Welcome everyone to our webinar. And good morning, good afternoon, wherever you are across the country. Today we're so excited to have Dr. McKenzie Cook from Oregon, and he's will be speaking on trauma care for the, excuse me, palliative care for the trauma patient. And one thing I wanted to bring your attention to is there will be QR codes throughout. So be on the lookout for those. And I'll let Dr. Cook go ahead and introduce himself. Thank you so much, Dr. Cook. Of course, yeah. Good morning, everybody. Thank you for the opportunity to speak. I'm out in Portland, Oregon at Oregon Health Science University or OHSU. You see my Twitter handle down there at the bottom. I spend an inordinate amount of time goofing around on that if you want to send me messages or have questions at any point. So really what I'm talking about here is palliative care and palliative care for every trauma patient, every time. Now, full disclosure, I think this should be for every patient, regardless of their pathology, right? Our elective general surgery patients, our acute care surgery patients, medicine patients, everybody. I think palliative care, this is a belief of mine, but really we're going to limit it to trauma patients for the purpose of this talk. Now, a little bit about me. That's my official picture where I got all dressed up in a suit. I've been in Oregon now for about 11 years. I've been at OHSU for about four and a half years as faculty. I've got three kids. I get no money from Tillamook Creamery, which is out on the coast, but they do have the best ice cream that I have ever had in my entire life. And it's actually a reasonably okay ski season out here right now. That's my wife and I down at Mount Batchelor in Bend. So I enjoy spending my time outside. It's always a little strange to listen to somebody on the computer. So I want to give you a little bit of background about me before launching into what we're going to talk about today. So here are my educational objectives. I really want to talk about the difference between primary and secondary palliative care. I'll talk a little bit more about what those words mean, how you can use them, and really we're going to focus on primary palliative care, palliative care provided by the primary treating team. I'll talk about the benefits, although this is not really a convince you palliative care is important talk. It's more a how do I actualize that in my life or my trauma center's life talk. We're going to talk about three models of how to integrate palliative care into trauma care and talk about some pros and cons for each approach with the acknowledgement that there's no single model that is best. There's just the best model for you and your center. And then I'll talk a little bit about the best case, worst case communication tool and outline a couple of formalized studied research tools that can provide something you can take to the bedside at 1115 Pacific time, 115 Eastern time, and change the way you communicate with patients. So, it's helpful for me to know a little bit more about you all. So, there should be a poll opened up scale one of zero to 10, or one to 10. The lowest numbers are bad, the highest numbers are good. So, your trauma center, your current trauma practice, how well do you think palliative care is included? And so, I know it's an incredibly reductionist question for a very complicated answer but I'm just trying to get a little bit of sense of where we are. And the next question is actually going to be as you're working on that in the chat box, primary barrier or primary barriers or barriers that you see to better palliative care integration in your trauma system, cost, expertise, time, patient approaches, buy in, staff. Great. And that distribution of that bar graph distribution about what I expected. Doctors want to save everybody. End of life. Yeah. Well, hopefully everybody can see the chat. Great. Not enough staff, administration staff. Sure. Wonderful. Excellent. All right. I'm going to talk a little bit about how framing, you know, a lot of what I see in the chat here is some variation of resources, cost, staffing, and then buy in from either the treatment teams or the administration for palliative care being important. So, just kind of what I anticipated. I'm going to talk a little bit about how you can, ways to think about framing that and go from there. So, I am of the firm belief, and when I talk to my residents about this and when I talk to other surgeons, I really emphasize that, and I think we know this, hope is essential, right? I'm a surgeon. I like taking out spleens. I'm a surgical intensivist. I don't really love crowning people for ARDS, but it's academically interesting. But really, probably the most important thing we do as a healthcare system, as people who interact with those who are sick, injured, and dying, is provide hope, right? And sometimes that hope is for recovery and return to function, and sometimes that hope is for end-of-life care that is peaceful, pain-free, and surrounded by family and friends in a supportive setting. Now, one of the things that, a primary barrier that I see, and I think this came up in the chat to a certain extent, is there's this perception of, this is an adapted, this is a figure from that paper there, and they say hospice care, but I think you can view hospice care as palliative care, particularly in the hospital. Is this the line, right? Like, we're trying to save your life. We're going to save your life. Oh, God, you're going to die. Now it's time for palliative care, right? And that results in this sort of tension between people who view themselves as recovery-focused care, people focused on recovery-focused care, right? Like surgeons and the intensivists who are raging against the dying of the light, and people who are focused on end-of-life care, palliative care specialists or surgeons with a palliative care focus who really are viewed sometimes as the angels of death, right? So I would view, and this is intentionally a transition from a black and white to a color model, again, from the same paper, palliative care is much more than hospice, but palliative care proceeds in concert and should proceed in concert with recovery-focused care or curative-focused care, right? So the words I tend to use are palliative care and recovery-focused care. And I acknowledge that palliative care is much more than high-stakes communication. It's symptom management and guidance around the time before and after death. But really, I'm going to spend a lot of time talking about high-stakes communication, at least in this talk. So my conceptual model of palliative care in the trauma setting is this. It was very similar to this, which is palliative care and recovery-focused care are not two sides of the same coin. They are not separate circles. They are something we should be doing all the time for everybody. And in a lot of ways, that's a big conceptual change. That's a big change in the way of thinking of things. And it also helps to overcome some of those difficulties in buy-in from physicians, from patients, from the rest of the treatment team, from the