HeartBeats Episode 21: Palliative Care - Proving Support When Surgery Isn’t an Option

Host:

Welcome I'm Catherine Murtagh-Schaffer, and I'm your host for this episode of heartbeats. This podcast is brought to you by Shipley Cardiothoracic Center, an educational series dedicated to providing our patients and the community with information and education about our cardiothoracic surgery program, Lee Health, and matters affecting your health. Today, we're talking with Dr. Rabia Khan, Medical Director for Palliative Care, Jonathan Von Koenig, Medical Director of Palliative Care Outpatient Clinic Services, and Dr. Paul DiGiorgi, Lead Cardiothoracic Surgeon at Shipley Cardiothoracic Center. We're going to be discussing when is it time to say no to surgery and discuss end-of-life issues with a patient and their family, Dr. Von Koenig, perhaps we can begin with you. Before we get too far into this, you can explain the difference for our listeners between palliative care and hospice care.

Dr. Von Koenig:

Sure, Cathy. Thank you for inviting us to be part of this podcast. It's a good question because there's a lot of misconceptions about what is palliative care, what is hospice care. I presented as a continuum; palliative care is the beginning part of the type of care that we provide to enhance people's quality of life and then focus on their symptoms and put the quality of life higher on the spectrum of pillars that we're looking at. And then, gets involved at any time that someone has a chronic life-limiting disease. So, at the time of diagnosis, that's when palliative care starts. Hospice is that type of specialized palliative care that happens near the last part of someone's life, typically near the last six months of someone's life.

Host:

Dr. Khan, would you discuss some of the beliefs that Americans hold regarding death? For instance, it seems to be a really prevalent thought that doctors can cure just about anything with the right pill or the right procedure. Obviously, a lot of this is driven by media representation of doctors and the pharmaceutical ads that we see day in and day out. And the many technological advances that we continue to make in medicine. How do these cultural myths influenced the work you do?

Dr. Khan

First of all, thanks for having us on the podcast today. We're very excited to be here. You do bring up a really good point, there are a lot of myths and that TV portrays chronic illness differently, or people jump up miraculously after they have code blue or a cardiac arrest. So, this topic has come up a lot and recently there's been a lot of literature written by physicians like Dr. Atul Gawande, he wrote that book being mortal. So a large part of what we do is you know, bust those myths ahead of time. And the first thing that we do when we see patients is educate them on their disease process and just try to get a better understanding of what do you know, and then set some realistic expectations.

Host:

Dr. DiGiorgi, I'm sure as a surgeon you encounter this attitude all the time; patients who come in with severe heart disease or valve disease who have significant comorbidities, such as uncontrolled diabetes, bad COPD, morbid obesity, and these comorbidities obviously put surgery at a higher risk for failure or severe complications. How do you manage patients expectations of the risk and benefits of surgery?

Dr.DiGiorgi:

Well, when we walk into a room and talk to a patient about surgery. The first thing we do is you have a few seconds to size them up, and you're going to know pretty quickly the kind of environment that you're getting into when you walk into the room. You happen medical things, you can talk about with the patient, but then comes all the humanistic things, and they're their perceptions on quality of life and their perceptions of medical treatments in general, things like that. As you start to present what the findings have been and why you were called in on a case, and you've talked to them about how they have been feeling and what their history is, you get a feel for all of these things that are sometimes things you can't put on paper. Yes, we have risk scores, all kinds of data to help us make decisions, but you can have someone who seems low risk on paper who's very high risk in person when you meet them and you do not want to operate on and vice versa. It starts with a patient's attitude. Do they really want to be here or not? That they really want to have a fixed rule for whatever problems we've discovered for them? Then it gets into all the other things. When you get into difficult cases, it starts with, what does the data support, what kind of solution- because they're looking for us for solutions- What can I provide to the patient that is going to get them fixed enough to first save their life? Because everybody we operate on has a life-threatening problem and is in crisis mode because they probably just found out about it recently. Number two, which is just as important, maybe more important is am I'm not really going to impact their quality of life, because everything we do has some risk to it. Even this, what seems like the most straightforward, lowest risk case has some risks.

