Central Line

Episode Number: 144

Episode Title: Inside the Monitor: Palliative Care

Recorded: October 2024

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Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ZACH DEUTCH:

Welcome to the Central Line podcast series. I'm Zach Deutch, today's guest host. Today I'll be joined by Dr. Sandra Sacks, who's the guest editor of the November issue of the ASA Monitor. The topic of which is palliative care. This is a big topic, a very timely and important one as well. So we're very happy to have Dr. Sacks with us.

Tell us a little bit about yourself, your role, your professional situation right now and how you got interested in palliative care.

DR. SANDRA SACKS:

Thank you so much for having me. So when I applied to do anesthesiology, I had no idea what palliative care was. I didn't get any exposure in medical school. And the first time I encountered palliative care was in the ICU when we were taking care of patients with really challenging family dynamics. I was actually a little awestruck observing my first palliative care led family meeting, seeing the chaplains, physicians, nurses and social workers interact with these difficult family members. The family seemed like completely different people compared to how challenging they were being with our ICU teams. I saw the specialist engage with these families with active listening, being present and not doing anything magical, but it really brought it back to treating the patient as a person and who they were before they got sick. And it really brought it back to why I went into medicine in the first place. So now I work with cancer patients. I help to manage their pain and other symptoms, and I help support them and their families as they go through the ups and downs of having a cancer diagnosis.

DR. DEUTCH:

And you're at UCLA, is that correct?

DR. SACKS:

Yes. Correct. So I trained in palliative care after I did my anesthesiology residency and did interventional pain fellowship after that. So now I'm primarily outpatient at UCLA.

DR. DEUTCH:

And the clinical work that you do is limited to the arena of palliative care.

DR. SACKS:

Palliative care and pain management.

DR. DEUTCH:

Understood. Excellent.

So There is a lot of confusion regarding terminology. For example, people see palliative care as the same as hospice or end of life care. There's not a lot of understanding of these nuances. Can you kind of enlighten us a little bit as to that? Like what might the public perception and even the medical perception, what might be correct or incorrect in these arenas?

DR. SACKS:

Yeah, absolutely. I'm so glad you asked that. There is a lot of confusion in the medical community, especially amongst nurses and doctors, which then trickle down to the patients. And I think the confusion may be in part due to the fact that palliative care was actually born out of the hospice movement in the 1960s. But the distinction has been made since the 1970s, and it's even recognized as a distinct specialty by the World Health Organization since 1990. For us anesthesiologists, our encounters with palliative care is probably quite limited. It's usually in the ICU with a dying patient, or a surgeon might make some reference to consulting palliative care when they encounter extensive metastases in the OR, and they might have to abort the procedure. Many people have the perception that palliative care is synonymous with comfort care or withdrawing aggressive levels of care, but that would be incorrect. So essentially what palliative care specialists do is that we're working on improving quality of life for patients and their families by managing their symptoms and supporting the emotional and spiritual well-being of those diagnosed with serious illnesses. We go through a lot of communication training so that we can engage patients to share their goals and values, essentially what matters most to them. And we might actually recommend an invasive intervention if it aligns with goal concordant care. So it's important to know that palliative care can be delivered at any time, including at the time of diagnosis, and is often given alongside curative treatments. On the other hand, hospice or end of life care is when patients transition from getting curative treatments to focusing just on symptom management. And in these situations, patients must also make certain prognosis criteria, including an estimated life expectancy of six months or less, which doesn't apply to when people are getting palliative care. So I guess you could say that hospice care is a type of palliative care, but not all palliative care is or will be hospice care. I hope that clears some of the misconception.

DR. DEUTCH:

It does help, and I'm thinking because we have a whole issue, you know, targeted at this, that a lot of these terms and nuances will also be explained in that issue.

DR. SACKS:

Mhm. Yes.

DR. DEUTCH:

Okay. Um so let's go specifically into palliative care itself. Can you give us a little more specifics. What is it. How does it manifest itself clinically? What might we see or what might family members or friends see when they have people that are in the situation, that they're part of that team and that care delivery?

DR. SACKS:

Yeah, absolutely. So essentially what palliative care is: we're supporting patients with serious illnesses and their families through symptom management and decision making. So we're really leaning into goal concordant care. We're advocating for patients by learning more about their goals and values. So I see this often with shared decision making. I see in menu of items being presented to patients and putting the responsibility on them to pick. This is especially frustrating when I see people talking about code status options to patients and families. Do you want a tube down your throat? Do you want chest compressions? But unless the patients are medically trained, they really have no idea what these different options mean and the risks involved. So we try to understand what's most important to patients and guide the decision making process by keeping their goals at the forefront. And we also help with communication between different medical teams and patients and their families.

DR. DEUTCH:

Out of curiosity, we tend to be pretty aggressively interventionist culture here in this country. Do you encounter sometimes resistance or hostility from procedural teams that really want to do things that feel like you're being a barrier to that?

