Smilow Shares with Primary Care: Palliative Care

April 05, 2023

Information

April 4, 2023

Presentations from: Drs. Elizabeth Prsic, Morgan Bain, Aleksandra Rosinski, and Kristin Edwards

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00:00Hi everyone. Thank
00:02you for attending tonight. We're
00:06excited to have our palliative
00:09care team and as part of Smile
00:13shares with the primary care.
00:15This is a series that Karen Brown and I
00:19really have developed and lots of people
00:22have helped with to really focus on.
00:27The perspective of of of cancer
00:30and and palliative care,
00:32cancer and cancer and palliative
00:36care services for patients.
00:38And let's see,
00:40let's start with the slides please.
00:47And just so you folks know,
00:50if you ever, if you or other
00:52people want to access these
00:54afterwards there's a YouTube link.
00:56And actually we've been having lots
00:59of folks access those earlier or
01:01earlier lectures that we've had.
01:03So next slide please.
01:08As many of you may know this is a
01:11monthly lecture series that focuses
01:13on primary care perspectives
01:15and cancer and and hematology.
01:18We love having our faculty
01:21panel with featuring featuring
01:23primary care and our smilo.
01:25And other experts and we try for Tuesdays
01:29the first Tuesday of the month, 5 to 6.
01:33Again, you can access these afterwards.
01:36And while there are lots of
01:38different venues that can teach
01:39you about cancer topics,
01:41this is really a case based
01:44discussion that highlights key
01:47key understandings and advances
01:49from the primary care perspective.
01:54Next slide, we are going to
01:58do some introductions and then
01:59we'll jump into our cases.
02:01We have some great ones today. Next slide,
02:06I'm going to introduce, oh,
02:07I'm a medical oncologist.
02:09I'm going to introduce Doctor or
02:11Karen Brown is going to introduce
02:12herself and then and then start
02:14out with our introductions. Thanks.
02:17Thank you. Thank you, Ann,
02:18and thank you to everyone joining as well
02:22as to the panelists who have prepared a
02:26really terrific session in primary care.
02:29One of our greatest challenges is
02:31caring for patients with cancer and
02:34the most challenging parts of that are
02:36when they first present and we need
02:39to make a diagnosis and at the end.
02:41In the middle, there's a lot of
02:44heavy oncologic care and they kind
02:45of know where they're going.
02:47So I'm especially looking forward to
02:50learning more today about how we can
02:53help them at the the end of their
02:55cancer journey or as they get more
02:57advanced in their cancer journey.
03:01I want to introduce my Northeast
03:04Medical Group colleague, Dr.
03:07Ola Rosinski.
03:09She received her undergraduate degree in
03:11Physiology and Neurobiology at UConn.
03:14She then went on to medical school
03:17at Yagolonian did I get it right?
03:20University Medical College in Poland,
03:22and she completed her residency and
03:24internal medicine at Saint Vincent's
03:26Medical Center here in Bridgeport.
03:28She was in academic medicine and was
03:30the assistant and then associate
03:32program director for Internal
03:34Medicine at Saint Vincent's and she
03:36was also the ambulatory Education
03:38Coordinator and worked on developing
03:40the ambulatory resident curriculum.
03:43We were fortunate that she joined
03:45Northeast Medical Group in 2019.
03:46She sees patients full time in New Haven
03:49and also teaches students in her office.
03:53She is well regarded by her
03:55patients and our medical community.
03:57And in her spare time,
03:58she likes to bake,
04:00and she's a history buff with an
04:02special interest in the ancient Near East.
04:05I'll pass it along to you.
04:06And for your introductions,
04:10am
04:14I on now?
04:16That's helpful,
04:17I'd like to introduce Doctor Morgan Bain.
04:20He's currently the section head for
04:23palliative care at Greenwich Hospital
04:25and former Professor of Medicine at Duke.
04:27He studied undergraduate at Wesleyan
04:30and got his Med school degree at VCU
04:33and trained at Norwalk Hospital in
04:37Connecticut in affiliation with Yale,
04:39followed by a Geriatric Medicine fellowship
04:42at the at Mount Sinai in New York City.
04:45He's board certified internal medicine,
04:48Hospice and palliative medicine
04:49and geriatric medicine,
04:51and he has many years experience
04:53of experience caring for
04:55vulnerable adults with lots of.
04:57Complex medical needs.
05:00His passions are patient
05:02care and medical education,
05:04and having taught hundreds of
05:06medical students how staff and and
05:09physicians throughout his career,
05:11next I have doctor Kristen Edwards.
05:15She's a a board certified physician,
05:17controlled medicine,
05:18Hospice and palliative medicine.
05:20She's the medical director of
05:22palliative care at Bridgeport Hospital.
05:24She manages all aspects of
05:25the PAL care program there,
05:27including clinical care education management.
05:30She's the site director for the
05:33Yale Geriatrics Hospice and
05:36Palliative Medicine Fellowship.
05:39She's an assistant clinical
05:40professor of medicine at Yale.
05:42And in 2019,
05:44she was actually awarded emerging Leader
05:46in Hospice and palliative medicine,
05:49a national award given every
05:51five years to 40 leaders in the
05:53field of palliative care.
05:54So fantastic work, Christian.
05:57And then finally Doctor Liz Persich.
06:00She's a physician specializing in
06:03medical oncology and palliative care.
06:05She received her medical
06:07degree from George Washington.
06:09University School of Medicine and did
06:12her residency and fellowship at Brown.
06:15She is certified.
06:17Also in sorry,
06:19she had a fellowship also at Brown
06:22focusing on end of life and palliative care.
06:24So she's double fellowship, Medoc and.
06:28Palliative care.
06:29She's an assistant professor at Yale.
06:31She's the director of adult
06:33inpatient palliative care at Yale
06:35New Haven Hospital and firm chief
06:37for for the medical oncology unit
06:39at Smile Cancer Hospital.
06:41And she's dedicated to serving patients
06:44with serious life or life limiting
06:46illness with complex medical needs.
06:49Difficult to control symptoms
06:50and supporting their caregivers.
06:52This is a just a terrific team
06:54of folks I've had the pleasure
06:56of working with and so really,
06:59really excited about the panel tonight.
07:01I'm going to turn it over to
07:04Doctor Rosinski to to start off.
07:12Good evening everyone.
07:14So let's get started case one.
07:17Is an 82 year old female comes to the office
07:21for an urgent visit regarding a lump in
07:24her left breast that she noted yesterday.
07:27Her last screening mammogram
07:29was 15 years ago.
07:31She doesn't have any pain,
07:32although it does feel tender
07:34when she presses on it.
07:36She has no redness, skin changes,
07:39****** discharge or weight loss.
07:42The exam is notable for a
07:44mass in the left breast,
07:462 by 4 centimeters in the
07:4911:00 o'clock position,
07:5010 centimeters from the ******.
07:52The mass is firm,
07:53with no tenderness of the mass itself,
07:55but there is tenderness of
07:58the surrounding tissue.
07:59There is left axillary
08:02lymphadenopathy present.