CT surgery is one of the only specialties where anybody who walks in the operating room or comes to the operating room, elective or not can die that day because of technical problems that can happen in physiologic problems that can happen. So these are serious discussions and as we approached the patients, we first wanted to see, is this something that's technically feasible? What is their risk and what are they willing to undergo? Examples are patients who feel fine, you know, say a 95 year-old is going to need to open surgery for whatever problem they have and it's a high-risk case, and you talked to them and they're feeling fine, even though you meet every criteria to have that surgery say, "you know, its probably better off not having anything done." We do this all the time. I did it last week in the office, I'll do it again this week in the office I am sure. I did it this morning, talking to another patient. So we turn down a lot, which is good it means that we're getting consulted enough or we're getting consulted to a degree that we're actually turning patients down. We're not, hopefully not missing too many patients because I will tell you more patients die because they don't get referred for a therapy that could have saved them, than because they had a complication of a therapy that people were trying to do for them. For every five patients I see there are probably 10 more patients out there that have a surgical problem that I'm not even getting consulted on. I mean, that's the reality of how people die in the community. That's still why coronary disease is the number one killer. There's a lot of opportunities to help save people that we're not meeting. But for the patients that do come in, sometimes they appreciate our honesty cause they sometimes feel or think that when a surgeon walks in the room all they want to do is operate on you. But, if you've done it enough you realize that you don't want to be doing it on everybody, but it really is not just about the medical aspects of it, it's about the patient's experience and their quality of life, and of course their life. If you don't take those into account, you're gonna go down the wrong road very quickly. So we weigh all these things as we're talking patient and every patient is totally different. They all come with their own story and their own values, and you have to take that into account- and their own ability to understand what's happening. That's real, I mean medical literacy place a lot into this .

Host:

Yes, absolutely.

Dr.DiGiorgi:

We make decisions with patients based partly on that- What can I expect this patient to really be able to keep up with? We get consulted for patients that they know are going to be medically non-compliant, so some complex interventional case that's going to require a complex series of medications they know they can't take, they'll call for surgery. Surgery, in the long run, is a simpler solution and a better one for that patient. It plays into how we deal with IV drug abusers, it's how we deal with patients who are super high risk or are very elderly. It plays in with patients who just hate doctors and everybody is a problem around them, they're never going to be happy no matter what you do for them. And, that's fine- everyone has their own opinions about things, but we have to be able to navigate that and it's tricky. So, I'm sorry, it's a very long-winded answer, but everybody is so unique, but medical success, quality of life, and life and death are three very different things.

Host:

On a different scope, we've all seen young patients who are brought emergently to the hospital with either a critical injury of some of some type of severe exacerbation of an illness that had yet to be identified until the hospitalization. Often time these patients present in extremists, for example, a young trauma patient who has suffered a bad MVA (motor vehicle accident) now has atorn aorta and is hemorrhaging or a patient who presents with a severe heart attack after using cocaine or other illicit drugs. We know we have the technology that can support these patients briefly, such as ECMO and Impella and left ventricular devices (LVAD), mass transfusion protocols, et cetera. However, we also know that recovery from these types of severe insults take a tremendous toll on the body with complications that can include paralysis, loss of cognitive function, kidney failure, vegetative states, and dependence on a ventilator for life. Dr.DiGiorgi, talked to us a little bit about the process and thinking that goes into deciding whether to take these drastic steps of ECMO, Impella LVAD or not, and knowing when it's time to call Dr. Khan's group.