DR. SACKS:

I think it goes back to people having the misconception that palliative care is the same as withdrawing care, or not advocating for patients. So as palliative care specialists, we really are just trying to do what's best for the patients as long as it aligns with their care. I think that there's a misconception that we spoke about earlier, where other interventionalists or other specialties might view palliative care as the same as just comfort care. But I think if we're all in the same team and they understand that we're just trying to do what's best for the patient and may even recommend interventions when it suits the patient's goals, then there would be more support in our teams.

DR. DEUTCH:

And that goes back to what you talked about before that people are delivering palliative care, need to be communication experts. So by being able to make your purpose and your goals known, then other specialties and other clinicians will be able to understand that role and won't make false assumptions.

DR. SACKS:

Yes, absolutely.

DR. DEUTCH:

So you yourself, as you mentioned, are an anesthesiologist who participates in this type of care. Um, can you just generally speak to the role of anesthesiologists that are involved in palliative care, and how might this apply to some of our members, or even people that are interested in this type of pursuit? Yeah.

DR. SACKS:

So there is primary palliative care and specialty palliative care. I would say that many people are already providing primary palliative care on a daily basis in their practice, without giving it a label. So when you're taking care of basic symptom management, you're treating post-op nausea, vomiting or pain, or your soothing pre-op anxiety and providing support to patients and their loved ones. This is all considered primary palliative care. Um, but there's always room for more. I think that for people who are trained in palliative care, again, we spend a lot of time learning about different communication techniques.

There's a lot of discomfort in anesthesiologists that probably come from having conversations about prognosis and goals of care. And I do want to make the important distinction that goals of care is not a code status discussion, but it really is discussing more about goals. I would say that for people who are interested in learning more about palliative care principles, this is an area that could be greatly improved in our field. There's very little specialized communications training during residency to prepare for this. And I think a lot of anesthesiologists feel that they might not have a part in having these sorts of discussions. I mean, the decision has already been made to take the patient to the OR. What role do we have at this point? So oftentimes there are things that the surgeon or the proceduralists haven't discussed with the patient, and they may not have a full understanding of the risks involved undergoing anesthesia. And it's often these types of cases in these high-risk patients that make anesthesiologists feel really uncomfortable and experience what we call moral distress. In many of the situations I've heard of from my colleagues, it's usually trying to balance the ethical principles of patient autonomy with non-maleficence. And there's actually a great article in the coming issue of the Monitor, where we talk about how having a goals conversation with patients can actually help us with our own moral distress. And by understanding whether or not our patients expectations align with the anticipated post-op outcomes, we may actually find comfort that we're acting in concordance with rather than in violation of some of these ethical principles.

DR. DEUTCH:

And you spoke about that you were fellowship trained in this. And I know, for example, that for pain management there's multidisciplinary tracks into this fellowship. Um, can you describe the tracks and the different specialties that that feed into palliative care? And also kind of how common are these fellowships throughout the country right now?

DR. SACKS:

Yeah. So palliative care, anyone can go into palliative care. In my fellowship class, when I did palliative care, many people were internal medicine or family trained. Um, but in the class after myself, there was an emergency medicine. There was an ob gyn. Anyone can go into palliative care. It's just a one year fellowship. And there are fellowships all around the country that are ACGME fellowships. I think it's a lot of great learning from multidisciplinary fellows that have had different types of training. I know as an anesthesiologist, I was able to provide lectures for my co-fellows and teach them about different types of nerve blocks and pharmacology that they didn't get in their residency, and I was able to learn a lot from them as well.

DR. DEUTCH:

That's interesting, just to explore that a little bit more, because you did have pain training in your roles of palliative physician, would it be appropriate for you personally to provide that type of care, like say, someone needs a certain type of of neurolytic block for cancer pain? Would you yourself provide that?

DR. SACKS:

Yes. So that's actually what I do on a daily basis. That is my job. So I do cancer pain, interventional cancer pain, and palliative care. And so between the two fellowships, I feel pretty well equipped to help these patients, not just send them to a different specialist. But if I'm able to do the nerve block, then I'm able to help them with these symptoms by offering interventional procedures.

DR. DEUTCH:

So that gives me two follow up questions. And forgive me, but this is I find it very fascinating. So I'm hoping, by extension, that listeners would also find it fascinating. Those who are in your fellowship class that were not anesthesiology or pain trained, but might have had other procedural based training, for example OB or surgery, would it be appropriate for them to provide invasive procedures that are indicated as part of the patient's care plan? So that's my first question. And my second question would be, do you feel that the others that were in this class, by not having the interventional pain training, is it a little bit more difficult for them to provide the type of care that you are providing?