C-suite, because if palliative care is what you do for everybody, right, then that's what you do. It's an essential part of what we do. And sometimes our goals are recovery, and sometimes our goals are peace, comfort, and family at the end of life. But it doesn't matter because everybody gets palliative care. This is our job, right? Dr. Mosenthal and Dr. Murphy outlined this in 2003. I would like to emphasize that in 2003, I could not legally have a beer, so this was quite a while ago. But it's a statement that, in the end, are the trauma system, me as a trauma surgeon, us as a trauma hospital, us as a statewide trauma system, us as a specialty, that palliative care and trauma care should be integrated. And there's a good reason for this, right? And we know this because we see this in our patients. Trauma leads to marked changes in function. Life after injury is not the same as life before injury. It can happen to the elderly, you have multiple comorbidities, varying goals of care, right? A lot of our patients with ground-level falls, that's a marker of ongoing medical and physical debilitation. Their life afterwards is never the same before. And the patients need support as well as their families, right? We see this all the time. It's worse in COVID because everything's virtual. But the families of these patients need support too. So for all those reasons, palliative care has to be part of trauma care. American College of Surgeons says that too. Again, full disclosure, I graduated from college in 2005, so this is a bit ago, but palliative care is our job. The American College of Surgeons said all surgeons or surgeons should provide high quality palliative care to all of our patients, not just those at the end of life. Trauma patients, cancer patients, complex general surgery patients, acute care surgery patients. Going back to that model where palliative care proceeds in concert with recovery-focused care. They're not dichotomous, they're not separate. It is absolutely the same thing. I think a graph that I showed, or a picture that I showed very similar, it was written by Dr. O'Connell and Dr. Mayer, both in Seattle. And this is your very first QR code of talk. If you scan that QR code, it should, fingers crossed, take you to the PubMed site for this paper. They highlight that surgical palliative care is an essential part of our job as acute care surgeons. So my job as an acute care surgeon, it's trauma surgeries, taking out spleens and packing pelvises. It's surgical intensive care, it's proning patients with ARDS, it's starting dialysis, it's treating septic shock. Emergency general surgery, taking out appendix, dealing with perforated colons, all of these things. And equally important is guiding patients through high stakes decisions. Accurately providing an expectation for the future, supporting patients and their family at the end of life, providing pain relief, nausea relief, symptom mitigation for those people who are suffering. And you can, there we go, lost, had a PowerPoint seizure there. You can do this without a specialist. And I would argue, and I'm not going to go into this at length in this talk, but as with everything, there is a current and projected future lack of palliative care specialists. There's just not that many people are going to do palliative care fellowships. As soon as you start getting out of the big cities, as soon as you start getting out of the big hospital systems, it becomes progressively more difficult to find somebody who has done subspecialty training in palliative care. There are well less than a hundred, I think in the seventies, nationally of surgeons who are also board certified in palliative care. So the number of surgeons who also have subspecialty training in palliative care is exceptionally limited, which really brings us to palliative care is our job. Primary palliative care, palliative care provided by the treating team, whether or not that's the intensivist, the trauma surgeon, the ward team, somebody, but palliative care to a large part is going to have to be provided by the primary treatment team because there's just not enough subspecialty trained surgeons. So TQIP says this, these are guidelines from 2017, just because that's the screenshot I grabbed. But the TQIP, the palliative care best practice guidelines are palliative care proceeds in parallel with life sustaining treatment, like that colored graph we talked about earlier. Palliative care and recovery focused care are, go together, they have to go together. The unit of treatment is the patient and the family. We can't ignore our families. It's the importance of the family is obvious when patients are unable to speak to themselves and we're working through complex decisions with surrogates. But the family is also who's going to be supporting these patients when they leave the hospital, should they survive their hospitalization. They're the ones who are going to spend the next year recovering from complex grief after their patient, after their family member dies in the hospital. TQIP says core palliative care can be provided by the trauma team. I think it stays away from saying should. I personally believe should, I'm going to sort of make that argument through the course of the talk, but can be provided by the trauma team, even without subspecialty palliative care training. You don't need a trauma surgeon that's done a palliative care fellowship in order to do this. Although there's sort of an acknowledgement that subspecialty palliative care has a role and an important one and we'll talk about that in a little bit. But really the optimal care comes with multidisciplinary teams, but they do say trauma surgeons or trauma physicians must have basic primary palliative care skills. Now, this doesn't mean that we can manage slates of patients who are in outpatient hospice, that's not our job, right, but high stakes communication in the hospital, that's totally our job. Providing goal concordant care and removing life sustaining treatment if it's not consistent with the patient's wishes, that's totally our job. Assessing patients realistically what their chances of survival and return to recovery are and acknowledging that they may not want to or be willing to go through those things. That's totally our job, and we should do those things. The AAST says the same thing. This is again a QR code linking you to the PubMed abstract of this paper, but the critical care committee of the AAST put out a paper, gosh, 2020, 2019, 2020, something like that, addressing research priorities in surgical critical care. And the number one research priority is addressing goals of care in an acute care setting. It's something that we have to do. It's something that we need to do. It's something that we just can't, it's no longer, I would argue, acceptable to just provide maximal, maximally interventional care to every single patient every single time without at least thinking about who we're doing it to and why. So what does this look like? Primary palliative care is a big topic. There's a ton of stuff that can go into that, but really what does it look like? And again, Dr. Mosenthal, Dr. Murphy outlined this 15 years ago. It's grief support for families. This is probably the most challenging one. We've all kind of gotten pretty good at sitting at the bedside with a family and helping them work through sort of the immediate recovery, immediate recognition of their family members injured or dying. But that grief extends on for months and years. It's a little bit outside of our scope to care for families either grief road outside of the hospital and after death, but it is something important to think about and often requires integration with regional hospice resources. A little bit easier, quote unquote, easier to integrate is a palliative care assessment within 24 hours. Patient comes into the hospital and you assess their palliative care needs. 