we tend to sometimes do. Then circle back and summarize the plan from what you’re hearing the patient or proxy say: “How does that sound to you?”
Jafar: I’d say that sounds pretty good, Amrapali! Finally, once you’ve established the plan, R is for Record the discussion. Any documentation – even brief — will help your colleagues and your patients, as your note might be all they have in a pinch.
Mariah: I think the most important thing is those like key things that you have a conversation about. If they have an advance directive, making sure it’s in the chart, making sure the code status is there and making sure that people that people need to reach are like numbers that work and are appropriate. And that I’m documenting that somewhere very clearly on the front of the note. You know, the most recent note, it’s not as important right now to be very flowery and conversation and it’s much more important to have those like key pieces of information that are easily accessible for somebody inpatient.
Amrapali: I always tend to write a novel after these conversations, but really our geri and pall care experts suggest a bullet-pointed approach: highlight 1) healthcare proxy, 2) code status, and 3) any specific considerations or language patients use. Put it in your note, put it in bold, and put it front and center!
Jafar: A few other documents you should consider when discussing advance care planning with your patient are an Advance Directive and a POLST. Completing an Advance Directive is a great way of legally documenting who that patient wants as their healthcare proxy, and in a more open ended way, what they see as an acceptable Quality of Life. It goes through specific kinds of medical care – like feeding tubes, prolonged mechanical ventilation – and the End of Life care they would want. All the nuances of advance care planning can be difficult to tackle at once, so this is something you can direct your patient to start looking over, and then come back to on a subsequent visit. I like to frame it to patients that writing this out can really take the burden off your loved ones who might otherwise struggle with how to handle medical decisions if you couldn’t speak for yourself. What’s great is that the document is valid no matter where they get medical care, but to make sure that everyone in your system sees it, make sure to have a copy scanned into the EMR.
Amrapali: On the other hand a POLST, which stands for Portable Order for Life Sustaining Treatment, is a medical order signed by a clinician that spells out a lot of this same information but in a more direct way. Different states vary in both the form and the name (also goes by MOLST, MOST, POST), but they are always brightly-colored pieces of paper that patients keep at home or while in transit to alert medical professionals about the kinds of care they find acceptable. For example, if EMS is called for a patient found down who has filled out a POLST, they may come into the home, see this document pinned up on the fridge saying that the patient is DNR/DNI, and then know that they should not attempt to code this person.
Jafar: Advance Directives are great to have, but a POLST is really what you need in the emergency-type situation to direct care, usually away from our default of full-code. Check out our show notes for links to examples, including how to fill it out electronically.
Challenges to Outpatient COVID Care
Amrapali: It’s great to have an outline for how communication SHOULD go, and all the documents you want your patients to fill out, but of course we know that things don’t always shake out that way. We wanted to take the final part of this episode to hit on some of the key challenges you may face in attempting these outpatient goals of care discussions.
Jafar: And the most obvious challenge is a classic one: patients don’t want to talk about it:
Mariah: I’ve had more than one person just say like, you know, this is too much. Like I’ve already been scared enough right now about all this. Like, this is too much to talk about right now. And you know, you feel this urgency, like I need to, I really want to help you come to a conclusion on this.
Jafar: You know, that’s always been a struggle for me–sometimes I let that urgency or my demand to talk about a certain issue that I think is important take precedence over what the patient is willing to do at that moment, in ways that just leave us both pretty frustrated. But Dr. Robertson had some good insight on this point:
Mariah: We’re not trying to like change people’s minds, right? Like it’s not our job to make people do something that like we want them to do or we think is best for them. At least not right this second. Right? And so we are trying to like, um, just help them understand the risks and anyway, like just let, let go of the ownership of all of it a little bit. Because I think it’s hard to do that as a, as someone who cares a lot.
Amrapali: I can’t hear that message enough. And remember that advance care planning is a process that you can keep coming back to–that’s the beauty of the work we do in our outpatient clinics. The goal is just to plant some ideas and get the conversation started.
Jafar: Then there’s the unanticipated logistic challenges of providing outpatient care to COVID+ patients whose goal is to remain out of the hospital at all costs.
Mariah: The thing that has scared me the most has been the people who say I want to die at home, but I live alone and I have nobody. And we are, we cannot say that hospice is going to be able to come into everybody’s home…I ‘ve had multiple patients ask me, okay, but how will you ensure that I don’t die alone or I don’t die really uncomfortable or I don’t, you know, I don’t suffer, because I chose to stay home? The first time someone asked me that, you know… I felt like I was like, “Oh, this is a win!” We got to this place where you realize it’s not right to go to the hospital, this feels like a win. But then they’re like, so what now you know, and call hospices locally and they’re all kind of like, we don’t know… We don’t have that much PPE… We don’t know what we’re going to be able to do in the next several weeks. And you’re like, okay, crap. Those are scary things to me. In some ways, someone going to the hospital, at least I know they won’t be dying alone. And I’ve had a patient actually say that like, I don’t want to be intubated, but I don’t want to die alone. So maybe I go to the hospital so then at least there’s like somebody next to me and so those are tough. Those are tough things to navigate.