Dr.DiGiorgi:

Well, it gets back to what I was saying earlier about how we evaluate a patient, whether they're in extremis coding, or they're coming electively to the office. And we look at what is the, in these severe emergency cases, what is the utility of what we're going to try to do? We get called for these regularly. Is this a hopeless case, and we're going to put someone through a big operation and there's going to be nothing in it for them? Or, is there some potential for saving someone? You're talking now about we're in an emergency situation where someone is actively dying and, we try to get as much information as possible ahead of time so you're not rushing into a situation that you're not prepared for and that helps a lot. Generally, the emergency room physicians are good about letting us- kind of give us some background, but then we have to look at it from a surgical standpoint that only we can really appreciate; Say, "okay, that sounds good but let me see if this is really going to work", and then we dive in a little bit deeper. Sometimes we do say, "this is technically not going work, or if it does work, they're going to have no quality of life", you're going to be in a vegetative state or potentially worse would be very aware, but be extremely debilitated. When it's really obvious, it's an easy answer. When it's in between somewhere and the patient can't speak for themselves to us, having family around is very important and really ask them, is this something that they would want? That's the basic approach to these things for anything? Is this person really ready to be in rehab for a year and never be living at home again, and these kinds of things, and sometimes, usually actually the answer is no way you were very independent until this happened today. It's important in these situations because family involvement is very important and guilt about therapies or not doing therapies or was everything done that could have been done is tremendous and understandable. These are the kinds of things that we try to communicate to patients or families after the fact. When someone dies, we try to meet with the family and discuss things with them. One of the biggest questions is always, are they comfortable the whole time, was everything done that could have been done, was it appropriate? We try to address these things with them so that they don't have, you know, lingering questions later on that eat away at them- either about the quality of the medical care or their own personal guilt about, you know, pushing their family member to have something done. How you manage surgery and saving people is important, how you manage your failures when people don't make it is probably more important.

Dr. Khan:

Can I chime in for a second? So I would have to say too, it's really good to use palliative care at the same time of these types of diagnosis, whether the patient is going to do well or not, especially when they're coming in the ICU and it's such an intense time and the patient is very sick and, you know, the families are very distressed. So we actually, you've probably seen us really active in the ICU and we're consulted on almost every patient and basically we tell the families like- Hey, we're your guide here in the ICU and just kind of arrange for family meetings, just make sure they understand what's going on. If they say, Hey, I had this question for the cardiologist but I didn't get to ask sometimes we'll go ask the cardiologist ourselves and come back with the answer, or we'll say, Hey, cardiologist can you come back, or the surgeon? And so we do these, these types of like care for them and that's basically what I say, is we're your guide while your loved one is in the hospital and we take you through it. If you're doing well, that's what we all want, and if you're not, then we're here to help you through that too.

Host:

Dr. Von Koenig, I'm curious, do you see these families in the outpatient setting after they've lost their family member and how does the unexpected nature of the death affect them?

Dr. Von Koenig:

So, we see patients and their families at all stages. We do have an interdisciplinary team that helps provide support for these patients, especially when dealing with grief, and have formal counselors that do provide that support. It's these tragic cases that happen emergently or unexpectedly that we do see lend to the development of complicated grief, and this is why we talk about advanced care planning so much, because it truly is not only a gift for the family members, but it's also a gift for- it makes it easier for the physicians and surgeons to take care of patients when the patient can't tell us what they want done. You know, if they've done some of this planning and they've put it in writing that if I'm going to be in a persistent vegetative state, I would never want to be in that position and give XYZ what they would want done. Then it makes it easier for the physicians caring for those patients and families to really carry out the wishes that the patient would want. Cause that's what we're asking for, what would this person tell us if they could tell us what they wanted? Grief counseling and dealing with grief after an unexpected death is really a focus that hospice provides, and one of the services that whether your loved one was on hospice or not there in most communities are the number one resource for grief counseling, and it's usually a free service that is provided and definitely provided if the loved one was on hospice. But, even in our community, even if you don't pass away on hospice your family can still turn to the hospice services to get grief counseling. Usually, that grief counseling extends for 13 months after someone's someone's death.