23-year-old with a broken tibia probably doesn't have a ton of palliative care needs. 85-year-old, multiple complex medical issues, ground level fall with significant traumatic brain injury. There's some really complex palliative care issues coming here, throwing some difficulties with surrogate decision makers. And you need to know what you're dealing with in the first 24 hours. And it's the first family meeting for severely injured patients within 72 hours. Again, 23-year-old broke their tibia while mountain biking. Probably don't have to have a, you know, formalized scheduled sit down family meeting with 35 people. Patients admitted to the ICU, totally. Within 72 hours, sit down, deliver the news, answer questions, begin to lay out what the future looks like. And I'll provide a format for that a little bit later in the talk. And that goes along with the palliative care plan. So based upon your palliative care assessment that was done within the first 24 hours and your results, excuse me, of your family meeting within the first 72, have a palliative care plan. And integration of an order set for the imminently dying. I think in the era of electronic medical records and computer supported physician order entry, this is a little bit easier. It's much easier to sort of execute the palliative care order set. But having the ability to let your nurses give escalating doses of narcotics, benzodiazepines, and manage symptoms at the end of life is important. And I think the most important thing is you think about primary palliative care in the TICU. So palliative care, high risk communication, high stakes communication that's provided by the primary treatment team integrated into your M&M process. Now, not meeting your palliative care assessment goal within 24 hours, not having a family meeting within 72 hours isn't going to generate a residency, excuse me, a registry flag. Right? You're not going to be dinged by your site reviewers for not having those things. But thinking about how you provide that primary palliative care in the TICU, did we support this family sufficiently? Did we provide goal concordant care early in the resuscitation? Did the patient's goals of care change and did we adapt to that through the course of their long and complex ICU stay? Did this patient actually have to fly here? Oregon's a geographically big state. We struggle a lot with the profoundly injured patient who's geographically remote from a large trauma center. And it doesn't do much good to put them on a helicopter for three hours, arrive at our hospital and die remote from their family and loved ones. But integrating your palliative care performance into M&M helps you be better. You measure what you get better at the more you measure it. So it can work, right? Trauma teams can lead palliative care. We can be the people who are associated, who can be the people who lead these palliative care meetings. A couple of papers here, our group just published one too. Early family meetings, early assessment of palliative care needs is associated with reduced ICU and hospital length of stay. It's associated with fewer ventilator days, it's associated with less death during a code, right? But most interestingly, it's not associated with a change in mortality. So trauma teams integrating palliative care into their workflow, providing goal-concordant care for patients and transitioning people to comfort-focused measures and ceasing life-sustaining treatment when it's not consistent with their goals, doesn't result in an increase in mortality. This is the case I think if you're struggling with buy-in from physicians or administration. This is a case to make. It's not that we're, and I'm gonna put really big air quotes here. It's not that we're giving up on patients, right? Because one, we never give up on our patients. We always care for our patients. We always provide hope and support our patients. We just hope for different things. It's not that we're giving up a chance for recovery. There's a whole series of papers on this. No change in mortality, no change in mortality. Early comfort-focused care, less time in the ICU, less time on the ventilator, less traumatic death, i.e. death during a code, no change in mortality. So we're done right, done well. Primary palliative care provided by the treatment team identifies people who most likely aren't gonna survive their hospital stay. And we acknowledge that and we support them and their families at what is likely the end of their life and help those last few hours or days be as minimally painful and as family and love-filled as possible, not coding them as they die. So does it really work? Variable. This is just a comparison between patients who are admitted to the hospital with either advanced pancreatic cancer, there's five, they looked at 500 patients and patients admitted with a major trauma, life-threatening injury, about 2,000 patients. We're not as good as the cancer doctors and this is metastatic pancreatic cancer. So it's really the medicine and medical oncology. We're not as good about talking about code status as some of the cancer doctors are. And we're not as good about talking about goals of care. Now, I acknowledge there's gonna be wide variation from hospital to hospital on this, from region to region and evolution in time. But there's often a lot of room to improve. And I think everyone's comments in the chat highlight that, right? We feel this, we see this and it is born out of literature. So why? You highlighted, y'all highlighted this in chat. Why? There's surgeon-specific barriers, there's family and patient-specific barriers and there's systems barriers. This is the QR code to link you to this paper but I am gonna talk a little bit more. I wanna bring up a little bit of this data. For those of you who haven't looked at qualitative data before, what it ends up is looking like this. So there's a series of interviews. It's done in a semi-structured way and we pull out illustrative quotes. We, this was not my paper, this was Dr. Swanepoel's. And then identify emerging themes. So emerging themes, surgeons' knowledge and attitudes, right? Surgeons tend to be fixers. We are trained to be fixers. We're trained to believe that we can solve the problem that exists and the transition away from that, right, is it happens in time and it happens with the support of