08:04Diagnostic mammogram and
08:06ultrasound were ordered.
08:08The patient herself is very afraid that
08:10this is cancer and that she will die.
08:12She says that she's not ready.
08:18So you order the mammogram and there is
08:21a 3.2 centimeter irregular mass with an
08:24indistinct margin and the left breast
08:27at the 12:00 o'clock middle depth.
08:30And the biopsy shows invasive ductal
08:34carcinoma poorly differentiated.
08:37The patient would like to
08:39pursue curative treatment.
08:41So how would you structure your
08:44conversation with this patient
08:46and would you even mention
08:48palliative care at this point?
08:57And to help us answer those questions,
08:59I'd like to turn over to my
09:02colleague, Doctor Edwards.
09:04Thank you. So couple things I think let me,
09:08can everybody hear me,
09:08okay, on this patient.
09:10You know really we're still trying to
09:12find out what is her prognosis at this point.
09:14I'm sure she's overwhelmed with
09:17emotions and really just trying to
09:19figure out what next steps are.
09:20So I think the conversation would
09:22really be a lot of listening and and
09:25I we're going to get to some of those
09:27communication pearls in my second slide,
09:30I'm going to tackle the first question,
09:31the second question first then,
09:32which is what I mentioned palliative care.
09:35I probably wouldn't mention palliative care
09:37in this particular interaction because again,
09:40it's very early and still trying to
09:41figure out what exactly is going on.
09:43And part of that is because of what
09:44the definition of palliative care is.
09:46So if you can, go to the next slide.
09:49So there are a couple of models
09:50out there for palliative care
09:52that are helpful to understand.
09:53Palliative care used to be
09:55thought of as very sequential.
09:57So the Top Model is what's
09:58called an integrated model,
10:00which was the new and improved
10:02way of thinking of palliative
10:03care about 10 to 15 years ago.
10:06Before that we thought of it really
10:07as all of these therapies to prolong
10:09life then almost a flip the switch
10:11and then there was Hospice which was
10:13approximately the last six months
10:15and bereavement care afterwards.
10:16And that was when the Hospice
10:18benefit was introduced in the 1970s.
10:20The integrated model recognizes
10:22that palliative care includes
10:24the end of life portion,
10:26but also includes all of these therapies
10:28that are geared at relieving suffering or
10:30improving quality of life along the way.
10:32Palliative care is the other part of
10:34it's really important to understand is
10:36that there's primary palliative care
10:37and specialty level palliative care.
10:39And so everyone who's on this call
10:41already does some primary palliative care.
10:44That is the the basic how do
10:46you deliver bad news,
10:47how do you have a serious conversation,
10:50how, what symptoms are you controlling?
10:52And so whether or not you referred
10:53this patient to specialty level
10:55palliative care initially,
10:57I'm not sure that I would introduce
10:58it in this particular conversation.
11:00If it came up, I certainly would,
11:02but and I would have that explanation that
11:04palliative care is an extra layer of support,
11:05but I wouldn't necessarily introduce
11:06it as the first thing on my mind.
11:08The second model that I think is important
11:10to understand is this other model,
11:12which is the bow tie model.
11:14This one came out in about 2014
11:16and it's one of my favorite models
11:18because it shows it's the same
11:20diagram but it shows how they overlap.
11:22And whether you look at it from
11:23a disease manager perspective or
11:25a palliative care perspective,
11:26you see that palliative care is
11:28much more than just Hospice.
11:29So in fact palliative care can be
11:31done even when patients are expected
11:34to get better.
11:35This this talk is obviously focused
11:37about patients with oncology,
11:38but we do palliative care in all settings.
11:40So we do palliative care for other disease
11:42serious illnesses and even include.
11:44Trauma, burn, etcetera, in which patients
11:46are definitely expected to get better.
11:48So it's someone who has a serious
11:51illness but not necessarily terminal
11:53illness and needs additional symptom
11:57management communication and goals of
12:00care decision making along that process.
12:02Can we go to that, my next slide,
12:04oh, oh, sorry, let me go back,
12:08let me go back to that one.
12:09The the communication phrases I'm going to.
12:12I think what I would focus on
12:14for this particular patient would
12:15be setting the stage for her to
12:17focus on specifically next steps.
12:18So one would be addressing the emotions
12:22and empathy and then helping her focus
12:24on truly what are the next steps that she
12:27wants to know about and how would she
12:29focus specifically on just the next steps.
12:31For the moment,
12:32I think my communication pros will come
12:34in after the next part of this case.
12:36So I'll I'll talk about that then.
12:41So we're going to continue the case.
12:43The patient afterwards underwent
12:45lumpectomy with lymph node dissection.
12:48She had 12 or 14 Sentinel notes
12:51positive for metastatic disease.
12:54About four months later,
12:56the patient really begins to decline.
12:59The work up at that time included a
13:01pet CT that showed avid mediastinal
13:04bilateral hilar and left internal
13:06mammary lymph nodes that were
13:09highly suspicious for metastasis,
13:11avid multifocal liver and osseous metastasis,
13:14lytic metastasis involving
13:16the right occipital condyle.
13:18Her daughters at this point are
13:20with her in the appointment,
13:21and I've heard that even with Mets,
13:24some patients can be cured.
13:27Her declining functional status is noted.
13:30She has by this point been spending more
13:33than half her time in bed during the day.
13:37So the question that we have is
13:39how do you transition her goals of
13:42her goals of care at this juncture?
13:45And I think Doctor Edwards is going
13:47to talk a little bit more about that.
13:50So if we could go to, yeah, so,
13:51so this is the slide that I'll walk
13:53through some of the communication
13:55tools and some of these would have
13:56been appropriate even in the first
13:58conversation that I had with this patient.
14:00So that's really important to recognize.
14:03You may have seen some of
14:05these tools already there.
14:06While we do think of them
14:08as palliative care tools,
14:08they're really just communication tools
14:10and some of them you will have seen
14:12in other forms that do communication.
14:14So whether it's leadership
14:15training or education or patient
14:18standard relation communication,
14:19you may have seen similar
14:21phrases that are used.
14:23So I'm going to go through each one of these.
14:24Some of these are what the I wish statements,
14:29I'm sorry the the slide I think got.
14:31Change. So the first one is
14:32actually supposed to read, ask,
14:33tell, ask and then the second
14:35one is I wish statement.
14:37So bear with me.
14:37It's not important for the slide but it does,
14:39it does matter in terms of the the terms.
14:41So ask, tell,
14:41ask is a way we think of
14:43structuring the conversation.
14:44So actually if you go back to
14:46that first conversation with the
14:47patient what you when you ask,
14:49you ask what they know and
14:51what they want to know.
14:52You wait for their answers and
14:54then what based on what they say
14:56then you tell them what they've
14:58asked and what the clinical update
14:59is and then you ask again.
15:01What have they heard so that you make
15:03sure that you have explained it well?
15:06What questions do they have and
15:08what else do they want to know?
15:11And the reason to do it in this
15:13structure is it really helps pace the
15:15conversation for what somebody can absorb,
15:17especially when they're overwhelmed
15:19with emotion in a first encounter.