Host:

I recently did a CME course called the Cultural Meanings of Death and Dying, and it certainly opened my eyes to the different cultural practices and attitudes towards illness and dying that I wasn't really aware of. For instance, in the United States, caucasians tend to be more independent in their views of dying and as you said, we make advanced directives indicating our preferences for how we wish to be treated if we became critically ill, for example. However, in many cultures, it's the extended family that's responsible for those of decisions. Even the way we communicate and discuss end of life issues is culturally influenced. For example, in the United States, our Western biomedical model emphasizes full disclosure of information to allow for informed decisions. We assume that patient autonomy is paramount and that patients want to hear the "truth". But for example, traditional Japanese and some Pacific Islander cultural beliefs maintain that language has a soul of its own and is so powerful that words can dictate the course of event events. These are folks who may not want to discuss death and dying. Dr. Von Koenig, I think it's safe to say that no matter what the cultural beliefs are, families play a huge role in decision-making processes around a terminally ill patient. In fact, some difficult family disputes can erupt due to the differences in acceptance of the inevitable. How do you help families come to terms with accepting the unavoidable and then move to doing what is best for the patient?

Dr. Von Koenig:

Well, to be honest, I wish there was an easy cookie-cutter approach to these really difficult situations. To be honest, we always ask how much do you want to know? What do you want to know? We are surprised often in that a patient will say, I don't want to know you need to talk to my eldest child or to my spouse, and we honor that as much as possible. We do have an ethical and legal responsibility to give full disclosure and obtain informed consent. Usually, when presented in a way of asking, and being invited in to have these conversations, families and patients are usually willing to engage at some level. We try to get our foot in the door to however much a patient and their family will let us because they're talking about something that we're all going to experience, death-and it's an uncomfortable thing to talk about. I very rarely phrase my consultations or discussions centered around death because, to be honest, we don't have control over death- even in situations where we don't expect someone to die, eventually someone is going to die and we don't participate in physician assisted suicide at all. So how we frame our conversations is surrounding, how does someone want to live? You know, here are the cards, here's the situation that we have, and acknowledge that we wish we could change some of these situations and change some of these cards but we can't, and these are the options that we have ahead of us. Here are the risks of some of these options. This is why it's important, and what our team does is works with everyone because we're experts in palliative care, but we're not cardiothoracic surgeons, we're not neurologists, we're not intensivist and so bringing everyone to the table to be able to answer the questions that usually come up in some of these conversations and being honest and then creating an environment where patients and their loved ones can ask questions, and we are able to present things in a way that they can understand and doing that footwork to understand how much do you want to know, how do you want to know it, really makes these difficult conversations, easier.

Host:

Dr. Khan, I'm sure you've run into this particular issue on many occasions. How do you assess what the cultural beliefs are in a family who is scared and perhaps untrusting and probably in denial?

Dr.Khan:

This is a good question, and I think to piggyback on what Dr. Von Koenig was saying is we approach them by asking them, you know, what are you thinking about, what are you scared about, what are your questions, and just kind of come from a place where we're trying to meet them where they are and help them. If we have a family that's untrusting or in denial like I said, we usually support them and then we spend a lot of time answering their questions if they have them, and like Dr. Von Koenig also said, we lean on our partners to help us with any of the questions that they have. We also lean on our chaplain services and bring them in when needed, and then we have family meetings and then we help them formulate questions to ask the other specialists.

One big thing I think is also- working in palliative care for so long now- I think that we have to understand that we're not going to fix everything and then people have their own journeys and sometimes what happens is supposed to happen. I can also give you a personal example because my family is from Pakistan, my parents came here in the seventies, but I was born and raised here so I have that independent kind of attitude that you were talking about with most Americans. So my husband and I have our administratives done were DNRs, I guess you guys can know. But my father, my parents had traveled to Pakistan to see family and my father became very gravely ill, and he was comatose and intubated in the ICU in the Capitol. I traveled over there and he was actually comatose for several days and he wasn't on any sedation. I have had conversations with him about his goals of care. In Pakistani culture, maybe similar to the Pacific Islander and Asian cultures, you said that sometimes we think that if you say something aloud, it's going to happen. So, it was difficult for them to have the conversation with me about their beliefs. I had asked them ahead of time, and you know- are you talking about this? And I said, no, we need to know, we need to know your values. So my father had told me ahead of time, he would never want to be having a tracheostomy or a peg tube and living in a nursing home and, you know, not be home. So when he was about like day six or seven, that he was still in the coma, the ICU team had come in and there were residents and the attending and I know my head was down, I was very sad you know, it was happening. I had tears coming out of my eyes, and I had my head down and I said, you know, my father wouldn't have wanted all of this. If this continues, you know, we're gonna need to terminate care. He's not going to want to be on a tracheostomy and have a peg. I looked up and I had like 10 eyes bogged out at me that couldn't believe that the American daughter had said that, she was willing to, you know, terminate care on her father. So, that was an experience and I said, these people need a palliative care team (laughter)