your colleagues but a culture shift is essential. Now, driving that culture shift which is often the biggest barrier. A lot of these other barriers, billing, time, cost, all that kind of stuff is really dependent upon culture shift from the medical team. That's often buy-in from a leader, the division chief, trauma medical director, an ICU medical director. And it also can be driven if you're in an organizational role by incorporating some of this into your M&M or your process improvement study. If every week you have to talk about how you subject people to care that's not consistent with their wishes at the end of life eventually and talk about how you could have done it better, eventually you can start to drive some of this culture shift. I acknowledge it's difficult. There's also the prognostication challenges. It's really tough to predict who's gonna live and who's gonna die. We're not actually not very good at it. There's some of the calculators like the geriatric outcome score is helpful but there's really just not, we are not that good at predicting who's gonna live and who's gonna die. I'll talk a little bit about some structured communication tools again and keep alluding to this to help incorporate some of that unknown into family meetings and high stakes communication. And I wanna go back to that data that I previously presented that even with earlier transitions to comfort focused care and earlier implementation of palliative care, there's no change in mortality. So we feel that we're not that good at it but maybe we're a little bit better than we think. And again, going back to surgeon identity, surgeons get trained as like in that first model, that gray and white model I presented where there's recovery focused care and then it stops and there's palliative care. As we move into the modern era, working towards integrating palliative care into recovery focused care helps drive some of that surgeon identity. We deal with patient expectations. There can again be pretty wide patient variation. There's regional variation. There's variation based upon religious and cultural traditions. This is probably fixed. There's probably not a ton you're gonna be able to do about changing a patient's religious or cultural traditions in the moment. But it is one of the markers that will for engagement of secondary palliative care. I'm a believer in primary palliative care and I also think I'm a believer in secondary palliative care, which is when the time is right, we need to involve subspecialty trained palliative care folks. And dealing with discordant patient beliefs or a culture that is antithetical or not supportive of palliative care can be those times. Okay, so that was kind of depressing. Can we be better? Yes, we can be better. Here's how you'd be better. You improve what you measure, 24 hour and 72 hour benchmarks. In our ICU, and now I acknowledge I'm at a level one trauma center and we have fellows and residents and APPs, but 24 hours and 72 hours, there are structured templated notes that go into Epic, typically written by the fellow, occasionally written by one of our advanced practice providers, but structured. Epic templated notes, right? What are their palliative care needs? What do we estimate their next couple of days are gonna look like? When's our family meeting scheduled? What are the outcomes of that family meeting? And now this is not at 72 hours, everybody goes to comfort focus care, right? That's not right. But this is at 72 hours, we sit down and we talk to the patients and we talk to the family about what the future is gonna hold. And we track those. And if we miss it, we talk about, if that note didn't go in, we talk about why it didn't go in. It was it, did it happen? And it didn't get tracked. Was it, we got too busy, whatever. Again, you improve at what you register. Managing surgeon and intensivist conflict, or for those of you who have surgeon intensivist, managing the surgeon intensivist conflict within themselves can be difficult. That's a link to the Vital Talks organization. Again, not associated with them, but I do find their work on high stakes communication would be some of the most valuable that's out there in the world. A specific guide to dealing with physician level conflict. So the surgeon and the ICU doctor are arguing about, should we, again, big air quotes, give up or is it time to involve palliative care? And really the guidance for that. And again, this is difficult from an organizational perspective, but it's time is building with value statements and building consensus around what kind of care do we provide? And then I do think that as you're working towards culture change, buy-in from medical teams, buy-in from the C-suite, reminding people that there's guidance from the Marin College of Surgeons, the AAST, Western Trauma and East, that palliative care is an essential part of what we do as acute care surgeons, is an essential part of what we do as trauma systems. There's national level guidance on this. There's national level research on this. I think as the decade goes on, you're gonna see more and more and more and more discussion around this. So how do we actually do this? As I tell everybody, I'm gonna tell y'all now, I tell my residents this, tell my students this, I tell my kids this, but they're little, so they have no idea what I'm talking about. The right time to discuss a patient's goals is now. It's always the right time to discuss a patient's goals, even in the trauma bay. This is a picture actually from one of the ATLS books, but it's actually OHSU's Trauma Bay 3, and you can tell it's the pre-COVID area because nobody has face masks on, but even in the trauma bay. Now, how do we do this? Because we do this in Oregon. How do we do it? Now, we are lucky in Oregon because the Oregon Post Registry, led by Dr. Susan Paul, really was founded in the early 1990s and again, full disclosure, in the early 1990s, I was seven years old, so I have exactly no bearing on this other than to reap the benefits in my medical career. The Oregon Post Registry exists. It was originally called Physician Orders for Life-Sustaining Treatment. It is now Portable Orders for Life-Sustaining Treatment, and that's the form. It can be filled out by any LIP, an MD, a DO, a nurse practitioner, a PA, it can be filled out. We have a fairly sizable naturopathic community in Oregon, it can be filled out by an ND, and these are medical orders that follow the patient regardless of their physical location. Now, it's relatively straightforward or relatively simple. Do you do CPR or not? Do you transport this patient to a hospital if they're found an extremist? Do you admit them to the ICU if they're found an extremist? Pretty limited. It doesn't provide a lot of guidance about like, do they want a tracheostomy? Do they want a long-term feeding tube, et cetera, right? But what this is helpful for is an elderly patient is found down at home. They're transported to the trauma bay. They have nobody to speak for them. They can't speak for themselves. What do you do? And it's searchable. OregonPulse.org, for those of you who want to review it, is