Podcast appearances and mentions of Diane Meier

In 1983, a 25 year old Nancy Cruzan was thrown from her car while driving home in Missouri, landing in a water filled ditch. She was resuscitated by EMS, but did not regain higher brain function, and was eventually diagnosed as being in a persistent vegetative state.  In 1988, Cruzan's parents requested that her feeding tube be removed, arguing that she would not want to continue in this state. The hospital refused without a court order, and the case eventually made its way to the Supreme Court. Arguing for the state of Missouri against the Cruzan's was Ken Starr, who would later be assigned the role of special prosecutor in the investigation of the Clintons (Whitewater, Lewensky, etc). In 1990 the Supreme Court ruled…for the state of Missouri.  On the one hand, this was unfortunate, as it meant Nancy Cruzan could not be disconnected from the feeding tube immediately. On the other hand, the ruling allowed states to set their own evidentiary standards to refuse or withdraw life sustaining interventions.  Missouri set a very high bar, explicit written documentation that applies to this specific circumstance, which the Cruzan's eventually cleared.  Other states set lower bars, including oral assignment of surrogate decision-makers. The Cruzan ruling led to a flood of interest in Advance Directives, and eventually to the Patient Self Determination Act, which mandates provision of information about advanced directives to all hospitalized patients. Today, we talk with Bernie Lo, prominent bioethicist and practicing primary care internist, and Laurie Dornbrand, geriatrician at the IOA On Lok PACE, about the legacy of Nancy Curzan.  We use Bernie's NEJM Perspective as a springboard for discussion.  We discuss, among other things: How and why in the 30 years since the Cruzan ruling the emphasis has shifted from advance directive forms to in-the-moment discussions And validating the importance of the advance directive forms in some circumstances, and in starting conversations The role of the clinician in engaging patients in advance care planning and in-the-moment serious illness conversation: what questions are important? What words to use? Is the POLST useful? How? Under what circumstances?  Should we abandon the term, “comfort measures?” In case you miss the introductions at the start of the podcast, Bernie and Laurie are married, and offer wonderful reminiscence of their clinical practice over the last several decades.  So when Bernie says, “I've heard you take these phone calls in the middle of the night, Laurie…” Now you know why! And great song choice: Both Sides Now by Joni Mitchell.  Joni suffered a stroke and had to completely re-learn how to play guitar.  Her comeback performances are inspirational, such as this one at the Newport Folk Festival, attended by another influential GeriPal couple, Sean Morrison and Diane Meier. You get to hear my stripped down Hawaiian slack key style version of Both Sides Now (easy to play with 2 fingers, still in rehab for broken hand, hoping to have full use again soon). Enjoy! -@AlexSmithMD  

Palliative care is growing as a movement to maximize quality of life for those with serious illness. Yet to many, the concept and reality of palliative care is unclear or unknown. Dr. Diane Meier — Founder and Director Emerita of the Center to Advance Palliative Care (CAPC) — and Rabbi Dr. Edith Meyerson — Director […] The post Palliative Care, and Why You Need to Know About It: Dr. Diane Meier and Rabbi Dr. Edith Meyerson appeared first on Plaza Jewish Community Chapel.

One of my favorite Piece of My Mind essays in JAMA is by Rebecca Sudore, titled, “Can We Agree to Disagree?”  And today our guests agree to disagree.   And yet, and yet… They also agree across a whole range of issues, some of which surprised us. This is the latest in our series of podcasts on concerns about, and potential of advance care planning.  If you're new to this discussion, don't start with this podcast!  Start by reading this article by Sean Morrison, Diane Meier, and Bob Arnold in JAMA, and this response from Rebecca Sudore, Susan Hickman, and Anne Walling. Then listen to these prior podcasts with Sean Morrison and Rebecca Sudore about this issue, and we recently discussed differences between Advance Care Planning and Serious Illness Communication with Juliet Jacobsen and Rachelle Bernacki.   On today's podcast we ask our guests about areas in which there might be agreement or disagreement, including: The Best New York style bagels are made in California. Assigning a surrogate decision maker is important for everyone, including those who don't have serious illness. Where does POLST fit in with this debate? All decisions are made in advance, the question that we are debating is how far in advance and what to call it Completion of advance directives and billing codes for advance care planning as quality metrics Among other topics.  I'm heartened that we could have this discussion as a field, as it shows that we've grown to the point where we can agree to disagree respectfully with each other.   We can work it out! Links to a few couple items mentioned on the podcast: Objectives for Advance Care Planning 2018 Systematic Review of Systematic Reviews on ACP -@AlexSmithMD