Host:

Thanks for sharing that, that's a very interesting story.

Dr. DiGiorgi, families in denial can throw the proverbial wrench in your decision-making process. As a surgeon, I know that you always do your best to present both the risk and benefits of a potential surgery and if you think the risk is extreme, you say so. But families in denial are grieving and often there's this concept of, we want everything done it doesn't matter about the risk. Where do you go from there?

Dr.DiGiorgi:

Well, I think that is a reality. Sometimes in my personal experience, I never really had a problem with that. I think the reason is in how you explain what's happening. If they have a misperception about what you're going to do, and what's going to happen afterwards, then they're going to come up with opinions that you find unreasonable. But if you explain things well to people and talk about what would they really want, and this isn't something that's going to get better in a day. This is going to be a protracted recovery if they even make it and they're not coming home ever again. These kinds of things, and you have to be realistic about what's happening. I have never experienced that actually. Because most, any reasonable person can look at that and say, well, no, they wouldn't want that.

So I've never really found myself at odds with a family because they're relying on, they don't know medicine. They're relying on me to tell them how it's going to go to the best of my ability- obviously, and they appreciate that. When you're honest with them then I've almost always found them to be reasonable and about their decision-making afterward. I really think that that outside of, you know, a real psychotic kind of break, I think that should never be a problem when you explain it. Now, if there are other people in to be involved, you can come back and readdress, you could have a second meeting if more families coming into town, those kinds of things, I think there are some other ways you have to deal with it. Sometimes where the person who you're actually talking to you right there is not prepared for that conversation. One example is when you have a post-op patient who's not doing well, and you believe they're not going to survive, and it's unexpected- It should be any relatively unexpected. Hopefully, you're going in and thinking that it's going to go fine, but, if you believe they're not going to survive, don't go to withdraw support in the first 24 hours. I mean, people need time to process that. That's been our experience, I'm sure it's what everyone's experience when these things happen. I tend to give them at least a few days to process, go through their questions, go through their grieving, and it's a very different response from a patient's family member between day one and day five. It gives them time to get family in town to come and see the patient before they would withdraw, support those kinds of things. So you also manage that that way. I think it's really just about being sensitive, what a reasonable person would want and how they want to be spoken to, and not trying to hold back information about, or be unrealistic about how something is going to go. It probably comes with more experience that I think also over time, because you yourself lived through those experiences with the patient as their physician, and you recognize, okay, I used to think this was going to go okay, but I know now it's not going to go okay. But in general, the more open you are and the more information you can give about what to expect, I find families to be very reasonable.

Host:

Grieving is a particularly sensitive topic for many people. In our Western biomedical model, we are uncomfortable with people expressing the emotional chaos of grief. We believe that grief should be short-lived. In fact, most businesses only give three days off for the loss of an immediate family. Essentially, the message is people should get on with their lives. I personally believe that we do a lot of psychological harm with those beliefs and that grief is a very personal issue that cannot be timed. Dr. Khan, can you comment a little on grief timing, and does religion play a role in any of this?

Dr. Khan:

Yeah, I think you said it right. That there's no real timing on grief of, I think it's understandable in the acute time. You know, right after the patient passes away, the loved ones go through very intense reactions. And then, you know, weeks and months later things come to like a new normal. I'm sure religion does play a role in it. And if I can say in my experience, I think it depends on how the patient's family view, the disease process of they were going through or the patient was going through or death. If they think of the disease or death as a punishment, then it's a little harder, I think, to go through the grieving process. But if they think of it as a natural occurrence, that death is part of life. I feel like they tend to come to terms with it a little bit better. In our team, like I said, we really lean on our spiritual support, the spiritual team, and the chaplain team to help. They're non-denominational, and then sometimes the families will say, Hey, I want so-and-so from my church. So then they reach out to them and bring them in. So we're just, you know, we're not here to judge, so we just support people wherever they are.