sort of the website that tells you more about the Pulse forms. And I want to say there's something like 20-some-odd, 20, 30 states in the country have at least some version of this. Sometimes they're called the most, sometimes they have other names, but it's probably most well-developed in Oregon. This is work out of our group. Dave Zonies is one of my partners and our assistant CMO. And he looked at patients older than 65, 3,000 of them, admitted to our trauma center for about five years. They matched patients who had Pulse forms limiting care with those who did not. And patients who had Pulse forms that limited care had shorter ICU stays and no difference in mortality. Again, just because you're limiting care, limiting recovery-focused care, not admitting to the ICU, not doing CPR, for patients whose goals don't include that care doesn't mean that you're, again, big air quotes, giving up on patients. What we're doing is identifying patients who are probably not gonna survive anyway and providing care that's concordant with their wishes at the end of life. Or patients who have a high risk of mortality and for whatever reason, religious, cultural, personal, whatever reason, aren't interested in the care that we would provide in order to focus on recovery. And that's fine, right? But more people aren't dying from these interventions. Now, interestingly, this is probably the process improvement form for us, and it'll go to what I talk about next. But in patients who had a pre-injury Pulse, it was only acknowledged in the trauma teams now 57% of the time. So we missed about half of these. And based upon this data, we actually altered our approach. This is how we do it at OHSU. This is the guideline, and it's really, it's for use of Pulse in the trauma bay. So here's where it goes. Here's how it works. When we have a patient admitted to our trauma bay who is thought to be 80 or older, now you don't always know somebody's age, that's fine. If they kind of eyeball as 80 or older, we identify them as fast as we can. And this becomes the ED social worker's job to identify the patient. They call the Oregon Pulse registry, which is available 24 hours a day on a hotline. And we search for Pulse forms. Any Pulse form that's filled out in Oregon is uploaded to this database. I'm sure there's a little bit of a lag time, but they're uploaded pretty quickly. And they search based upon the patient's name, their identifying information, and then they let our trauma chief know. Now this is, sometimes they end up having to page us, but I would say just based upon my personal experience, more than 80% of the time, I know a patient's Pulse status before they leave the trauma bay. And our goal is to have patients out of the trauma bay within 10 minutes, either the CT scan or OR, ICU, wherever they're going. But I would say 80 plus percent of the time, I know the Pulse status of an elderly patient before they leave the trauma bay. And sometimes that's, we know who this person is. They don't have a Pulse form. That's fine. Sometimes it's, we have no idea who this person is. And then we proceed with recovery focused care until we know something better. And sometimes it's, we know who this person is. They have a Pulse form. Their Pulse form says DNR comfort only measures. CT scan shows a big subdural. Great. They're not going to the operating room. They're not going to the intensive care unit. We're going to admit them to the ward. We're going to provide symptom control. We're going to identify their family and we're going to support them at the end of their life. So those Pulse forms, they are actionable and they change our management in the trauma bay. Took a little bit of work. We had to get some buy-in from the social workers, but they're there anyway for particularly the full trauma activations. And again, having the statewide searchable Pulse registry helps, but it's a system that can be effective. Again, the right time to discuss goals is now. In the ideal world, we'd talk about them in the trauma bay. If you can't talk about them in the trauma bay, you talk about them in the TICU. There's really three ways to talk about it, three structures as I think about this. The first one I've really hit pretty hard is the primary palliative care. Palliative care provided by the primary treating team. It's a good option for hospitals with limited human resources, right? Like if you're a level three trauma center and you don't have an in-house subspecialty trained palliative care doctor, or gosh, even if you're a level one trauma center and don't have an in-house subspecialty trained palliative care team or don't have a subspecialty palliative care team that is an interest in coming to the TICU, primary palliative care is a great option. There's integrated subspecialty palliative care, right? This is somebody who rounds with the ICU team on a daily basis, right? A little more difficult from a human resources perspective. And we'll talk about that in a second. And there's consult-only palliative care, right? This is when you need them, you call them. Now, again, I'm gonna emphasize there's no best option here. I have my beliefs about the best option. I'll tell you that at the end. That's a data-free opinion. But there, and there are real logistical and financial barriers to all of this. And so there's really only the best option for your hospital. Primary palliative care, we've talked about this. This is palliative care provided by the primary treating team in conjunction with recovery-focused care. Assessing primary palliative assessment within 24 hours, first family meeting or patient update within 72 hours of admission. We can do 80 plus percent of this job with buy-in and support. Benefits, everybody, hashtag, has their needs assessed and met on a daily basis, right? If the intensivist rounding on a patient in the ICU, the surgeon rounding on the patient or the APP rounding on the patient on the ward is also in charge of their primary palliative care, you know, you get to the end of your ICU presentation, you do your fast tugs and talk about feeding, analgesia, sedation, thromboprophylaxis. And at the end, you talk about family updates and palliative needs, right? We're gonna start this patient with a DVT prophylaxis. Last time we talked to the family is 48 hours ago. We need to schedule a meeting tomorrow. Everybody gets their needs met on a daily basis. Now, limitation, there's only so much time in the day, right? Summertime, we have 35 trauma patients in the ICU. There's just literally only so much we can do. And I'm not subspecialty trained in primary palliative care. The more complexity that comes, cultural differences, disagreement between surrogate decision-makers, really emotionally challenging cases, devastating young people, like devastatingly injured young people, the more we need access to secondary palliative care, subspecialty trained palliative care. And I think in the interest of full disclosure, we need to be aware of the Dunning-Kruger effect. This is the graph of the Dunning-Kruger effect, which is competence and confidence do not necessarily track together. And we