15:21So if you think about that very
15:23first encounter when you met her,
15:24to help her focus on those next steps,
15:27I would have used an ask,
15:28tell,
15:28ask strategy to get through
15:31that conversation.
15:31The other comments tell me more is a
15:34good one to use when you're not sure
15:37what someone is saying or what you're
15:39there said something but you want
15:40to explore a little bit more what's
15:42behind the statement or the question.
15:44So simply tell me more
15:47and then the the next one.
15:48That should be an I wish statement
15:51or an I worry those two things
15:53I wish and then I worry we use
15:56I wish statements there to say.
15:58When someone is expressing something that
16:00you don't think is realistically possible.
16:02So an example would be I wish that
16:04we were going to be able to cure
16:07this cancer with more chemotherapy,
16:09and I'm worried that that may not be
16:12possible given your functional status.
16:15The When you combine them that way,
16:17it does two things.
16:18One is it,
16:19it reinforces the reality of what's there.
16:22It also with the I wish it
16:24aligns you with
16:25that person. And so it's really is empathy
16:28building and relationship building.
16:29The I worry part of it allows
16:32you to introduce some of the
16:33concerns that might come up.
16:35It'll like again allows you to
16:37empathize and to align yourself
16:38with that person and it allows you
16:41to introduce a little bit of the
16:43humanity of you as the clinician
16:44interacting with that patient as well.
16:48The next one here is we're
16:49in a different place.
16:50This comes from vital top training.
16:52I know Liz will certainly recognize that one,
16:55and that's.
16:56But this patient in particular,
16:57she may have wanted curative intent.
17:00You may have had suspicions that that might
17:01not have been possible in the first time,
17:03but it wasn't entirely clear.
17:05But then to say,
17:06I know we started chemotherapy
17:07or I know we wanted chemotherapy,
17:09we're in a different place
17:11now than when we first met.
17:13Let's talk about how we can
17:15still meet your goals here.
17:16It's a way to signpost that we're
17:18going to be transitioning to a
17:20different plan than we had before
17:22in terms of exploring goals.
17:23So when you do signpost,
17:25then we're we can transition.
17:26So what are you hoping for?
17:27Now that you've gone through some of that?
17:29Here's where we are.
17:31This is what's realistic.
17:32I like to ask what are you hoping for?
17:34It gives an understanding of
17:35what their values are.
17:36If time were short,
17:38I use were in this case because sometimes.
17:42Well,
17:42actually almost always planning for
17:44the future and putting some distance
17:46between you and the future is actually
17:48much easier for patients to to do.
17:50So if if you were to get sicker,
17:53can we talk about what you would want?
17:55It's often psychologically easier
17:56to discuss than if you do get
17:59sicker or when you get sicker.
18:01So that's a little bit of a a nuance there.
18:03And then the comment of what else
18:05are you hoping for can be useful
18:07in terms of when somebody says,
18:08well, I'm hoping to get better.
18:10Well, I I'm hoping for that too.
18:12And I'm worried if that doesn't happen,
18:15is there something else that you're
18:16hoping for that we can aim for?
18:18Again,
18:18it just softly redirects them to
18:20something that might be able to be achieved,
18:22rather than perhaps something
18:23that's not realistic for them.
18:25One of the other key things that
18:26we use is silence, obviously,
18:28to allow people to express their emotions,
18:31gather their thoughts.
18:32Most people on the giving end of information,
18:36so clinicians feel much more
18:37uncomfortable with the silence than
18:39the person on the receiving end.
18:40They're just trying to get their heads
18:42around whatever news has been delivered.
18:44And so if you wait,
18:46they will usually offer what
18:47they need to say next.
18:48And then finally,
18:49if it goes on and on,
18:51you can certainly ask can you
18:52tell me what you're thinking?
18:54And that will prompt them to to
18:56discuss what's on their mind.
18:57Lastly, there is a pneumonic to help
19:00reinforce those empathic statements.
19:02So nurse emotions,
19:03which is stands for you, name the emotion.
19:05It it sounds like you're very frustrated
19:08or it sounds like you're very sad.
19:10Understand. Can you tell me a little
19:12bit more about what's helping?
19:13What's making you feel sad right now?
19:16I respect.
19:16So respect is we respect the journey,
19:19respect that personhood.
19:20I can understand how you might
19:22feel sad in the circumstances.
19:24I would certainly feel sad too.
19:27The support piece is really important
19:29for aligning yourself with that person
19:32for the duration of their care.
19:34I am going to be here and walk you
19:36through every step and then lastly
19:38is explore what else is making you
19:40sad or what would support you so.
19:42So that's just a little snippet of how
19:44to address emotions in an encounter.
19:47Lastly,
19:47I just wanted to leave some tools
19:48that we have within our system.
19:50So within Epic itself there are two
19:52places where you can find some advanced
19:54care planning pathway tools that
19:56can help guide these conversations.
19:58So one is the advanced care planning pathway,
20:01unfortunately it is only for inpatient
20:02right now, but it does exist.
20:04And then the other is advanced care
20:06planning tools where there is a
20:07serious illness guide conversation,
20:09it is literally you can you can
20:11print it out and while that sounds.
20:15Scripted if you say, you know,
20:17I'm just going to keep these questions
20:19here because I want to make sure I
20:21cover the important things for you
20:22many times that is actually very well
20:24received by patients and families.
20:25And then lastly if you additional
20:27training on how to have some of these
20:29conversations would be through catsy
20:30vital talk and then the serious illness
20:32conversation which is the last one there.
20:34So I think for this individual
20:36going back to the case,
20:37can we flip back one more slide backwards?
20:41So the how would I transition her from
20:43goals of care, from cure to treatment
20:45would really be that conversation.
20:46What's important to you?
20:47I do see your your functional
20:49status is declined.
20:50I'm worried that we're not going to be
20:51able to get more chemotherapy at this time.
20:54What would be important to you?
20:56And then I would go, I'm
20:59going to pass on to that.
21:03Okay, so now we're on Case 2.
21:08So case two is a 47 year old female with
21:11a gist tumor metastatic to the liver,
21:14treated with SUTININIB,
21:16seeks advice for fatigue,
21:18abdominal pain, sores in the mouth,
21:20nausea and insomnia.
21:22Her dose was actually recently increased
21:25and she does not think this is going well.
21:29Her gist tumor was first
21:31diagnosed five years ago.
21:33At that time she underwent
21:35surgery with splenectomy.
21:36Initially she was treated with imatinib
21:39and then transitioned to sunitinib
21:4150 milligrams due to recurrence.
21:47She's having the abdominal pain every day
21:50and she wants to avoid opiate medications.
21:53She has nausea daily.
21:55She has trouble eating and
21:57has lost about £10 so far.
21:59She has a sore in her mouth which
22:02is bothering her greatly and also
22:04prevents her from eating.
22:06Overall, she's feeling stressed,
22:09tired, and she can't sleep.
22:12So the questions are,
22:14how can palliative care help
22:16us manage her symptoms?
22:18How does prognosis factor
22:20into this discussion?