One aspect of the medical profession that doesn't often garner a great deal of public attention is that of caring for patients who are dying. For Dr. Mimi Dunne, the relief of suffering has been her life's calling — specifically the mission of relieving mental and social suffering in the lives of terminal patients, and helping them and their families find solace and meaning as they face mortality. This week, we ask Dr. Dunne to share insights and lessons from her experience in palliative care.In this episode, you will hear about: What palliative care entails and what kinds of physicians specialize in it- 02:06Dr. Dunne's path from emergency care to palliative medicine - 3:36Common misconceptions about palliative care - 7:43Stories of a pivotal patient case that illuminates Dr. Dunne's career - 11:33What it is like to accompany patients at their end of life - 15:59A discussion of Narrative Medicine and storytelling - 23:44A discussion of the Top Five Regrets of the Dying by Bronnie Ware - 29:29Works, Organizations, and Individuals Discussed:The American Academy of Hospice and Palliative MedicineThe Center to Advance Palliative CareDr. Diane Meier, professor of Geriatrics and Palliative MedicineBill Moyer's PBS docu-series Healing in the MindDr. Laura Carstensen of the Stanford Center on LongevityDr. Ira Byock's work on Developmental Tasks of the End of LifeNarrative Medicine: Honoring the Stories of Illness by Dr. Rita CharonProfessor Dan McAdams' work on Narrative IdentityThe Top Five Regrets of the Dyingby Bronnie WareVisit our website www.TheDoctorsArt.com where you can find transcripts of all episodes.If you enjoyed this episode, please subscribe, rate, and review our show, available for free on Spotify, Apple Podcasts, or wherever you get your podcasts. If you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments or send an email to info@thedoctorsart.com.Copyright The Doctor's Art Podcast 2022

Daniela Lamas, M.D., is a critical care physician at Brigham and Women's Hospital in Boston and a faculty member at the Harvard Medical School. She's also a frequent opinion writer for The New York Times. The paper published her piece, "When Faced With Death, People Often Change Their Minds," earlier this year.    "We need to shift the focus from talking to healthy people about what would happen should they stop breathing during a routine procedure, and toward improving conversations with people who are already seriously ill," Dr. Lamas wrote. Her op-ed piece comes on the heels of an essay the Journal of the American Medical Association published a few months earlier, "What's Wrong With Advance Care Planning?" by Drs. Sean Morrison, Diane Meier, and Robert Arnold, which argues that advance care planning has failed to accomplish its goals of aligning care and improving communication at the bedside. Joining Dr. Lamas in conversation is Ira Byock, M.D., a palliative physician, author, longtime advocate for advance care planning, and the founder of the Providence Institute for Human Caring, where this podcast is produced.  Dr. Byock holds that while there's dire need to redesign advance directives, providers should talk with patients about who they trust to speak for them and their general healthcare goals — optimally long before onset of a medical crisis. .  *******************.The podcast producers are interested in hearing from providers with questions or suggestions for an upcoming webinar on BEST PRACTICES FOR SOCIAL MEDIA USE FOR HEALTHCARE PROFESSIONALS. Have a story to share with us? Have suggestions? Write to us at HearMeNowStories@providence.org or leave a voicemail message on +1 424-212-5436. And thanks! 

Before 70 Over 70 goes on hiatus, Max sits down again with the person who inspired the show, his dad Marty, to talk about what he has learned from these conversations and what he hopes will stick with listeners.  Thank you to the more than 70 people over 70 who helped make this show possible:  Alice Waters, André De Shields, Anna Fisher, Dr. Anthony Fauci, Arlene Heyman, Arthur Russell, Austin Sarat, Barney Frank, Bertha Riley, Dr. Bessel Van Der Kolk, Betty Goedhart, Beverly Glenn-Copeland, Bob Iger, Carolyn Doelling, Dan Rather, Darryl Cox, David Crosby, Deanna Gobio, Diana Nyad, Diane Meier, Diedre Wolownick, Dionne Warwick, Dolores Huerta, Donalda MacGeachy, Evelyn Griesse, George Pettigrew, Gloria Allen, Greg O'Brien, Sister Helen Prejean, Howard Kakita, Jackie Batson, James Hong, Jim Clyburn, Father Joe Carey, Dr. Joycelyn Elders, Judith Light, Konai Helu Thaman, Krishnamurthy, Dr. Laverene Wimberly, Liliana Weisbek, Lillian Faderman, Lilly Ledbetter, Lucia DeRespinis, Lois Lowry, Lynn Staley, Madeleine Albright, Maira Kalman, Marty Linsky, Mavis Staples, Michio Kaku, Miriam Moss, Nikki Giovanni, Norman Lear, Paul Price, Paula Weinstein, Peter Leighton, Phyllis Irwin, Raffi, Renata Adler, Russell Banks, Sandy Levin, Scott Kalin, Shirley Ross, Sid Moss, Sjanna Leighton, Steven Berman, Susan Lucci, Timothy Fullam, Tom Locke, Travis Mayes, Twiggy, William Locke Learn more about your ad choices. Visit podcastchoices.com/adchoices