DR. SACKS:

So answering your first question, I think that as long as any individual physician has the skill set and feels comfortable offering a procedure, as long as they were trained in it, and it aligns with palliative care principles, then they should be able to offer that as an option for patients if it applies to their situation. And it's great that so many different specialties are now interested in palliative care, because it's just expanding the options for these patients to get the care that they need.

In terms of if a fellow or a trainee doesn't have a procedural background, I don't necessarily know that it is detrimental to the care that they can provide for the patients. There's still a lot that they can offer, especially when we're talking about helping patients make medical decisions, helping their families, supporting them because it's still a very big medical system that they have to navigate. So there's still a role, even if it's not just interventions, but just through, I think, the palliative care fellowship and getting to know so many different specialties that are involved in patients care when they have serious illnesses, They know who to refer to. And that in itself, even if they're not the ones doing the procedures, is still really beneficial to making sure the patient gets the care that they need.

DR. DEUTCH:

All right. So you've given me a little bit about the nuts and bolts here, which is very helpful. Moving to two areas that we might not associate traditionally with palliative care that of pediatric care and obstetrical care. Can you talk about the role that palliative medicine plays in these these patient subpopulations?

DR. SACKS:

Mhm. So with pediatrics, we know that our pediatric anesthesiologists take care of various kids. And the topic of perioperative resuscitation probably comes up often. And we know that our colleagues can definitely feel the emotional weight of parents having to make these decisions for their children. It can be heart wrenching to see families make difficult decisions for their little ones. Um, but there can be also touching moments seeing them cherish precious time together, creating mementos. So palliative care, I think in these situations is not just about managing pain or preparing for the worst, but can really empower families to shape their own journey.

And then with obstetrics, I think that it's often filled with joy and hazardous moments. But for any of us that have done OB anesthesia, we know that things can change in an instant. In general, I feel like there's very limited support systems for patients who go through the devastating experiences of birth traumas, miscarriage, intrauterine fetal demise, or neonatal death. These are most likely going to be the most difficult times of their lives. So palliative care or palliative care trained OB anesthesiologists can make a huge difference in supporting these women and their families.

DR. DEUTCH:

One of the topics that clearly is right in the wheelhouse of this discipline is, as you alluded to yourself and as you are participating, is is cancer and oncology care. Can you expound a little bit on the type of things you're doing, and where you feel like you're making the most positive inroads and really kind of what we're doing these days that's very positive in medicine.

DR. SACKS:

So the term palliative care was actually coined by a Canadian surgical oncologist back in the 1970s. More and more institutions are incorporating palliative care as part of the multidisciplinary oncology team for patients. So they're pushing for earlier integration. Oftentimes, even at the time of diagnosis, especially with those who are diagnosed with a more aggressive disease. So palliative care can have more of a limited role when things are going well. But if symptoms increase, whether it's from disease progression or their chemo or surgery that they're undergoing, then patients already have an established relationship with the palliative care team. For myself, I feel that being involved early and then knowing what is upcoming for them, so radiation or surgery, I'm really able to give them a peace of mind. I think that we forget that anesthesiologists are one of the few specialties that can have a role, both inside and outside the operating room, and really help patients go over expectations. Because undergoing any big surgical procedure can cause a lot of anxiety. And so going over pre and post-op expectations, pain management plan before they even go into surgery can be really helpful for patients. And you know cancer care is really a team approach. So having a multidisciplinary palliative care team involved can really help prepare patients.

DR. DEUTCH:

Have you personally experienced instances where you felt that the the promises, the prognoses that were given to the patients were really unrealistic and you felt uncomfortable because they were basically being offered options or things that you didn't think was worthwhile based on the clinical scenario.

DR. SACKS:

Yes, I think we've all probably been in that situation. But I think the most important thing is, again, talking to the patients and families. Sometimes they're willing to accept or proceed with something that seems unreasonable to us. And again, it goes back to, you know, us feeling moral distress. Are we respecting patient autonomy? Do they really know what they're agreeing to? And we won't really know that unless we have a more in-depth goals of care conversation with them. So I think that, again, it all comes back to making sure that we are performing goal concordant care and talking to the patient. I think there's only so much that can be gained from looking at the notes or talking. Even with the surgeons, we're going to be a lot more information if we're having a goals conversation with the patient ourselves.

DR. DEUTCH:

And I guess, again, this goes back to being communication experts, because the last thing you want is patients and families to be caught in the middle of hearing conflicting messages between care delivery teams. That must be a delicate balance at times. So another area that's clearly in the wheelhouse of this clinical arena is the ICU. Can you comment for us about the role of palliative care in the ICU and how that might be going currently, and what directions you see it going in the future?

