Transcript
Speaker: This is the Pallium Podcast, a production of pallium.org at the intersection of palliative and emergency medicine.
Speaker: I'm your host, Justin Bruton.
Speaker: Today on the PallyM podcast, I'm joined by Suzanne Bigelow.
Speaker: Dr. Bigelow is an emergency medicine attending at Providence Regional Medical Center in Everett, Washington, and she's a clinical instructor at Elson Floyd School of Medicine with Washington State University.
Speaker: She's been involved in palliative care for nine years, and she's worked in developing residency milestones related to emergency medicine training and palliative care.
Speaker: Thank you so much for joining me today.
Speaker: Thank you, Justin.
Speaker: It's nice to speak with you.
Speaker: You've had an interesting course in developing this as a part of being an emergency physician.
Speaker: And what led to your interest in palliative medicine?
Speaker: That's a good question.
Speaker: So it was interesting.
Speaker: I was at my most current job and was probably about two years in and a nurse came up to me and started talking to me about end of life care.
Speaker: And she really had a passion for it and we really connected over it.
Speaker: And it was one of those things where I realized I wasn't very good at having these conversations with folks that
Speaker: And really started seeking out ways to improve my skills.
Speaker: And that really got the ball going.
Speaker: And what were some of the things that you started doing to kind of help augment your understanding about how to integrate palliative medicine in the emergency room?
Speaker: So I went to our medical director for the emergency department and we started talking and we created this role for me as the emergency department palliative liaison.
Speaker: So I'm like the point person for all things palliative care and the ED.
Speaker: It's a pretty big emergency department.
Speaker: At that point, I think we were seeing probably around 95,000 patients a year.
Speaker: So lots of volume, lots of opportunities to have conversations.
Speaker: And from there, Enrique and Guilinos was really supportive.
Speaker: He was the director at that time and helped connect me in with
Speaker: some people in the hospital who were higher up in the C-suite that gave us a lot of support.
Speaker: And we just started collecting numbers, watching data to see how many people were dying in the hospital within a 72-hour period of them being admitted, how many of those came through the emergency department.
Speaker: And so once we had that data, it led us to other things.
Speaker: I think at that point we had numbers that reinforced the need for palliative care in the emergency department.
Speaker: I was also really lucky because the chief medical officer who had been a palliative care physician was super supportive of what we were trying to do.
Speaker: And so she actually brought in some palliative care conversation specialists.
Speaker: And there was a small group of us who were invited to do some specialized training and started making connections.
Speaker: And then people would introduce me to other folks or invite me to other meetings, that sort of thing.
Speaker: And so it's interesting how it snowballed from an initial conversation with one nurse.
Speaker: Yeah, that's actually really, that's really fascinating.
Speaker: And I think that's one of the things that we're good at as emergency medicine doctors is we adapt.
Speaker: And you get your training, but you find, you know, there's gaps in what I know.
Speaker: And there's gaps in the patients I'm seeing and the kind of things I need to be able to provide for those patients.
Speaker: So I think it makes a lot of sense to me.
Speaker: Your palliative care department at your hospital that you were at, was it already pretty well developed?
Speaker: And they just were kind of doing things asynchronously from the ED?
Speaker: Or what did that look like?
Speaker: Yeah, that's actually a really good point.
Speaker: So our palliative care department, the inpatient palliative care team, was pretty small.
Speaker: I think at that point when I first started getting involved with it, there were two nurse practitioners and I think two physicians, and they were so overwhelmed.
Speaker: I mean, they just, they had so much they needed to do.
Speaker: And while they really wanted to get into the emergency department, they just didn't have the bandwidth.
Speaker: Yeah, and I'm actually interested because I think, and the literature supports this too, when you start doing consults earlier in the ED and you see effects on hospital length of stay and dispositions to hospice, et cetera, you can see where that can be very beneficial to a health system.
Speaker: I'm curious if some of the initiatives you started have helped to augment the resources the palliative care team has.
Speaker: Well, yes, they have.
Speaker: So just getting somebody embedded in the emergency department, even for part of a day, has been a huge help.
Speaker: And so that person falls under the purview of the now much larger and more broadly staffed inpatient palliative team.
Speaker: But that nurse is downstairs probably like kind of later morning and through afternoon, early evening, and
Speaker: And yeah, it's such a bonus to have someone who can help sort out goals of care conversations, reach family members, they're able to really step in and help out.
Speaker: And they have that specialized training, the expertise to be able to do it effectively.
Speaker: What does that look like career-wise?
Speaker: Yeah.
Speaker: So for me, this was a side project that I put a lot of work into.
Speaker: So we actually got a grant to fund the position in the emergency department.
Speaker: The hospital system had money available.
Speaker: And so she's like the nurse manager for the ED in the ICU and I co-presented the proposal for this role and it got accepted.