Paul Price shares what he has learned about how to make the most of the time we have left. Then Max talks with Dr. Diane Meier, a geriatrician and founder of Mount Sinai's Center to Advance Palliative Care, about what she has learned from helping so many people make meaning of the end of their lives, how to have hard end-of-life conversations with people we care about, and why 70 feels exciting and unknown. Special thanks to Agnes Firth and The Golden Wattle Cafe, “a regular cafe event for people living with dementia, their carers, and others who would like to join us.” Learn more about your ad choices. Visit podcastchoices.com/adchoices

Trained as physician, Dr. Meier was geriatrician at Mt. Sinai who has been a thought leader in palliative care. She has been involved in many aspects of palliative care. She created CAPC and won a MacArthur Award for her work.

There is a conversation that we are not having in medicine – and that is related to our dying.  Oftentimes when this conversation does happen, it is often too late for palliative care to do some good, to relieve suffering, to improve quality of life, during the time that we have left.  And because this conversation doesn’t happen, or doesn’t occur early enough, death has become painful.  Death is inevitable, it is a universal process that we all will go through one day, as we are living organisms.  I believe that we have lost our way in the practice of medicine.  We have forgotten the very foundation of medical practice, which is to relieve human suffering.  We sacrifice our human connections in the practice of medicine because health care is first and foremost a business.  We continue to treat patients even if the effort is futile, and sometimes we even offer harmful treatment, in the name of prolonging life- when it can be physically, emotionally, and spiritually damaging to our patients.  Join us in this eye-opening conversation about palliative care, as it is a field that still represents ‘the good and humane’ in medical practice.  Dr. Diane Meier, MD  is the founder and was the longtime director of the Center to Advance Palliative Care, a national organization devoted to increasing access to quality health care in the U.S. for people living with a serious illness.  She has received numerous awards and was the 2008 recipient of the MacArthur Foundation Fellowship (aka the MacArthur Genius Award).

In this episode of Hear Me Now, a conversation with Dr. Diane Meier, professor of geriatrics and palliative medicine at Mt. Sinaia School of Medicine, about increasing access to quality palliative care programs and the state of palliative care today.

In this episode of Hear Me Now, a conversation with Dr. Diane Meier, professor of geriatrics and palliative medicine at Mt. Sinaia School of Medicine, about increasing access to quality palliative care programs and the state of palliative care today.