Host:

Dr. Von Koenig, do you have an illustration of a cultural belief around grief that surprised you?

Dr. Von Koenig:

I'm pretty open in there. I'm pretty hard to surprise. So I can't say that I really have been surprised by someone's grief response. To piggyback off of what Dr. Khan was saying, I think especially this past year with the pandemic, there's a lot of talk about grief, and in recognizing that the system of grief, that we understood, as stages that you moved from one stage to the next to the next, and then eventually you were done with grief. It's not realistic. I ascribed to more of the model that we grow around grief. I have seen some pretty amazing, I guess, surprised, in a good way, people responding to grief and growing around some really tragic situations. We seem to have a handful of cases that when it rains, it pours for the family that they're not just dealing with the death of one person, but they're also dealing with several family members that are dealing with issues and the loss of a job, or, multiple losses that would contribute to grief. I'm surprised by those people that can really grow around it and carry or, and be present. There are some niche things that I think are pretty cool and surprising that have become bigger businesses that really stem from grief. You can now have your loved one made into a diamond. I've seen a recent startup that the casket is surrounded in a seed pod and you plant the casket and a tree grows. And so I think those are beautiful ways that people can cope with grief and grow around it. I also, when talking to families and loved ones that are grieving, I also frame grief as you know, it's love for something that's no longer present. And I can't take credit for that- You know, that that comes from lots of different philosophers and authors and poets. But I think you're right, Cathy, that expecting that we get over this in three days or any time period is not realistic because like Dr.DiGiorgi was talking about there's anticipatory grief when something's not going well, you anticipate that my loved one's going to die, and you can have a reaction that becomes very visceral and emotional. I think it's very wise for physicians to acknowledge that that's grief and that's the grief of someone anticipating what inevitably is going to happen, that we know from a medical standpoint is going to happen. And that they're just coming to terms with, so giving patients the space to, to have that grief and I will never tell someone how to grieve. I am more of giving the space of, you know, you're grieving and what resources can we help you with that? Because I, unfortunately, don't have a fix. I don't have a drug company that can come up with a medication that has no side effects or addictive properties that help someone cope with grief.

Host:

I don't know if I'd want that, to be honest. I don't know if I'd want that.

Honestly, I think grief is something that's a natural thing for humans to do, and they have to do, like you said, in order to grow and to get into continue. Dr. DiGiorgi, how does a surgeon support the stages of grief?

Dr.DiGiorgi:

The stages of grief of a patient? .I think, yeah, I was saying earlier you have to be patient and understanding about what the reaction is going to be initially, and how you talk to people and inform them about things and answer their questions and let them go through it. Then ultimately come to, you know, a more stable place, but there's going to be different waves of it, that take place at least initially over the first several days and longer terms. We have conversations with patients, and their families around the day of the operation saying the worst-case scenario or preoperatively, then the day of the operation, and then the next day and the next day, and gradually kind of bring them along that journey of what has happened, even though it's not good, let's say in a bad case, which fortunately isn't often, but you have to prepare for it. And you help manage that grief for them as they go along. So they feel like you're still there for them, which was the expectation when you went to the operating room first place. Then follow up later if necessary as well. It's just about being there for the people that you expect them to be there for in the operating room, but also afterward. Our responsibility doesn't end when the patient pulls out of the operating room.