22:22Remember, she does have
22:23metastatic disease to the liver.
22:26And what is the role of
22:28primary care here now?
22:30She's been stable for a long time,
22:32even with the metastatic disease.
22:35So I'd like to go to my colleague and
22:43thank you Doctor Brzezinski.
22:44Actually you can go back the
22:45previous slide and we can tackle
22:47some of these questions though.
22:49So this is an example of a patient who is is
22:51not in the beginning of her cancer journey.
22:52She's been diagnosed and has been undergoing
22:55treatment for many years at this point,
22:57but is experiencing a lot of side effects
23:01and disease related issues at this point and.
23:05This is a typical patient we would
23:07kind of see in the outpatient
23:09pitive care arena before coming
23:11to you on the Haven health system.
23:12I was at Duke as the medical director
23:15outpatient pitive care and so many
23:17patients in the Duke Cancer Center that
23:19were actively going through treatment.
23:21We weren't at end of life scenario.
23:23This was trying to help them live as best
23:25as possible and so that's the goal of
23:28Pitive cares to help improve quality of life.
23:30Regardless of where they are
23:32in their treatment trajectory.
23:33So how can palliative care help
23:36manage her symptoms?
23:36So we'd like to think that we're experts in
23:39managing symptoms related to serious illness,
23:42in this case cancer we.
23:45Kind of are the ones that assess
23:48them frequently in our visits.
23:50We have some assessment tools like
23:52the Edmonton Symptom Assessment Scale,
23:54which just has 8 to 10 different
23:56questions about do you have fatigue,
23:59do you have pain, are you sleeping,
24:01are you anxious, are you nervous,
24:03are you depressed?
24:04So,
24:05so it's a regular thing that we assess
24:08for when we have patient encounters
24:11and not uncommon pain and fatigue
24:12are the most common symptoms that
24:14we find for patients with cancer.
24:16So we deal with it quite frequently.
24:20So one is just assessing how severe
24:22are the symptoms.
24:23Is it just mild and a mild nuisance to
24:26her or is this something that really
24:29is moderate to severe and so it's
24:32just trying to figure out where they're at.
24:33And those are through basic questions
24:35that we're all taught through
24:37our medical training, so.
24:39When we are taking care of patients,
24:42we will frequently see them.
24:43It may be every week depending upon the
24:46severity and if we're titrating medicine,
24:48sometimes it's every couple of weeks,
24:50but for more stable people is usually
24:52once every month they would come
24:54and visit us and we would assess
24:56change medications,
24:57change treatments and then go from there, so.
25:00So we certainly could help
25:03this patient manage her pain.
25:05She has a preference for not
25:07using opioid medication.
25:08I often say that when we're
25:10managing symptoms,
25:10it's best to use non
25:12pharmacologic therapies first.
25:14So that might include psychological support
25:17through cognitive behavioral therapy.
25:19It might include sort of alternative
25:22therapies like acupuncture,
25:24meditation, things of that nature.
25:26Certainly we could use pharmacological
25:29medications that don't use
25:31opioids right up front.
25:32Sometimes we can use adjuvant
25:34medicine such as gabapentin or other.
25:38You know, nonopen medications.
25:39But when it does get moderate
25:41and severe and it's not being
25:43controlled with the current
25:44regimen, then sometimes quite frequently
25:46we have to escalate into the stronger
25:49pain medicines and that it's really
25:51weighing the benefits and burdens of it.
25:53But hopefully our role is to help
25:55support the patient through that
25:57process so that they are aware,
25:58they know what they're getting into,
26:00where they're to monitor them closely.
26:03Nausea is certainly another chemo related
26:07immune related disease side effect.
26:10And so one other thing I'd like to say is
26:13that sometimes we like to pull things out
26:16of our sleeves like with fatigue certainly.
26:19Most commonly, we recommend exercise.
26:22Sometimes we're talking about
26:24energy conservation techniques,
26:25but sometimes we pull out medicines that
26:27most others don't think about or don't use,
26:29such as methylphenidate.
26:31Sometimes for severe cases,
26:33we'll use those kind of medications and
26:35it's not something that many providers
26:38will know how the expertise and how to use.
26:41Moving to the second question,
26:42how does prognosis factor into
26:45the discussion?
26:45It's a very good question as hopefully we
26:49follow these people through their journey,
26:51we will get a sense of what they're
26:54likely prognosis is.
26:55Certainly there are therapies that
26:57we wouldn't recommend if it was
26:59a long prognosis of many years.
27:01Certainly steroids we use for
27:03pain management as an adjuvant,
27:05but we don't want to put people on
27:07steroids for several months to years
27:09knowing the side effects of that.
27:12There's certain things that we wouldn't
27:14recommend if prognosis is short,
27:16things like total parental nutrition
27:18for help with nutritional support.
27:21If the prognosis is less than three months,
27:23the literature would generally
27:24not support that.
27:25So it definitely plays a factor into
27:28what is going to provide the most benefit
27:31and minimize the burdens in those situations.
27:34So and we we get that through
27:36following the patient,
27:37we also get it through frequent
27:40conversations with the oncologists.
27:41The goal is to work side by side with them
27:44and that's how my experience has been.
27:46And so it's a dialogue back and forth as
27:48to how are they doing on their regimen,
27:50are they progressing,
27:51are they improving,
27:52are they changing treatments?
27:54What does that mean for the patient?
27:56So it's a close collaboration to get
27:59a sense of what that prognosis is.
28:00Certainly prognosis can be talked
28:02about at length in another venue,
28:05but it's important for patients
28:07to know that sometimes for life
28:10planning and other things.
28:11Moving to the last question,
28:13what is the role of primary
28:15care in the care team here?
28:17As mentioned,
28:17I'm trained in geriatric medicine,
28:19Hospice and palliative medicine.
28:20And in those two disciplines
28:22it's very much a team sport.
28:24I know that I can't provide the care myself.
28:27It takes, you know,
28:28our social workers, our therapists,
28:30our nurses, our other volunteers.
28:33And so primary care is a very important
28:36part of that team collaboration.
28:39It also depends on the scenario.
28:40I I've seen patients where they
28:42just started with a new primary care
28:44physician and don't know them very well,
28:46don't you know,
28:47haven't had many interactions.
28:48So there's not a lot of trust build up yet.
28:51But then certainly there's patients
28:53who've been followed by their primary
28:54care physician for several years
28:56and they completely trust them.
28:57So it's good for us to know those
28:59things because we can go back to their
29:02primary care physicians and try to
29:04include them in the care and sort of
29:06again have a dialogue back and forth.
29:08A lot of times patients when
29:10they're getting cancer care,
29:11just want to know who do I call
29:13when I have a problem, you know,
29:16as opposed to just going to
29:17the emergency department.
29:18They want to have somebody at the at
29:20the ready on the phone and we kind
29:22of try to help sort that out with
29:24them and who's responsible for what.
29:26So including primary care is certainly
29:28an important part of that next slide so.
29:33And I was asked to talk about a
29:36few things related to this case
29:38and that the case is presented one
29:41about Pine to care triggers.