Speaker: So we got funding for six months and hired a
Speaker: for current emergency department nurses to work separately in the palliative care role, banker's hours, you know, so Monday through Friday, and just to see what would happen.
Speaker: And it was great.
Speaker: People were so sad when the study sort of trial period was done.
Speaker: I think they had really shown what they could do and just how grateful everyone from like nurses and techs were through to the physicians to have someone to be able to help out in those situations.
Speaker: And I'm actually interested, were these, you said these emergency nurses, were they emergency nurses that just had an interest in this or were they nurses who worked in hospice and palliative medicine?
Speaker: What did that look like?
Speaker: Yeah, so they were nurses who had a strong interest in palliative care and of life care.
Speaker: And nobody had any specific, I think, hospice training or hospice care experience prior to coming to the ER.
Speaker: Yeah.
Speaker: What would you say to the emergency physician who's working in a department that doesn't have these resources?
Speaker: That's an interesting question.
Speaker: I think if I were in those shoes, and I'm thinking back to when we first started this, you know, educating myself was really helpful.
Speaker: There's some really wonderful resources out there, which I'm sure you're familiar with.
Speaker: CAPSEA was really helpful.
Speaker: Vital Talk also has some really wonderful resources.
Speaker: But that seemed to be the first step.
Speaker: And then once I was learning more, and again, I had the support of the medical director for the emergency department, I put together a couple of short lectures for my colleagues to spread what I had learned as far as having conversations and just some basic information on hospice and palliative care.
Speaker: Because there's just a lot of just unknown at that point.
Speaker: Like people didn't realize there was a difference between the two.
Speaker: So I say that education is
Speaker: And then also reaching out to your local hospice and palliative organizations.
Speaker: They can be really helpful, either coming in and giving lectures to your group, helping you connect patients to services.
Speaker: And I was pleasantly surprised at how receptive they were to the random ER doc giving them a call.
Speaker: How did that change your approach to these situations when you got some of that additional training?
Speaker: What did you notice is the biggest difference now than where you started?
Speaker: Oh man, I like, I'm such a better listener.
Speaker: I was talking way too much and it was far too directive.
Speaker: You know, I think sitting back and giving patients the chance to actually tell you what's important to them and what they're worried about, it, uh,
Speaker: It really, really changed the conversation and felt so much less stressful for me when I would talk to people about these topics, you know?
Speaker: Yeah, I agree.
Speaker: I think one of the things that's tough is this feeling of, oh my gosh, if I open up this Pandora's box of issues, how am I going to manage the rest of the emergency room?
Speaker: So give me an example of, let's say you've got a patient with say advanced cancer that comes to the emergency room and they're not doing well.
Speaker: What might that process look like?
Speaker: How is the embedded nurse going to help them navigate their resources and involve the provider team?
Speaker: Yeah, so there's probably a couple ways it could go, but if the nurse isn't trolling the board to see if there's anyone who looks like they might benefit from his or her services, oftentimes it'll be the primary nurse caring for the patient who gives the palliative nurse a call.
Speaker: Sometimes it's the doc, but oftentimes the nurses would start the ball rolling.
Speaker: And then the nurse would take a quick look through the chart and then go in and chat with the patient and get an idea about just their goals of care and work with the doc and the nurse as far as trying to figure out what kind of care needs to follow.
Speaker: Like in that patient you described, like assume they're going to get admitted, sharing that then with the inpatient team,
Speaker: contacting the palliative team to make sure they get a much longer consult than like the probably 10 or 15 minutes that she spent with the patient and the ED.
Speaker: So that way the conversation is continued.
Speaker: So it was nice because it made things fairly seamless.
Speaker: Whereas before, like...
Speaker: Someone would have a code discussion in the ED, and for some reason, the note wasn't finished, or they hadn't yet put the code order in, and the patient would go upstairs, and the hospitalist would know that the conversation had been had.
Speaker: And so it was just, it really smoothed things out as far as that transition between...
Speaker: the ED and inpatient or even back to like their primary care.
Speaker: Like the nurse would also reach out to PCPs and let them know what had happened and conversations that had been had.
Speaker: So things could be continued once they left the ER.
Speaker: Yeah, that's a great point because you're right.
Speaker: It can be just a lack of documentation or a lack of communication in the primary team.
Speaker: So it can totally get lost in the mix.
Speaker: And that's one of the things that I like.
Speaker: That's why I always like to tell my colleagues, you know, go ahead and just get palliative care involved because at least that way they can continue the conversation and we'll have consistent documentation about what's been said and what's been decided.
Speaker: Because it is, it's a giant game of telephone.
Speaker: Unfortunately, even these days, it's still the case.
Speaker: You know, one of the things I was curious about, so you mentioned the, you know, we're talking kind of the gradual transition.
Speaker: So I think about like maybe the more critically ill patient where let's say maybe it's a big neurologic event or something else that's pretty serious.