Host:

In my experience, I would say that patients and their families are probably most concerned with pain. Will it hurt when I die? Is he in pain? Did she suffer? Those are the questions I've been asked by patients and family members as they came to terms with death. These questions always touch me because I always feel the emotional pain behind them. And in reality, that's what we are dealing with is the emotional pain of dire loss. Dr. DiGiorgi, I had the greatest respect for the Shipley surgeons being willing to engage the palliative care team, to help patients and their families with this intense moment in time. But I would like to turn the table for just a second and ask how do you, as a surgeon deal with the loss of a patient. I know as a team member, I'm always devastated when we have a patient's death, but for you, the connection can be very deep. Can you talk about this?

Dr.DiGiorgi:

You know, the expectation and what we try to convey to the patient is that we're taking on an operation. When we walk into the operating room, we are going to give it our all, and you're gonna win every time. Without that confidence, you probably shouldn't be doing that specialty. And so we have this preconception that no matter what is waiting for us in that operating room, we're going to beat it. It's like going on the field and you expect to win that game every single time. So with that high expectation of yourself, when things don't go well in the operating room or postoperatively, depending on the exact reason, some are frustrating things on a small level, some are personal things, some are physiologic things that you may not appreciate it going into it or that developed later on that you might not have been able to predict. But whenever something isn't going right it can be devastating to a surgeon, something that you'll always remember. And you have to be able to handle that both on the spot and then afterward. The team is looking at you, you set the tone, and that operating room, the whole team was looking at you, and their performance is dependent on your emotional state in your confidence in that room and you have to appreciate that. So no matter what you're feeling you have to convey, you still have to convey this sort of captain of the ship thing and bring people along in that room so that, you know the whole team's performing at their best. So you have to be able to compartmentalize a lot of things personally and continue to move forward for a case. And it can be extremely difficult, to the point where if people might think that some people are very gruff or, you know, just not nice in the operating room- cold, you know, all the bad things you hear about surgeons. Part of that I'm sure is due to the fact that they're internally trying to cope with the situation, because there are expectations all over the place for them, and everyone is staring at them to deal with it and then they're trying to deal with their own sense of failure, let's say at that time and their own grief about that. It's is not for everybody, and many people won't be able to handle it, even when they go into the specialty and they'll fail at a specialty because they can't handle that. They used to say, every gray hair on a surgeon's head is one death they had throughout their career. Not only that, now you have to deal with then, but that might be your first case of the day, and the next patient is getting rolled into the operating room and you have to be on your game for the very next case. So it may be surgeons who need palliative care as well.

I will tell you that we all remember cases, dramatic failures throughout our career for as long as we've live. As you alluded to that, I think is a good thing, because then we have M& M conferences to formalize this process because we want it to happen once and never again. And so we learn from these things. The next patient deserves it, that patient who didn't do well deserves it too, whether they lived or died, but, you know, they might've had a complication. And so every, I wouldn't say every single one of them, but a lot of them you'll always remember because it was something that changed your attitude or your technique or your management style about something. That's kind of putting a silver lining to that cloud every time, as much as you can. And that's what you should do. It's not just about being nice and trying to cope, it's about how you've learned to get better at your craft. The expectations are high, and you have to figure out a way to handle it and it is not easy. And then you, and then you don't want to bring that home to your family on top of that. I had a bad day and so that's one of the things that's why I think the interest in surgery, especially surgery that deals with life and death on a daily basis is not for everyone, and only certain kinds of people who have, you know, for lack of a better term, just kind of the capacity to deal with that. I don't think it's necessarily a great thing to have, but it's what you have to have. It's really not for everybody, but you have to weather a lot and live with that and thrive off it in some ways. Because you know that if you weren't doing that, they would die. Ultimately, whether you win or lose, you're doing the right thing for humanity. I just try to not bring it home, not let the next patient suffer because of it , and try to learn something from it at the same time, but I can assure you that there's a lot of grief that goes on with surgeons

Host:

Yeah, I believe that.

And so you bring up a good point Dr. DiGiorgi, Dr. Khan, does your team engage with physicians and staff to do a debriefing or act as a support network when a patient dies? In particular, a patient who's been struggling for a long time, or has many ups and downs and finally succumbs. This can be particularly difficult for the healthcare team, and of course, I'm thinking of this last year with all our COVID deaths and how difficult 2020 has been for everybody.