29:42When do you want to get
29:44pine of care involved?
29:45Sometimes it's readily apparent
29:47and sometimes not so much.
29:48So this is just a list of some criteria.
29:52Certainly there's many different lists
29:54in the literature about criteria,
29:56but quite often we're thinking
29:57of people that have life limiting
30:00or life threatening illnesses,
30:01what we call a serious illness.
30:03There's primary criteria,
30:05secondary criteria,
30:06and this was published by Dr.
30:07David Weissman and his colleague Dr.
30:10Diane Meyer several years ago.
30:12But we also talk in the π to Care
30:14World about the surprise question,
30:16and that is,
30:17when looking at a patient in any venue,
30:20would you be surprised that this
30:22patient died within the next 12 months?
30:25And it's used for research purposes
30:27and just an easy question to gauge
30:30whether somebody would potentially
30:32benefit from palliative care.
30:34Palliative care is more focused on
30:36needs and not necessarily prognosis,
30:38but it's a it's an entry question
30:40to figuring out the trigger.
30:42Certainly people are coming to
30:44the hospital frequently if they've
30:46had a severe decline in function,
30:48unintended decline in weight.
30:50Secondary criteria include things
30:52such as an elderly patient,
30:54metastatic or locally advanced cancer,
30:58cardiac arrest. So it goes on and on.
31:01And so they exist out there.
31:03We in the hospital here have a
31:05resource card which we carry around
31:07and it has a number of questions.
31:09Or triggers both in the Ed and
31:11also in the ICU.
31:12So.
31:13So we have tools in the system that
31:15can help people understand when they
31:17might want to get pit of care involved.
31:20I was also asked to talk about sort
31:21of the pit of care stigma and I I
31:23leave a quote from my mentor and
31:25national leader and pit of care, Dr.
31:26Diane Meyer out of Mount Sinai.
31:28And she told me early on when I was a
31:30fellow that if you're trying to sell death,
31:33no one is going to buy.
31:35And I think frequently my
31:36colleagues and I run into patients,
31:38run into staff who, you know,
31:41we hear the words patient is not ready
31:44for palliative care and that is a barrier.
31:46If they're not ready for palliative
31:48care or don't want palliative care,
31:50then we're not allowed to
31:52be involved in their care.
31:53And so it's trying to highlight the
31:58positive things about palliative care.
32:00You know, palliative care is there
32:02to help improve quality of life.
32:04And that's the focus talking about Hospice,
32:08talking about stopping treatments,
32:10talking about death is certainly
32:12very charged and very powerful
32:14and patients don't readily.
32:16Embrace that and that is often a barrier
32:19to getting high to care involved.
32:21So, so this is a what I call a Diane
32:23Meyerism that sticks in my head and
32:25it's always to try to highlight the
32:27positive things that high to care does.
32:30We certainly do help manage
32:31with end of life situations,
32:33but we don't sort of bill
32:35ourselves as that next slide.
32:39Another part of support for patients
32:41and especially the Cancer Center
32:43is about advanced care planning.
32:45Most patients and families don't know
32:48exactly what advanced care planning is,
32:50but really the goal of it in our
32:53daytoday conversations is to enhance
32:55patient and family education about
32:57their illness about likely prognosis.
33:00Outcomes of alternative care plans,
33:02we hear what treatments they're on.
33:04We gauge how well they're
33:05doing with those treatments.
33:06We kind of want to know what other things
33:09might be available if it doesn't work.
33:11So we take the time to talk to patients and
33:13families about all those different things.
33:16Certainly, we wanted to find key priorities
33:18in the end of life care and develop a
33:20care plan that addresses these issues.
33:22A lot of those conversations is something
33:24that Kristen already brought up and we
33:26use those tools in these conversations.
33:28And also to help shape future
33:29clinical care to the fit the patient's
33:32preferences and values, you know,
33:33do they want to go to the emergency room?
33:35If they should get sick,
33:36would they want to be transferred
33:38to the intensive care unit?
33:39Would they want to be resuscitated?
33:41These are all conversations that
33:42we have every day in the hospital.
33:44And if we can move some of these
33:47conversations into the nonemergent setting,
33:48into the primary care office or to
33:51the Cancer Center visit, you know,
33:53it's a better conversation in that sense.
33:56There are certainly documents in
33:58Connecticut that help with these things.
34:01Most recommended I would say is the
34:03healthcare representative form.
34:04If a patient lacks capacity to
34:06make decisions in the hospital,
34:07the providers are going to be
34:09looking for somebody that can
34:10make decisions for that person.
34:11And we want the patient to maintain
34:13control as much as possible.
34:15And so through this document they
34:17can designate who they trust to
34:19make medical decisions for them.
34:20Living Will is sort of another
34:23document that exists.
34:24It's.
34:27Not the greatest tool in my sense,
34:29but certainly helps with
34:31promoting the conversation.
34:32And then the last document is the
34:35medical orders for life sustaining
34:36treatment which is exists in Connecticut.
34:39We do have conversations
34:40but it's not most common.
34:42I'd say the healthcare representative
34:44conversation is the most common that we have.
34:47The next picture on the slide
34:49is just go back one is just
34:52how for all of our encounters,
34:54all of our patients,
34:55we always keep them in the
34:57center when we work as a team.
34:58We're all working around the patient.
35:00And so certainly primary
35:02care is part of those,
35:03one of those surrounding circles
35:05along with physicians and others.
35:07So it's just again A-Team sport and we
35:10just need to communicate with each other.
35:12Next slide.
35:15This is the last slide I have.
35:17It's just some common things that
35:19we are concerned about when we
35:22engage with patients and families,
35:24we sort of look at, you know,
35:27suffering as a total, total pain scenario.
35:31You know, what are they suffering from?
35:33Is it physiologic, is it social,
35:35is it spiritual, is it emotional?
35:37So questions that we have are
35:40are there distressing symptoms?
35:41Is there significant social concerns,
35:44spiritual concerns affecting
35:45their daily life?
35:47Does a patient,
35:48family surrogate understand
35:50the current illness?
35:51There's many a times when I speak to
35:53patients who have incurable disease,
35:55but they still think that it is
35:58curable and we do have to help
36:00with those conversations to help
36:02transition the goals at that point.
36:05We also asked what are their goals,
36:07what treatment options they prefer?
36:10Have they completed advanced care
36:12planning documents or conversations?
36:14And then lastly,
36:15what are the key considerations for
36:16a safe and sustainable transition
36:18from one setting to another?
36:19Certainly,
36:20we see patients that come back and
36:22forth from home to the hospital
36:24or hospital to nursing home,
36:25nursing home back to the hospital.
36:27And so we are familiar with a
36:29lot of transitions and we try to
36:31help support it as best we can.
36:33And I think that is it.
36:41Okay. So this is our last case.
36:44It is a 65 year old female with
36:47metastatic lung cancer who presents as
36:49a new patient due to a recent move.
36:52She is there with her niece
36:54who is her caregiver.
36:56She is being managed by a new oncologist and
36:58is not responding to the current regimen.
37:01She is on causing great distress to her.