Jafar: Wow… it’s hard enough having these conversations, but to realize that for patients who live alone, you may be choosing between two bad alternatives… that’s a painful reality to think about. We can have faith that over time and with more preparation and PPE, hospice will get better acquainted with meeting this challenge. In the meantime, it was encouraging to hear from Dr. Robertson that some innovative strategies are already starting to form.
Mariah: One thing we’ve talked about is having palliative care kits like made up for any patient who starts to have COVID symptoms, who decides to stay home. and we kind of follow closely and then we disperse these kits to these homes, like to people and, or teach their family how to administer if they’re not alone alone. You know, providing PPE maybe to family, finding ways to get some PPE specifically to be able to give to a family to help them care for their family member.
Jafar: Check out our show notes, where you can find links to the Center for the Advancement of Palliative Care (CAPC) COVID19 Response Resources Toolkit, where you can find a medication guide for COVID19 symptom management at home, among many other helpful resources.
Amrapali: We wanted to leave with you some parting thoughts. We know that talking about advance care planning with our patients can be very challenging, but I do feel that there is some meaning in the work of bringing out our patients’ values and doing our best to honor them.
Mariah: As a primary care doctor, we love our patients. Everybody loves their patients, but like you get to know them over time. I love my patients very much and I feel like they’re my family members to some degree at times. Honestly though, the actual act of talking to my patients about these things helps relieve some of it for me, um, because it allows me to, to talk to them about it, to relate to them about how scary this time is, to reassure them that while I understand it seems like our society is like not, um, appreciating older adults… we appreciate you and we’re here for you. And so, you know, you have us in your corner and we’re not gonna like, let you get sick without support. We’re not going to make … we’re going to make sure you get the care you need. And so I actually find, I draw more, um, relief and positivity from having these conversations by and large, while some of them are much tougher than others because I feel like it allows me some control over helping at least a small subset of people feel, feel better, and know that they’re cared about.
Jafar: We hope we’ve shown you a few tools to make this connection with your clinic patients. Having a framework for going into tough conversations can really help, so try the CALMER mnemonic the next time you’re faced with this, which again stands for C- Check in, A- Ask permission to dive deeper on COVID, L- Lay out your concerns, M- Motivate advance care planning decisions, E- Expect Emotion, and R- Record the conversation. Don’t forget that hidden M- Make a recommendation! Patients come to us for help and advice, and although it may not always be well received, or the logistics of outpatient COVID19 may be in flux, we can take heart in trying to do the right thing.
Mariah: We’re doing our … we’re doing our damn best. Every one of us, like wherever we are, we’re trying really hard to, to do, to take good care of people into preserving their wishes and doing right by people. Right? So like, I just think, um, advance care planning is tough. These are hard conversations. They rarely go exactly as you hoped they would. Um, and you know, you can’t take it personally and recognizing that we’re all human.
Jafar: Thanks for tuning in. We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences and reflections dealing with advance care planning conversations during the COVID pandemic. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website: www.coreimpodcast.com/contact/
If you enjoyed listening to our show, and it matches your overall goals of care, give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.
Finally, special thanks to all our collaborators on this episode, our wonderful audio editor Julia Skubisz, infographic by Gaby Mayer, endless technical support from Harit Shah, moral and executive support from Shreya Trivedi, and most importantly thanks to you, our listeners!
References and Resources
- American Heart Association (AHA): Cardiac Arrest Statistics https://cpr.heart.org/AHAECC/CPRAndECC/ResuscitationScience/UCM_477263_AHA-Cardiac-Arrest-Statistics
- American Society for Clinical Oncology (ASCO) Coronavirus Resources https://www.asco.org/asco-coronavirus-information?utm_medium=email&utm_source=TAPEN-+2020-0420
- Center for the Advancement of Palliative Care (CAPC) COVID-19 Toolkit https://www.capc.org/toolkits/covid-19-response-resources/
- POLST COVID-19 Resources https://polst.org/covid/
- VitalTalk COVID Ready Communication Playbook https://www.vitaltalk.org/guides/covid-19-communication-skills/
- PREPARE for your Care COVID-19 Resources https://prepareforyourcare.org/covid-19
- Center to Advance Palliative Care (CAPC) COVID-19 Response Resources https://www.capc.org/toolkits/covid-19-response-resources/
- ACP What Matters Most Workshop (online, for patients) https://www.eventbrite.com/e/what-matters-most-a-free-in-depth-advance-directive-workshop-registration-60629719122?aff=MERI
- Richardson, S., Hirsch, J. S., Narasimhan, M., Crawford, J. M., McGinn, T., Davidson, K. W., … & Cookingham, J. (2020). Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA.
Tags: coronavirus, COVID, goals of care, Medical Humanities, primary care