all need to be aware of the fact that the minimally competent patient may be at the peak of Mount Stupid, which is you feel really good about how good you are at this and you're actually kind of terrible. Those of you who work with residents traditionally see this in somewhere between the second and third year resident. I remember being a second and third year resident and feeling the same way. And then you transition to later in your training, you're like, oh my goodness gracious, I didn't actually know anything. So I think if we're being honest with ourselves, we have to be careful about where we are in the competence and confidence graph. And I think this is why incorporating palliative care principles into your M&M process is so important. It's great to do it. I think it's massively important to do it and we actually have to do it well. And to do it well, you have to track it in the same way you track your outcomes from shock and TBI and renal failure and all those other things. Primary palliative care includes teaching it. There's two papers here. They're not actually, they're not the same QR code. They're two separate papers focused on teaching palliative care. At OHSU, we embed palliative education into the resident's TICU rotation. There's a dedicated intern rotation where the general surgery interns do nothing per month but surgical palliative care. And we have a culture here that really fosters the development of primary palliative care within our trainees. So I think if you're gonna do it well and if you're at a training institution or an institution that works with residents or students, you also need to teach it. Obviously you gotta do it before you can teach it, but they go hand in hand. Second model, integrated palliative care. This is Dr. Katie Drago. She's one of our geriatricians and she's integrated into our ward teams, not necessarily our ICU teams, but she co-rounds with the ward trauma teams on patients who are 80 and older and have complex medical issues. So in the integrated palliative care model, Sub-specialty trained palliative care doctor or palliative care EPP rounds every day in the ICU or on the ward. Do specific palliative care rounds, either simultaneous with the primary team or contemporaneously and then touch his base. Now, the benefits of this, it overcomes the consult barrier, right? When the palliative care team sees every patient or every patient who meets whatever criteria you set up, you don't have to worry about calling them. They just show up. Improved quality of life, less frequent non-beneficial treatment, all the other benefits come from palliative care here too. Primarily limited by human resources. There's just not that many sub-specialty trained palliative care providers, doctors, nurse practitioners, PAs in the world. It would be wonderful if every one of our ICUs have them. And realistically, that's just not feasible from a human resources perspective. So great model, limited on availability. And then Q&A question, sorry. Oh, I'm sorry for missing this question. Do we have small hospitals look at Pulse prior to transfer? We do. This is to go back to that Pulse question again. Do we look at Pulse before transfer? We do. I think one of the things that COVID, I'm going to table a little bit of discussion for a second, but one of the things as COVID has taught us is that the functional infinite capacity of level one and level two trauma centers is not infinite. And I think a lot of hospital systems are dealing with this right now. We are in Oregon at the state level. Who needs to come and who doesn't? If you have a devastating brain injury and are 85 years old and are very unlikely to survive and are six and a half hours away from Portland, we're going to talk to the presenting hospital and say, hey, listen, this person's goals are not consistent with the care that we would offer for recovery focused care. They don't want it. Why are we flying in here and spending $10,000 the last day of their life? And I would say most of the time it goes okay. It requires state level cultural change. And that, again, takes time. Back into the flow. Consultative palliative care. The third model is you call subspecialty palliative care when you need it. So this presumes two things. One, there's a low barrier to consultation, i.e. people don't view palliative care as big air quotes, giving up. The people who are providing the primary recovery focused care think that it is important to have contemporaneous palliative care and that there's some amount of comfort and skill from the ICU team in identifying who needs palliative care. Now, the challenge with this model, which is a sort of traditional model called the palliative care folks when you need them, is if these presumptions are incorrect, either there's a belief in the team providing recovery focused care that palliative care should not be provided contemporaneously or is separate from recovery focused care, or if they can't identify who needs it, they're not going to call. This can be mitigated to a certain extent by structured triggers. Again, the American College of Surgeons lays out a couple of triggers in the trauma ICU that can be used to trigger a palliative care consultation. Family wants it. There's a disagreement between the family and the primary training team. GCS presenting GCS less than three or GCS less than three on post-injury day one. Medically futile, that's a very charged term that we're just going to stay away of right now, etc. If you're in a hospital where you're going to take that third model, subspecialty, consultative subspecialty palliative care model, right, call the palliative care folks when you need them. It can actually really help to use these triggers. Now, again, as you work through culture change, referencing the American College of Surgeons, like as soon as you, I mean, if you take a bunch of surgeons and say American College of Surgeons wants you to do this, like it's kind of hard to argue against that, but like these triggers, the American College of Surgeons laid out as triggers for palliative care consultation, and you can implement them relatively wholesale, and that'll get you most of the way there, right? Because then you can start to remove some of the artificial dichotomy between recovery-focused care and palliative care and bring them together in that sort of that multicolored model that I showed at the beginning. Now, you're still going to have to, if there's really that much disagreement between the teams, you still got to sort out the like intensive a surgeon palliative care dynamic, and that takes work and time, but at least you get the right people involved in the care of the patient, and the QR code there links you to the document that supports those palliative care triggers. So, what do I think is the ideal structure? This is evidence-free opinion. I think all TICU or SICU patients should get primary palliative care. Primary palliative care should be provided by the primary treating team, all patients, all the time. Most people get family meetings, comfort or comfort-focused care transitions that are run by the TICU. I think