37:04The patient had to move in with her niece
37:06as she lost her house due to mounting
37:09medical bills and inability to work.
37:11The patient herself has no children.
37:14She needs help with toileting,
37:15dressing meals and ambulates only with a
37:18Walker for short distances in your office.
37:21She is in a wheelchair.
37:25The niece has bags under her
37:27eyes and she looks very upset
37:29throughout the entire encounter.
37:31You ask her what is the
37:33matter and she begins to cry.
37:35The niece tells you she is under
37:37a lot of stress, taking care of
37:39her aunt and working full time.
37:41She feels like she is working two jobs.
37:44She is not taking care of her own.
37:46Diabetes and her blood sugars have
37:48been in the three hundreds recently.
37:51This is clearly an argument
37:53the Paris had in the past.
37:55The patient states she does not want
37:58anyone else in the House because she
38:00would not trust them and she's far
38:02too young to go to an old folks home.
38:05Also she says she has no money and if
38:08her niece does not take care of her,
38:10she will be out on the street.
38:13So this is a very difficult situation.
38:15So how can you take care of the
38:18patient and help the niece as well?
38:21And how can palliative care
38:23help you in this scenario?
38:26So I'm going to turn over to my colleague.
38:36Liz, you're on mute.
38:43I am so sorry about that.
38:44I was trying to make sure you
38:46didn't hear my kids screaming in
38:47the background, and here we are.
38:49So I'm Liz persichen.
38:50Thank you so much for giving me the
38:52opportunity to speak here today.
38:53I think what struck me most about that
38:55last slide is the comment that the niece
38:57felt that she was working two jobs.
38:59And I want to take a moment to
39:01acknowledge the significant
39:02caregiving burden that so many of our
39:04patients and their families face.
39:06And I know that many of you in the
39:08primary care field have seen your own
39:09patients be caregivers and seeing the
39:11significant caregiving burden that
39:13many of your patients require for care.
39:15And I think one thing just to step
39:17back is to define palliative care.
39:19And palliative care is really a
39:22team based interdisciplinary means
39:23to support patients facing serious
39:25illness as well as their caregivers
39:28and addressing the caregiver distress
39:29and the caregiver needs is an
39:31important part of what we do as well.
39:33So the niece is working two jobs.
39:36She's a caregiver.
39:38And our team offers a true
39:40interdisciplinary mechanism to
39:42support patients and families that
39:44are facing serious illness together.
39:46And what I wanted to highlight
39:48here is really the amazing team
39:50that we have both within SMILO and
39:52in the palliative care programs
39:54throughout the only Haven hospital,
39:56the only Haven health system.
39:58And I was going to talk through
39:59them one by one.
40:00So many times people think you know.
40:03Patient is very sick.
40:04They need certain resources.
40:06Let's send a referral to palliative
40:07care and what exactly does that mean?
40:09What do you get with a palliative
40:10care referral?
40:11What do you get with a palliative
40:13care consultation?
40:14And I,
40:14I want to make sure folks know that
40:16consultations are available in the
40:17inpatient setting for patients with all
40:19diagnoses and in the outpatient setting.
40:21Our current availability is really
40:23only for the patient population with
40:26cancer and that is a big limitation,
40:28I understand,
40:30but.
40:31We are working on that in the
40:32background today,
40:33we're going to talk about resources
40:35for patients with cancer.
40:36So when you do place a palliative
40:38care consultation or referral,
40:39you're getting an entire interdisciplinary
40:42team that's working together
40:44with expertise for supporting
40:46patients facing serious illness.
40:48We have a team of physicians,
40:50nurse practitioners.
40:52Social work chaplains,
40:54bereavement care as well as
40:56ancillary services within and
40:58without our palliative care program,
40:59including medical, legal support,
41:01psycho oncology,
41:03integrative medicine and also
41:05relationships with Hospice caregivers.
41:07So our social work groups offer
41:09individual and group programs including
41:11both bereavement and grief support groups,
41:13not just for patients but
41:15also their caregivers.
41:16So a mechanism to connect
41:19with other caregivers,
41:20connect with other people who are
41:21facing loss or serious illness.
41:23Whether you are the patient or whether you
41:25are the caregiver is really important.
41:28Our spiritual care chaplains are
41:30available both inpatient and outpatient.
41:32They help with Valuebased resources,
41:36spiritual resources,
41:37support for existential concerns,
41:39and also help complete some of
41:41the advanced care planning that.
41:43That Morgan had discussed earlier,
41:46our palliative care chaplain at Yale
41:47is actually one of 20 palliative care
41:50certified chaplains in the country,
41:51which he's really proud of.
41:53So really a dedicated and
41:56focused response there.
41:57Our Psycho Oncology team has
41:59support for resilience building,
42:01emotional support skills,
42:02CBT as well as expressive therapy
42:05and art therapy and we contract
42:07with the art therapist who is
42:09part of our services as well.
42:11And then we have a very well structured
42:14bereavement group as well for both
42:15telephone outreach in real time,
42:17monthly bereavement seminar support
42:19groups and also support around
42:21times of holidays and memorials
42:23for patients and families.
42:24So this is all clearly kind of.
42:27Some of this is at end of
42:28life and post end of life,
42:30but available for patients and caregivers
42:32throughout the disease process.
42:34And of course we have our physician
42:37and APP colleagues who work with
42:39primarily symptom management and
42:41also navigating these difficult
42:43conversations for goals of care,
42:45medical decision making, et cetera.
42:48So when you reach out for
42:49a palliative care consult,
42:50you're getting all of
42:51these different services.
42:52I did want to speak briefly about
42:54the medical legal support system.
42:55So within Yale we have a relationship
42:57with Yale Law School and they have a
43:00pro bono program for medical legal
43:02support for patients that are in need,
43:05whether that be related
43:06to financial constraints,
43:07social constraints or health related issues,
43:10so.
43:11Guardianship Wills financial complex
43:12situations that need to be dealt
43:15with in a time sensitive manner,
43:17whether that be in the hospital,
43:19in the patient's home, etcetera.
43:21We've helped navigate guardianship
43:22instant for instance for patients
43:25that are facing serious illness
43:26that have either minor children
43:28or dependent adult children,
43:30where times of the essence and
43:32these are very important things,
43:33not just logistically but also
43:35in terms of bringing peace and
43:38a sense of closure to families,
43:39knowing that their loved ones
43:40will be cared for and.
43:41Things that are important to
43:43them that they value are done.
43:46We also work with our integrative
43:48medicine colleagues who have both
43:50inpatient and outpatient services.
43:52For patients that are within the smilo
43:54system, they offer massage therapy,
43:58Reiki,
43:58aromatherapy as well to patients
43:59in and out of the hospital,
44:01which is a huge support.
44:04And then also we work closely with Hospice.
44:06So if there's any questions about
44:09the Hospice referral program
44:10resources in the community,
44:12we're not a Hospice agency.
44:13Of course, a lot of times people can
44:15found Hospice and highlighted care,
44:17but we can certainly help navigate
44:19what that system is,
44:21inform,
44:22educate and also be a bridge if
44:24and when Hospice is appropriate
44:27for patients and families, so.