Age-Friendly Ecosystems "It's a blessing to be an older adult." -Melissa Batchelor, PhD, RN, FNP-BC, FGSA, FAAN For decades, advocates have called for communities, neighborhoods, and organizations like hospitals to become more "age-friendly." Although the idea of an age-friendly society has been promoted both locally and internationally, adoption remains more aspirational than an organized practice.  In this week's episode of This Is Getting Old, Dr. Terry Fulmer and Amy Berman walk us through an overview of what it means to have created an Age-Friendly Ecosystem.  Part One of 'The Age-friendly Ecosystems'. The John A. Hartford Foundation has been working with the Age-Friendly Foundation to convene leaders of these age-friendly movements. The goal is to help make the "age-friendly" moniker clear to all stakeholders in terms of what it means.  At the George Washington University’s Center for Aging, Health and Humanities, we have adapted the Age-Friendly Ecosystem to include Arts & Creativity.’ What Exactly Is an Age-friendly Ecosystem?  An Age-Friendly Ecosystem refers to the collective of all efforts to adapt society to meet older adults' needs. In simpler terms, Age-Friendly Ecosystems are the comprehensive, collectively built, and ever-expanding platform whose goal is to improve older adults' quality of life through enhanced, collective impact.  Moreover, understanding the Age-Friendly Ecosystem draws on the social-ecological model that acknowledges the connections and interplay between older adults and their environments or contexts. Proponents of the Age-friendly Ecosystem Movement The Age-Friendly Ecosystem is a movement to create age-friendly cities and communities started by the World Health Organization and carried forward by AARP (American Association of Retired Persons).  The John A. Hartford Foundation (JAHF) launched the Age-Friendly Health Systems movement with the Institute for Healthcare Improvement in 2017 to ensure the specific needs of older adults are met in health care. JAHF in 2018 then collaborated with the Trust for America's Health (TFAH) to involve public health agencies to expand the implementation of the age-friendly guidelines to the public health domain, acknowledging that these programs, notwithstanding their goals, have remained constrained and siloed. Many other organizations are advancing initiatives to make universities and businesses age-friendly.  The Goals and Objectives of Age-Friendly Ecosystems The goal of Age-Friendly Ecosystems has been to help make the "age-friendly" moniker clear to all stakeholders regarding what it means and how it should be adapted.   The work is leading to developing a common language and shared metrics so that anyone can recognize it and know what should be expected when we say "age-friendly." By working together across silos, different age-friendly initiatives can maximize their collective impact.  "An Age-Friendly Ecosystem refers to the collective efforts to adapt society to meet older adults' needs worldwide." -Terry Fulmer, PhD, RN, FAAN Guiding Principles and Frameworks of Age-friendly Ecosystems Each of the age-friendly initiatives has its guiding principles and frameworks. A big part of our effort is to help us understand those frameworks and what the shared characteristics are across them. The 4Ms Framework  An Age-Friendly Health System reliably delivers evidence-based care that reduces harm and focuses on What Matters most to older adults and their families. It is based on what we call the 4Ms Framework – essential elements of care that need to be addressed for all older adults – What Matters, Medication, Mentation, and Mobility. The 5Cs Framework The Age-Friendly Public Health Systems movement uses the 5Cs Framework:  Connecting and convening sectors and professions  Coordinating existing supports and services  Collecting data to assess community health status  Conducting, communicating, and disseminating research findings and best practices  Complementing and supplementing existing supports and services,  These frameworks are specific to the sector, clinical or public health in these examples but undergirding all of these frameworks are commonalities that lead us to the characteristics of an Age-Friendly Ecosystem. Part Two of 'The Age-friendly Ecosystems'. Characteristics of Age-friendly Ecosystems The convenings of leaders in the Age-Friendly Ecosystem, in addition to surveys of older adults, literature reviews, and expert interviews, have led to an understanding that several characteristics represent an age-friendly ecosystem. Understanding these characteristics helps us get to common language and metrics.  A forthcoming journal article will explain these characteristics and their definitions.  Age-Friendly Ecosystems: Current Standing in Terms of the Needed Common Language and Metrics  Since the fall of 2020, the Age-Friendly Foundation has been drafting a measurement taxonomy. They did that by identifying six outcome measurement domains that represent dimensions of age-friendliness. The domains are groups of similar outcomes, while the outcomes are explanatory concepts that can be inferred from measured or observed data. The Foundation is also looking at indicators or ways of measuring desired outcomes. They've looked at all the different frameworks outcomes and indicators – the Age-Friendly Health Systems, the Age-Friendly Public Health, WHO Age-Friendly Cities, AARP Livable Communities, Age-Friendly CAFÉ (Employers), and Age-Friendly Universities Principles— to supplement work in the health and public health frameworks.  Furthermore, the Foundation reviewed CDCs Healthy People 2030 indicators for Healthy Aging and Access to Care and the Association of State and Territorial Health Officials Policy Statement on Aging to expand and quantify outcomes related to health well-being. They've started with specific outcomes, such as Mobility, Walkability, Access to Jobs, and Labor Force Engagement. For each outcome, they identified indicators (or measures) recommended by IHI, CDC, WHO, and so on.  In some cases, they've added indicators where there were gaps based on a review of the literature. All of these are still in draft stages, and there is more to come. "Everyone has a role to play in eradicating ageism." -Terry Fulmer, PhD, RN, FAAN. How To Do Your Part In Building The Age-friendly Ecosystem? Everyone is encouraged to implement age-friendly programs, which will also  help us counter ageism and help all of us age with dignity and respect. In whatever sector you are in, reach out across to other partners. Start by checking out the blog on MelissaBPhD.com. You can find linked additional resources for age-friendly initiatives such as the Age-friendly Health Systems, Age-friendly Universities, and many more.   You can also join in the existing age-friendly initiatives, for example, the Age-Friendly Health Systems movement, by going to ihi.org/agefriendly. Or visit Trust for America's Health or our johnahartford.org website for more information on how to join the Age-Friendly Public Health Systems initiative, which has a new website: https://afphs.org/. "We've seen great success in this with public health working with aging services, working with health systems. This all connects to a crucial issue and call to action - everyone has a role in eradicating ageism, which is discrimination based on age. This means calling it out when you see and hear it. It requires you to make sure you aren't contributing to ageist perceptions of older adults." says Dr. Terry Fulmer, a nationally and internationally recognized leading expert in geriatrics.  “Older adults rightfully want and deserve dignity and respect.” Amy Berman, RN, LHD, FAAN About Terry Fulmer, PhD, RN, FAAN: Terry Fulmer, PhD, RN, FAAN, is the President of The John A. Hartford Foundation in New York City, a foundation dedicated to improving older adults' care. She serves as the chief strategist for the Foundation, and her vision for better care of older adults is catalyzing the Age-Friendly Health Systems social movement. Dr. Fulmer is an elected member of the National Academy of Medicine and recently served on the independent Coronavirus Commission for Safety and Quality in Nursing Homes to advise the Centers for Medicare and Medicaid Services. She completed a Brookdale National Fellowship, and she is the first nurse to have served on the American Geriatrics Society board. The first nurse to have served as President of the Gerontological Society of America, which awarded her the 2019 Donald P. Kent Award for exemplifying the highest standards for professional leadership in the field of aging. About Amy Berman, RN, LHD, FAAN: Amy Berman is a Senior Program Officer with The John A. Hartford Foundation. She works on the Foundation's development and dissemination of innovative, cost-effective care models that improve health outcomes for older adults. Among these efforts, Dr. Berman is responsible for the Foundation's work to advance Age-Friendly Health Systems, led by the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association.  She also leads many of the Foundation's efforts focused on Serious Illness and End of Life, including efforts to support Diane Meier's palliative care and the Center to Advance Palliative Care.    