Dr.Khan:

Yeah, we don't, our team doesn't have a formal process of debriefing. I know they do it in other systems, but I can tell you that we have a natural and kind of informal process with it. Definitely right before we see a patient, or I would say a consult. We talked to all the docs first, and I think that gives them a chance to kind of process what's going on and vent a little bit too, and just tell us their concerns. And we definitely do that with the nurses, especially because the nurses are right at the bedside, you know, for several hours at a time, they give us a lot of insight into the dynamics of the family and the beliefs of the family, and Hey, this sister came in or this daughter came in and this is what they're saying, so they give us a lot of information. I think also at that time, they have a chance to kind of, in a way debrief and let us know their thoughts too. Then after, you know, we'll meet with the family, then we'll go back and communicate with those team members. I do think that that type of process, is hopefully it's helping that we go back and we do talk to them and they got a chance to kind of say their opinion in a safe zone, like a no-judgment zone, also.

Host:

Dr. Von Koenig thoughts about that?

Dr. Von Koenig:

Yeah. So this past year, we actually have looked at formal processes of how do we, do a debrief and, that stemmed from seeing the grief from the bedside from the nurses, from our colleagues that were consulting us. It's still an in-process thing, I think, you know, resiliency is a buzz word and in medical society right now, or especially this past year, we're all looking at a way to become more resilient. It's just of the nature of what we deal with. I think it's powerful to give people the space to grieve. I mean, that, for lack of a better word, to vent, to feel the feelings that they're feeling, and be able to move on to the next case, to be able to treat the next patient. Because there is a skill, there is an art, and like Dr. DiGiorgi said that it's at his level, the stakes are much higher and it trickles down. And so that everyone on a team needs to have the resiliency to acknowledge a bad situation when it goes bad to acknowledge a good situation when it's good and then be able to in a healthy way, not carry that onto the next patient and not carry that home to our families, because we have to be able to take care of ourselves, to take care of our patients.

Host:

This has been such a thoughtful and thought-provoking discussion before we close. Does anyone have anything they'd like to add?

Dr.Khan:

I wanted to just thank you again for having us. We were very, very happy to be here.One thing, I do want to just add a plug for our teams, to normalize having palliative care as a part of anybody's team, with any chronic or end-stage disease or in the ICU or surgical cases that are a little more complex and the families may need more support. So we're here to support through good and bad outcomes and, you know, through curative and non-curative stages.

Host:

Can families ask for palliative care?

Dr.Khan:

Yes, they can, they can ask. Usually, they let the nurses know, or they'll let their doc know. Even the nurses can place a consult too excellent

Host:

Dr. Von Koenig any last thoughts?

Dr. Von Koenig:

Yeah, I'll piggyback off what Dr. Khan was saying. I speak for our community because palliative care in every community looks different. In our community, we try to convey that palliative care is here to broaden people's shoulders, broaden the team of physicians already taken care of you. We don't replace anyone. We're here to be supportive, and you don't necessarily need to be end of life to be one of our patients. So, we keep on with the education and we appreciate this opportunity to share that.

Host:

Dr.DiGiorgi?

Dr.DiGiorgi:

No, I can't say enough about the palliative care team. It's a huge adjunct to the way we care for patients, especially in a specialty like ours, where we're in the operating room all day. We can come in the morning and round at seven o'clock to call family members on the phone, or talk to a patient briefly before we go off to the operating room. But it's all there. The questions come up during the day when families come in and we're still operating all day. That's where really rely on the other members of the medical team, critical care and palliative care to come in and help and give a little bit different perspective on the same problem, which I think helps broaden the patient's and their family's perspective on what's happening, and help their understanding of what needs to ultimately happen potentially. It's a team sport and we're really lucky to have great palliative care. I want to learn a little bit more with the outpatient stuff too. I think I learned a little bit today.

Host:

Yeah, me too.

Until next time, I'm Cathy Murtagh- Schaffer and this has been HeartBeats Shipley Cardiothoracic Centers podcast, dedicated to bringing research innovation and education to our patients and the community until next time.