44:30You know,
44:31I think we have a lot to offer
44:33besides symptom management and
44:34goals of care and a lot to offer
44:36throughout the trajectory of
44:37a patient's serious illness.
44:39I think that alludes to Kristen slides.
44:41You know from the time of diagnosis
44:43whether the intent is curative or whether
44:45this is a lifelong illness or some an
44:48illness of the very short prognosis,
44:50palliative care has a lot to offer in
44:51terms of improving quality of life,
44:53not just for patients but
44:55also for their caregivers.
44:56And I think we all recognize the enormous.
44:59Financial, social,
45:00psychological and medical challenges that
45:04so many people face with serious illness.
45:07I think I answered all the questions
45:09that I was hoping to get to.
45:11I'm really looking forward to Q&amp;A.
45:12I hope, I hope this has been a
45:16helpful presentation and I look
45:17forward to discussing more with
45:19our audience and other panelists.
45:23Thank you so much. That was.
45:26Really great with a lot of very practical
45:29pearls in addition to kind of a nice
45:32theoretical concept of palliative care.
45:35I I love the specialty versus
45:38nonspecialty palliative care because
45:40I think in primary care we are
45:42doing palliative care all the time.
45:44And so it's it's nice to hear that,
45:46kind of recognize it and realize that
45:48some of the same tools you use are things
45:51we can apply across broader diagnosis.
45:56I think just a couple of housekeeping
45:58things is there will be a survey at
45:59the end and that's how you get the CME.
46:02Doctor Chang just posted that and
46:05we do have our upcoming talks.
46:08In the meantime,
46:09I want to make sure that we open
46:11up for questions.
46:13We've had some really,
46:14we have good attendance and I'm interested
46:17to hear questions that people have.
46:20And Ola,
46:20I don't know if you have any questions,
46:22additional questions on the cases
46:24that you presented before we
46:26move to those who are watching.
46:32I guess my just my one question is
46:35actually in terms of the medical
46:37orders for life sustaining treatment,
46:39I feel like that is a very useful
46:42tool and I'm wondering how we
46:44can get that in Connecticut.
46:48So the Department of Health actually
46:50will send them to you for free.
46:53That's how we get it here
46:56in Greenwich Hospital.
46:58It differs from state to state.
46:59It's based upon the.
47:01What was originally the pulsed
47:02paradigm out of Oregon?
47:04The physician orders for
47:05license taking treatment.
47:07My years in North Carolina.
47:08The document was what we called Pulsar Pink,
47:10very bright pink.
47:11Here in Connecticut,
47:12it's more of a neon green,
47:14so it was intended to stand
47:16out in a written chart,
47:19but we don't have written charts anymore.
47:21Some of my colleagues,
47:22it may not be just the
47:24completion of the document,
47:25but it serves as sort of a
47:27template for conversation.
47:29Yeah. And my understanding is
47:31that because it has to be green,
47:33it's not as easy to scan in.
47:35So the patient has to carry
47:37around the green form.
47:38But certainly having things well
47:40documented in the chart and whether
47:42we do it from inpatient or outpatient,
47:45these advanced care planning
47:46has a huge free text section.
47:48So I hope that you guys look at that
47:52when we do that from primary care
47:54for bidirectional communication.
47:58I'll just add a question as well
48:01while we wait for some in the
48:03audience to come up with some.
48:04So and we're getting that diagram
48:06that you gave which had that kind of
48:08circle and then all the caregivers
48:10around the patient and their family.
48:12Sometimes I feel like, you know,
48:14Smilo has such complete services
48:16that in primary care we're a little
48:18bit like in outer space around that,
48:20maybe not outer space,
48:21but in a different room.
48:22We're all on the same chart, right?
48:24But at the same time,
48:27sometimes that communication would be hard.
48:29Is it possible to initiate a palliative care,
48:33consult yet palliative care advice
48:37or or interact?
48:38What's the best way to kind
48:40of interact with you guys?
48:44Very good question.
48:46So different avenues.
48:47We all have main office numbers if
48:50people want to call and hopefully we
48:52can provide that to the audience.
48:55Epic, certainly there is messaging
48:57capability from provider to provider,
49:00so that could be another platform.
49:03And those are the the typical
49:05ways I communicate when I see
49:07a patient and write a note,
49:08I CC their primary care physician so
49:10that hopefully they get to see the
49:12notes as well and are up to speed
49:14with what changes may have been done.
49:18And then let's move.
49:20We do have a question that came in
49:23and and the question was,
49:25is it possible to introduce
49:28palliative care too late?
49:31And I think, Liz,
49:32you had answered that a little
49:33in writing, if you want to.
49:34Yeah, I I wanted to answer that.
49:36And you know, I, I do inpatient palliative
49:38care and a lot of oncology and and
49:40oftentimes like our consoles do come too,
49:42too late by some traditional metrics.
49:45I would argue to say that it's never too
49:47late to introduce palliative care, however.
49:50I think sometimes we're involved
49:52very short periods of time,
49:53but have an enormous impact on the patient,
49:56on the family, on bereavement for the
50:00caregivers and for a sense of closure and
50:02sometimes the most helpful support we give,
50:04just making sure I'm not muted is when we
50:07can help support those with complicated
50:09bereavement needs after a patient's death,
50:11let's say, you know,
50:12the illness was very brief and there was
50:14a very difficult short hospitalization.
50:16There's a lot of.
50:17Sense of regret or uncertainty or, you know,
50:20lack of closure for the family member.
50:22Our social workers will contact them
50:25and have bereavement support groups,
50:27one-on-one, counseling,
50:28telephone outreach,
50:28in addition to whatever other support
50:31services they may have access either
50:32through Hospice or other places.
50:34And that is a really important
50:35resource for many people.
50:37So I would argue it's never ever too
50:39late to introduce palliative care,
50:42ever.
50:43I'm so glad Liz asked that or answered that.
50:46I wanted to to piggyback on top
50:48of that because that was the other
50:49thing that I wanted to mention is
50:51the bereavements of part the other.
50:52The other thing, there's actually
50:54a study, and I'm sorry,
50:55I don't know the authors at the moment,
50:57but there was a study that
50:58looked at patients,
50:59families of patients who had died
51:01and asked them how they felt about
51:04when palliative care was introduced.
51:06And most of the researchers thought
51:08that they would be too late.
51:10And no matter when in the disease trajectory,
51:13palliative care was introduced,
51:14the family thought it was the right time.
51:16Which whether that's a psychological
51:18confirmation bias or what,
51:20it's just interesting to me that
51:22almost always families are just
51:23grateful for when it's offered.
51:25And and the one thing I will add is
51:27going back to that very first case.
51:29How early can you introduce palliative care?
51:31So, so that my one question was
51:33as as I was thinking that as this
51:35was coming up it it is possible
51:37to introduce it right early on.
51:38I wouldn't have referred that patient
51:41to palliative care at the time of
51:43diagnosis if it wasn't mastatic
51:45and she didn't have symptoms.