a competent ICU team who does accurate quality improvement and focuses on skill development and implementation can do 80 plus percent of these things. We have data to support that. It's in the process of getting published, and then some patients get secondary palliative care. Dr. Drago is our geriatrician. Dr. Tim Siegel is our surgical palliative care doctor here. Some of these patients do need subspecialty palliative care, and we do call them. We just call them. We get them involved in about 10 percent of our patients, 10-15 percent of our patients. So, let's say you have limited institutional resources. It's very common. Build capacity. Again, I referenced the Vital Talk group here. This is just a screenshot of their page. I'm not in any way involved with them other than I think that they are the single greatest, widely available training program for teaching people how to do high-stakes communication. There's resources online. They have videos. They have courses. They'll come and train your folks how to do it. It's really phenomenal training, and there's resources from the AAST, TQIP. There's published papers on what do we need to know. There was actually a really fascinating trauma cast series recently about how to provide primary palliative care in the TICU run by Dr. Brett Hoffman, and there's an increasingly large amount of resources out there, and as you work towards building either a primary palliative care focus or at least lowering the barriers to consultative palliative care, these resources can help direct your interested team the right way. All right, great. It's 1047 on the West Coast. I need to do this at 1115. How am I going to do it? Great question. I'm going to leave grief support alone. This is a Mosin-Ball and Murphy paper I referenced earlier, and let's really focus on high-stakes communications in the ICU because that's what you're going to be able to do, right? Grief support's hard, integration and palliative care and M&M's hard, but we can do some high-stakes communication in the ICU right now. So how do you do your first family meeting? Again, referencing the Vital Talks guide for this. Truly wonderful. If you haven't looked at Vital Talks before, they are truly wonderful. They have an app, life-changing app. I make all my residents do it. Step of first meetings, no decisions. The first family meeting is not about decision-making. It's about providing updates. Use the mnemonic guide. I see the question about CMS. I'll answer that in just a second. Get ready. Know what you're talking about, right? The care teams need to be on the same page. The family meeting is not the time for the neurosurgeon or the trauma surgeon to be butting heads about whether or not this injury is survivable or not, and know what the patient's advanced directive should they have. It says understand what the patient or their surrogate knows, provide a medical update, demonstrate empathy, and equip them for the next step. It's much easier said than done, but as with everything, and one of the things I really emphasize for my residents, preparation for family meetings should be done with the same intensity as preparations for cases. You don't just wander in and talk to a family whose loved one was just in a car crash or just shot. You got to prepare for it in the same way you prepare to do a splenectomy. Later family meetings are a little more complicated, right? Pre-meeting, introduction, assess current knowledge, empathize, etc. Again, referencing the vital talks guide for family meetings, but I really want to focus on medical updates and planning the next steps because this is where we get into the unknown, and one of the most uncomfortable things as a physician or really as any medical provider is simultaneously acknowledging that we don't know the future and also saying I have a pretty good sense of where this is going, right? If you're 85 and you've got a two centimeter epidural with a bunch of midline shift and oncoherniation, I don't exactly know the future, but I have a pretty good sense of where this is going. So how do you communicate to that patient and that to patients and their families, and that's where I want to emphasize the best case, worst case communication tool. If you remember only one thing from this entire talk, I would remember this. It is easy to teach people who are learning high stakes communication. It is easy to do. It's easy for their patients to understand. There's a broad and strong literature base. Again, none that I'm actually involved in other than I believe passionately that this is the best way to talk to patients about difficult decisions. Dr. Keith in Seattle, he was one of my faculty in residency, and he provides this guidance, right? Our job is to bring the medical expertise and the patients bring their expertise on their values. Patients with their surrogates bring their expertise on patient values, and how do we turn that into an actual decision or at least a range of decisions? Well, here's how. Again, QR code to the primary paper, which this figures from. You get out your pen and you draw a picture. You talk about the worst case situation. You talk about the best case situation, and then you do your best to give somebody a most likely outcome. Now, if you go forward with the surgery, gosh, I truly don't know what's going to happen. I have a sense, however, about what the best case and what the worst case could be, and I can give you my best judgment using all of this about what the most likely outcome is, and if you're looking at a decision, you do that with both decisions, surgery versus supportive care, and now the most important thing when you're doing, when you're talking to patients and their families about using the best case, worst case model is we tell stories. Patients will, and their surrogates will engage with their stories as you're teaching somebody to use this tool, getting, transitioning from the, you know, there's a 10% risk of infection and a 50% risk of death and all these statistics that are meaningless for patients and families in the moment into stories. You're going to be in the ICU for three to five days. It's going to be a week or two in the hospital. You're going to be in the nursing home for six months. Worst case scenario, you never wake up after surgery. You spend a few days in the ICU with progressive multi-system organ failure and die. These are the things people can wrap their heads around, particularly those with marginal health literacy. We don't, this is not, in this hour, I don't have the time to go into all of the details for how to, how to actualize best case, worst case communication tools, but I would direct you to this YouTube video. Again, I didn't produce it. I'm only referencing it here because it is really a fantastic 10 minute or so video about how to use best case, worst case communication tools in high stakes decision-making. You can either Google it. You can find it on YouTube. That's the QR code to the, to the YouTube link. And if, if you do nothing else out of this talk, watch that video. End of life. Very complicated. Again, I'm not going to be able to go into