Speaker: And it's the decision about intervention.
Speaker: Has this process affected those kinds of patients or is it more your communication with your colleagues about how to have these conversations that's influenced how those situations are handled?
Speaker: I mean, I'd like to think it's all me.
Speaker: But it's probably like a realistic reality is probably a mix of things.
Speaker: So part of the lecture series that I gave to my group was like how to have a brief limited goals of care conversation.
Speaker: how to get it done in like eight minutes sort of thing.
Speaker: And it's definitely like for the ER, I mean, that's probably about all the amount of time people could really spend, you know, like maybe 10 minutes or so.
Speaker: So I mean, I would like to think that that was helpful and gave people tools.
Speaker: We had the same, actually same lecture, but a little bit tweaked that was given to our nurses as well.
Speaker: And I've got to say like the nurses were the ones who really took this and ran with it.
Speaker: For like a month afterward, I feel like every shift I worked, at least one or two people were coming up to me and telling me about a conversation they'd had with a patient and how they were just, they were really happy about being able to have these tools now to speak with people in ways that they just had wanted to before, but didn't really know how to.
Speaker: So that was an interesting thing that happened.
Speaker: And I am digressing of it.
Speaker: Remind me again.
Speaker: Oh, no, you're talking about how the, no, I actually, I can relate to what you're saying because I've had the same experience when you start, when you start trying to show people, okay, this can be done in the same, same exact idea.
Speaker: We're going to have a very focused conversation.
Speaker: We can make it productive and compassionate and patient centered and still relatively short to allow for the timing of the ER follow-up questions.
Speaker: So how do you think you kind of, you kind of alluded to it already is these acute care situations that
Speaker: Oh, yeah.
Speaker: You know, I feel like that's that's very provider centric about how to handle those.
Speaker: And it sounds like what you're telling me is they it has changed how they interact with patients.
Speaker: Some of the education has been provided.
Speaker: I think so.
Speaker: And I think it's been more of a gradual change.
Speaker: You know, it's it's.
Speaker: And I don't know if you felt this, but I feel like with palliative care, it's just a slow, steady foot on the accelerator.
Speaker: You know, you just can't all of a sudden just like go to 60 miles an hour in like four seconds.
Speaker: Like you've got to slowly ramp up, you know, and get people on board.
Speaker: There still are a few docs who don't feel like the emergency department is the place to have a goals of care conversation per se.
Speaker: Like they feel like that needs to be done in clinic.
Speaker: Or maybe the hospitalist can sit down and have a long conversation about it.
Speaker: So it's interesting that just that mentality and, and, and, you know, for me, cause I'm like, I'm for you too.
Speaker: Like, I'm like, we're like, oh yeah, we drank the Kool-Aid man.
Speaker: Like we're totally on board with this.
Speaker: Yeah.
Speaker: You know, but like, what?
Speaker: Like, you don't feel the same way that I do?
Speaker: So that's always a little bit of a surprise.
Speaker: But I think it's helped.
Speaker: I feel like the nurses feel more empowered in these situations to speak up.
Speaker: And I think we're just thinking about it more now, too, whether or not people took anything away from the lectures.
Speaker: I feel like it's in our brains more as far as like, is this the right thing?
Speaker: Do we commit this patient to the ICU pathway?
Speaker: Or maybe there's another path we can put them on that's going to be in agreement with their goals.
Speaker: One thing that you've worked on as well is looking at milestones for emergency medicine residency training and curriculum with regard to this.
Speaker: So what are some of the work that you've done in that and where do you think we need to go with how we train emergency residents in these types of skills?
Speaker: Well, I would say, so first my role was, I was part of a team of folks through ASAP and we worked through what we felt the milestones should be and what, you know, each like first year, second year, third year, as you progress through your emergency training, what the appropriate kind of level of skills should be at each of those.
Speaker: And there were, I think, was it like...
Speaker: 12 or 13 different milestones, you know, everything from like managing pain to, you know, having the goals of care conversation, recognizing someone who, you know, needs to have that conversation.
Speaker: It was really a wonderful thing to be a part of.
Speaker: And I feel very lucky to have been included because at that point I was completely community based.
Speaker: And so I'm not sure how I snuck in, but there I was.
Speaker: What do you think needs to be done to kind of further that process?
Speaker: What do you think is still missing in resident education?
Speaker: Yeah, I mean, I feel like modeling is a big thing, you know, watching people do this.
Speaker: I feel like I never got any of that when I was training.
Speaker: I love where I trained.
Speaker: I got fantastic training there.
Speaker: But the way I have those conversations now is very different than I would have had them as a resident.
Speaker: You know, it's like, do you want CPR or not if your heart stops?
Speaker: And I'm no longer having conversations like that.
Speaker: Let's see what else.