51:46But if it was either metastatic or she
51:49had symptoms needing to be controlled,
51:52then yes,
51:53absolutely would consider referring
51:54to specialty level powdered care.
51:55And you can introduce it the way
51:57I introduce it and my guess is
51:59that my pallet care colleagues,
52:01it would be pretty similar
52:02because we have sort of a national
52:04expectation of how we stand.
52:05I say it's a, it's a specialty of medicine,
52:07it's a focus on symptoms,
52:09communication and sometimes decision making.
52:11The best way to think of it
52:12as an extra layer of support.
52:14There are other versions
52:14of that whether it's,
52:15you know,
52:16it's a team of experts who are
52:17going to help partner with me to
52:20manage your symptoms etcetera.
52:21But it's it's that whole concept
52:22of it's a team.
52:24So, so yes,
52:24absolutely could have referred it.
52:26I think that my thought in that first
52:28case is she's just getting the diagnosis,
52:30she's completely overwhelming.
52:31So you really just want to ground
52:33her in next steps and and if she
52:34weren't actively symptomatic,
52:35I'm not sure I would have referred
52:37at that point yet.
52:39If I can jump in, just give talks about
52:41what I call fishing further upstream,
52:42meaning trying to get involved
52:44earlier from the time of
52:45diagnosis for palliative cure.
52:46Because when you're introduced as
52:48just another part of the team,
52:50you're not sort of looked at as
52:52the Boogeyman or boogeywoman.
52:55That sense you, you know,
52:57I worked with the brain tumor center
52:59at Duke and it was sort of what day
53:01should we put the π to care visit
53:03on day one or day two. You know,
53:05as they're seeing the radiation oncologist,
53:07medical oncologist, surgical oncologist,
53:09it's just it was baked in into the
53:11care as that extra layer of support.
53:13And when you're caring for people earlier on,
53:16you develop relationships with them,
53:18they develop trust with you and
53:21you get to know the team and and
53:22know their their desires basically.
53:24So it's.
53:25Earlier is better but at any
53:27time we can certainly help
53:31that's terrific. I I don't,
53:34I don't see more questions coming
53:36in but I I'll just make one more
53:38comment and and that is that all,
53:40all of these words matter and I know
53:44that and you know Ola knows that
53:47because we see the families afterwards
53:50whether it's because they're also our
53:53patients or because we kind of do a.
53:55A later follow up that's I think not
53:58always but often part of primary care
54:01after a longstanding relationship.
54:03And I can't tell you how much words matter.
54:07And people will recount entire
54:09conversations that happened in those,
54:12you know, in the end of cancer care,
54:14whether it was a turning point in
54:17management to more palliative care,
54:20to Hospice care or the actual death and,
54:23you know, words that set them.
54:26Help them be comfortable with what's
54:28happening ring especially true it helps
54:31them to you know not feel guilty or
54:33not feel bad about how things went.
54:35So I think it's it's great.
54:38We have one more question that came in.
54:41Can you repeat information on training
54:43for having tough conversations.
54:45I think that was one of Kristin's slides.
54:47Yeah.
54:49Are these slides made available for
54:50people afterwards as well because they're
54:52actually links on them to the specifics.
54:55It's, yeah, it's a recording
54:57on any of the slides.
54:59Maybe I can send those to you Karen,
55:02and maybe we can send them out.
55:03But the there there are
55:04three sites, so one is cap
55:09CW w.capcapc.org. The next
55:10one is vital talk, which is W
55:21w.vitaltalk.isitorgorcapccapc.org.
55:23Vitaltalk.org I believe and then if you
55:25Google cuz the the the link was quite
55:28long the serious illness conversation
55:30would be the one that the other one.
55:33All right so
55:36and do you wanna I think
55:39you had one more comment.
55:41I I just wanted
55:42to I know this is geared towards
55:44the primary care population and they
55:46just want to highlight how important
55:48you know you Karen was saying that
55:50words matter and the words that you
55:52share the conversations you have
55:53with your patients matter more than
55:55any advanced care planning document
55:56or healthcare representative.
55:58Those are certainly important but
56:00for the patients and their loved
56:02ones to know what their wishes are
56:03what they would or would not want
56:05is so important in the earlier you
56:07have those conversations and more
56:09honestly and openly have those
56:10conversations they matter and.
56:11Been involved in the care of
56:13many patients and patient who,
56:14you know, they want to know what
56:15their PCP thinks that you know,
56:17they've seen a million specialists,
56:18they've been through the wringer,
56:19they've had every test under the
56:21sun and they want to know what Dr.
56:23Brown thinks.
56:23And so when I'm able to engage
56:25with primary care doctors,
56:27it's like speaking to an old
56:28family friend or a loved one,
56:29like getting that history and
56:31that collaboration and also
56:32the medical expertise is there.
56:34And so I really value that work and want
56:36to thank everyone who's listening for that.
56:39And also think of us if you're
56:40worried about a patient with
56:41serious illness and you want the
56:43palliative care team to do a check,
56:44you know, I'm worried about symptoms.
56:46I'm worried about.
56:46They've had a lot of financial stressors.
56:48Their loved ones are really struggling.
56:50You know,
56:50ask the team or or contact us directly.
56:52We're happy to see your patients.
56:54You know,
56:54we're here to advocate along with you,
56:57and our team
56:57rolls deep. It's not just doctors and nurses.
57:00You've got a lot of great resources
57:02to help support your patient.
57:05There is a question,
57:07let's see from the will you from an attendee,
57:11will you be able to send contact
57:13information for scheduling to
57:15those that attended night tonight?
57:17I don't know if we can put
57:19something into the chat or else.
57:22Maybe folks can repeat that for
57:26scheduling. So that's for scheduling
57:28palliative care consultation.
57:30You think maybe we need to clarify that
57:34question or is it, I think there's
57:37a different way to do it inpatient
57:39and outpatient, right folks, I mean.
57:43That that's how it kind of flows to us.
57:45It's an ambulatory referral to palliative
57:47care and it lists the different sites.
57:49So New Haven or Greenwich that is the easiest
57:52for providers through the epic system.
57:55Yeah. And it depends the,
57:57the organization is based on where
57:59their primary oncologist resides,
58:01quote UN quote. So if their primary
58:03oncologist is at York Street,
58:04then they're at main campus.
58:05If they're at North Haven or Greenwich,
58:07then that's where their palliative
58:08care services would be rendered.
58:11Yes, you can do it through epic.
58:13I do it once several times a week.
58:16We're a minute over want to thank.
58:18I mean this is such a terrific team.
58:20I'm so glad that you guys are here taking
58:22care of our patients and helping us.
58:24I've learned so much from
58:27this presentation, Chris,
58:28and I've used half of those things
58:31today when I've talked to patients.
58:33Hola, Karen, thank you.
58:35Thank you all for your input and
58:38thanks for folks for showing up.
58:40And continuing to show up.
58:42Please tell your colleagues and of course,
58:44feel free to access this online.
58:47Have a great night.
58:48Thanks everybody
58:49and stay on for the questionnaire
58:52because that's the CME.