all of the details, but this is from the Vital Talks group. Again, reframing, expecting emotion, mapping values, aligning with values, and planning to match values. Best case, worst case is immensely powerful in this area. As we transition to comfort-focused care, I'm going to provide a couple of guidances. We never withdraw care. If my residents will ever tell me that they're going to withdraw care on a patient, I will stop them. And we're going to have a whole long conversation about it. I will stop departmental M&M if somebody says withdraw care. I'm one of the most junior surgeons in the department. I will stop it and have this conversation again. We always change our goals to comfort-focused or comfort only. We never stop caring for patients. We never stop providing hope. We just change what we hope for or change the goals of our care. We'll remove life-sustaining treatment, right? Sometimes we take endotracheal tubes out. Sometimes we start dialysis, stop dialysis. Sometimes we turn off vasopressors. Sometimes we stop blood transfusions. That's fine. We're just removing life-sustaining treatment. We're not withdrawing care. We always care for our patients. And then the last thing is any CPR discussion really is the last thing. Once as you're guiding patients through high-stakes communication, you know, surgery versus not, supportive care versus not, comfort measures only versus recovery-focused care, code status, which frequently is the first thing people talk about, is actually the last thing to talk about. Because if your goals are comfort-focused care and acknowledging that this is the end of the life, the end of the patient's life, there's no role for CPR. It doesn't do anything. If the goals are recovery-focused care at all costs, which is fine, then CPR is within those goals of care. So it's almost a foregone conclusion at that point. So in summary, palliative care must be part of trauma and complex surgical care. I think there's broad support from the national level organizations. I think there's broad support from thought leaders in the community. I think there's an increasing literature basis. And I think as we see the decade going on and as we recover from, hopefully recover from COVID, there's going to be more and more of this. The model's institution-specific. However, regardless of the model, primary palliative care only, integrated palliative care, consultation-only subspecialty palliative care, improving the primary palliative care skills of surgeons, intensivists, emergency medicine doctors, APPs in those settings is essential. And that can either be done through vital pox, that can be done through subspecialty training or curriculum development. And you really have to start by building capacity within your own group. And last point, if all you do is talk about best case, worst case, or if all you remember from this talk is use the best case, worst case tool or email that YouTube link to your trauma medical director, I would feel like I would have won. Thank you. I really appreciate your time. This is a QR code to some feedback to help me give better talks in the future. And I will leave that up for a second while I answer the questions that I see in the chat so far. Thank you all so much for your attention. I really appreciate it. Leverage from CMS. Oh man, real complicated. That's going to be outside of my specialty area. The billing for palliative care is not the same as billing. It is difficult. As an intensivist, time that I spend leading family meetings, talking about clinical care, doing advanced care planning, I think counts for critical care time. So it can be added into that. Now CMS guidance. Oh man, that's beyond me, unfortunately. EHR templates, 97% sure. Let me just double check that I'm not going to get fired by the information security people. And yeah, great. Other questions? Okay, thank you so much. And I'm sure that others join me in being so impressed with the PULST program that's so well developed in Oregon. And just really want to compliment you on that. And thank you so much for the talk. I had nothing to do with it, but I will pass it along to the people who did. No, I didn't mean that. But if you have just, we just have a couple of minutes left. If you want to talk about, or any advice or ideas about starting a palliative care program at a smaller trauma center. Yeah, it's tough. I have two thoughts. The first is I really think leveraging the national level guidance, right? And it's not that all of a sudden at a level four trauma center, you have to like whole cloth implemented inpatient hospice program. That's not reasonable. A lot of what we're talking about is really high stakes communication and matching goals to the care we're providing. So probably the first step is building institutional expertise in those high stakes communications, either through vital talks, again, not directly involved with them or training programs that in large national meetings. I know the AASTS and palliative care focused sessions coming up at the next annual meeting. And the second is, this is a bit of a work in progress, tele palliative care, right? We provide tele ICU care, we provide telestroke care. I think, you know, complex family meetings over the, over the FaceTime are, you know, an unfortunate reality of the pandemic and we're getting better at it. And I think as time goes along, part of the like projection of expertise from big trauma centers out needs to be projection of ICU care, projection of trauma care, projection of surgical care, and also projection of palliative care so that when those subspecialty palliative needs are identified or the person at the level four trauma center has 17,000 other things going on, we can project that outwards. That's incredible. So I think that would be a big help. And I love, I love what you, you know, that you do give us also a, a source for the high stakes discussions, decisions to, you know, to learn and to develop our skills in that. Yeah. And I think it's really important, you know, like I frame a lot of this at end of life or situations where recovery is unlikely. It's also totally fine to say, Hey, listen, you're 80 years old. You have a big subdural, like your goals of care, recovery, focus, like let's do it. You know, like best case, worst case, we're pretty close to the worst case. But if you're okay with the worst case, that's fine. Right? The goal is not to have everybody transitioned to end of life care or comfort measures only. The goal is to make sure that for those patients who don't want the craniectomy, don't want the laparotomy, don't want the long ICU stay. We don't, we don't do it to them. And the ones who are, who are, that's great. I mean, limited resources, all that other stuff, separate issue, but. Okay. Thank you so much. And you've just done a great job and we all thank you. Yeah. You're very welcome. Have a great day, everybody. Thank you.

palliative care

trauma patients

primary palliative care

trauma centers

integrating palliative care

consultative palliative care

building capacity

training resources

high-stakes communication

Oregon Post Registry