DR. SACKS:

So palliative care is an inherent part of critical care delivery. I mean they're caring for the sickest patients. Patients often die in the ICU. Our intensivists, they have to be comfortable managing not just end of life symptoms but also emotions from families and loved ones. So I've talked to a few of my ICU colleagues, and what they're saying more and more of is primary palliative care, and they're only consulting specialty palliative care for extreme cases of complex dynamics or complex symptom management. So this could be complex family family dynamics or team family dynamics or even team team dynamics. And in terms of like what the future might look like, as we just discussed, palliative care has been part of oncology for decades, but we're starting to see how valuable it can be in other ICU situations like trauma ICU, transplants, CT ICU, and and an ECMO patient. And I think the feature is still it's still a work in progress, but I'm really happy to see that palliative care is playing a bigger role in some of these patients that could really benefit from their services.

DR. DEUTCH:

So yourself, being a palliative care expert, I'd like for you to be able to share some practical advice for our listeners. Most importantly. You know, we've talked a lot about communication in this episode, but about having crucial conversations as part of communication. And you know what could be more crucial than than goals of care and end of life discussions? Can you give us some expert background on how to approach that, how you handle it and what you've seen work well?

DR. SACKS:

Yeah. So I think the biggest thing to emphasize is that goals of care conversations are not the same as code status conversation. For goal concordant care, we really need patients to share what their underlying goals and values are, and to get to the bottom of what matters most to patients. So how do we navigate some of these tough conversations? Most people haven't had formal communications training, so I would say that there are a lot of resources out there. I can just share a couple of them with you. Vital Talk or Academy Communications in Healthcare are two of them. There's also a couple of frameworks that a lot of us use, the Spikes protocol or the Remap framework. And when I talk about prognosis with patients and their families, I often use a technique called Ask-tell-ask. It's a motivational interviewing technique by using open ended questions. So we really want to ask and assess what the patients understand and see what their goals are, and whether it aligns with what the expected post-op outcomes are. In the tell, section, this is what I often do: present as a best case, middle case, and worst case scenarios. It really helps patients picture possible and expected outcomes more clearly. Sometimes it's not as drastic as are you okay being, you know, a vegetable in a coma for the rest of your life? Sometimes it's really understanding for an independent 80-year-old, are they okay being in a sniff long term or becoming dependent on others? They may not necessarily have thought about it before. Um, and I would just say that we do have a role as anesthesiologists to have these conversations. We often have a better idea as their overall picture when we're taking into account their frailty, their cardiovascular pulmonary risk factors, and how all of this can be affected after undergoing the stress of surgery and undergoing anesthesia.

DR. DEUTCH:

So it seems clear that this type of team based specialty approach would be certainly available in places that are sophisticated, like UCLA or UT Southwestern or, you know, large private centers. Our regular clinicians who might have, um, questions or be faced with difficult situations, what's the availability of access to people with the expertise like yourself throughout the country and perhaps in smaller community facilities or rural facilities.

DR. SACKS:

I would just encourage people, if there are not readily accessible resources to palliative care specialty teams within your institution, if you're working at a smaller community hospital, and this is something you're interested in, to really try to look more into the resources that are available, there's a lot of communication resources like the ones that I just mentioned, Vital Talk and Academy Communications in Healthcare. Learn how to manage these challenging conversations. You know, there's a palliative care committee within ASA. Um, you can always reach out to us. We're more than happy to be an additional resource for you guys.

DR. DEUTCH:

Um, we're coming to the end here. I do have one last question for you. Since you were the guest editor of our November issue about palliative care, anything in particular really noteworthy that you learned from from doing this or anything specific that you really want readers and listeners to be aware of and to take home from that issue.

DR. SACKS:

Yeah. So, you know, it was such a great experience seeing the different articles come together and really humbling to see the work that my colleagues are doing around the country. The passion that they have for for palliative care and all the positive effects it has on their patients and families lives. And I just want people to remember that you're probably practicing primary palliative care already, but have never thought about it in that way. So keep doing what you're already doing, and don't be afraid to talk about goals with your patients. It takes less time than you think. It can feel awkward in the beginning, but the more that you practice the language, the more comfortable you'll feel. And if you're interested in specialty palliative care training, it's never too late. It's only one short year of training, and anesthesiologists make great palliative care specialists. We have a lot of overlap between our fields already, and I just want people to remember that with the aging population, there's going to be a growing need of perioperative palliative care specialists. There's a tremendous leadership potential in the perioperative space, and it can have a huge impact in patients lives.

DR. DEUTCH:

Dr. Sacks, thank you so much for joining us today. I've certainly learned a lot. I'm hoping that that our listeners will will learn a lot as well. And clearly as our population ages and becomes sicker, these concerns and the the field of palliative care itself are going to be very important in American medicine.

DR. SACKS:

Thank you so much for having me.

DR. DEUTCH:

And for our listeners, thank you for tuning in. And you're always welcome to delve into this topic or other topics online at asamonitor.org, and we'll see you next time on the Center Line podcast. Take care.

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