Speaker: That part, I think, and just like, again, like with having now that they have the milestones, having some concrete goals to hit as a resident and making sure it's part of the residency training.
Speaker: I think it's changing.
Speaker: I feel like there's definitely momentum.
Speaker: Yeah.
Speaker: within the training sector of emergency medicine to try and get us up to up to speed.
Speaker: I mean, we need it.
Speaker: People are getting older.
Speaker: There's so many more people who are over the age of 65, right?
Speaker: All those boomers, like it's something like 10,000.
Speaker: I think it might be a week actually are reaching age 65.
Speaker: So it's this very dramatic wave of people who are
Speaker: reaching their golden years.
Speaker: And I mean, they're going to start dying or getting sicker, you know, living with chronic illness.
Speaker: And I think we're just going to be pressed to have these conversations more and more frequently.
Speaker: You know, it's interesting too, where I work.
Speaker: So we looked at a subset of the patients that the
Speaker: palliative nurses in the ED touched and interacted with during the pilot six months.
Speaker: And population of about 100 patients that we looked at, so folks who had heart failure, EF of 40% or less, cancer with METs, COPD on home O2, and then stage three renal failure or greater, like only a third of those people had a pulse form.
Speaker: when we talk to them.
Speaker: So there was like, you know, two thirds of those folks, and if they're a representative sample, and that's a lot of people who haven't even thought about what they want to do when they get sicker, you know, and if they get to that moment where their disease has reached its end progression, you know, when they, you know, they die, like,
Speaker: I haven't thought about it.
Speaker: I haven't really talked about it.
Speaker: I don't have any documentation to help the medical community.
Speaker: And that was pretty shocking.
Speaker: Because you look at the folks you think would have at least maybe not the renal failure patients, but at least the first three you would expect that somebody's got to have told them, like, this is really serious and we need to start planning for when you get sicker.
Speaker: We're going to hope for the best, but let's keep all possibilities on the table right now.
Speaker: No, that's a really good point.
Speaker: And actually, you know, it's interesting.
Speaker: What happens in the emergency department brings this up with people.
Speaker: Even if they're not seriously ill when we see them, they're sick enough to come to the emergency room.
Speaker: And that's oftentimes an opportunity to at least bring these things up.
Speaker: And even if they're going to h ave a short admission or they're going to be discharged that day, we have the ability to bring up stuff in the context of illness that in some ways I suspect is probably hard during a routine outpatient visit.
Speaker: And I know the PCPs that are very proactive about this because I've seen their patients and I've read their notes.
Speaker: But a lot of times we do have the leverage to start that conversation.
Speaker: And one of the things you mentioned too, that you mentioned about being on the ASAP committee and being a community person, I think that's extremely valuable because I feel like one of the things I realized, and before I went to fellowship, I was just doing community practice after I graduated.
Speaker: And I had all these ideals in my mind about how I wanted things to go.
Speaker: But when you're in a busy community ED and you don't have these resources at your fingertips, there's a lot of stuff you have to really pick and choose.
Speaker: How am I going to approach this problem?
Speaker: How am I going to approach this patient, this family?
Speaker: How much of a conversation can I have with them?
Speaker: What can I start doing?
Speaker: So I think a community perspective is incredibly valuable because that's where a lot of our trainees are going to end up.
Speaker: Yeah, I agree with you.
Speaker: And the other thing too that I think that I didn't realize as clearly as now that I can look back is
Speaker: But I felt like, you know, you're either community and you're just taking care of patients or you're in academics.
Speaker: And in a lot of places, like the hospitals are big enough and robust enough that you can actually have a little like sort of like research kind of pseudo-academic side gig if you want.
Speaker: Like you don't have to necessarily be full academic.
Speaker: Because for some folks, you know, they make lifestyle choices that lead them to more of a community position.
Speaker: And that was just, it was, and it was something I hadn't realized.
Speaker: And it's nice now that I've had the benefit of being supported by the hospital and my colleagues to take this on.
Speaker: Yeah.
Speaker: So I would share that with anyone who's debating between, you know, academic field versus community.
Speaker: Just keep that in mind.
Speaker: You still can do lots of academic stuff when you're in the community.
Speaker: Yeah, absolutely.
Speaker: And that's, and it's, I think it's helpful to know too, that you were able to get funding, you were able to do this pilot project, you were able to, to really kind of proof of concept that, that, that it would work.
Speaker: So thank you so much.
Speaker: I really, I've enjoyed our conversation and it's been enlightening and I just appreciate what you're doing to, to move things forward where you're at and, and to continue to impact this group of patients and develop processes that will, will make sure that they get what they need in the emergency room and beyond.
Speaker: But thank you so much.
Speaker: Thank you, Justin.
Speaker: It's been lovely talking to you.
Speaker: For more information on current topics in the fields of palliative and emergency medicine, please visit pallium.org.