Diane Meier, M.D., is professor of Geriatrics and Palliative Medicine at Mount Sinai Medical School in New York, N.Y., where she also holds a chair in Medical Ethics. Dr. Meier is the director emerita and strategic medical advisor of the Center to Advance Palliative Care (CAPC) where she has championed the sharing of best practices in the field of palliative medicine.  She has been succeeded at CAPC by Brynn Bowman, MPA, the new  chief executive officer. They talk with us about palliative care, about goals of training for caregivers, and the expectations for care that patients and families should expect.  To find a palliative care program near you, visit getpalliativecare.org or follow them on Twitter. Here's a link to CAPC's Tipping Point Challenge. 

In this recap, Marla and Mary discuss the 30th episode of Elevate Eldercare with Diane Meier, MD, director of the Center to Advance Palliative Care, a national organization devoted to increasing access to quality health care in the US for people living with serious illness. While every podcast is a learning experience, both Marla and Mary were quick to admit that they both learned quite a bit about the difference between hospice and palliative care. According to Dr. Meier, it is a common issue and concern for her and the national organization. Find out more about Robert Butler, who established the field of geriatric medicine and how he coined the term “ageism” back in the late 1960s. Mary and Marla also discuss Dr. Meier’s comments about the fragmented healthcare system and why palliative care has not been widely adopted by long-term care, yet 76% of the hospitals in this country offer it.   Learn more about Robert Butler here: https://www.aarp.org/politics-society/history/champions-of-aging-photos/robert-butler-gerontologist-longevity/  Find out where palliative care is located near you: https://getpalliativecare.org/ 

In today’s episode, Susan Ryan talks with Diane Meier, MD, director of the Center to Advance Palliative Care (CAPC), a national organization devoted to increasing access to quality health care in the U.S. for people living with serious illnesses. Under her leadership the number of palliative care programs in U.S. hospitals has tripled in the last 20 years. The two discuss what Dr. Meier calls a “hyper-fragmented sub-specialization system” that often loses sight of the person in treatment, and how this observation became a catalyst for her in developing a palliative care program at Mt. Sinai School of Medicine, and how palliative care programs have since scaled across the country. Dr. Meier provides a wonderful definition of palliative care, along with the clear distinction between palliative care and hospice care and confronts the notion that suffering only deserves attention when someone is predictably at the very end of life. She is passionate in her quest to see the whole person and provide a plan that prioritizes quality of life and function for each individual, and how we must advocate for ourselves or a loved one to ensure that anyone with a serious illness gets the essential support.  Ryan and Meier also discuss the impact of COVID-19 on the critical necessity of palliative care, and how CAPC was able to provide tremendous support and resources to patients, families, and healthcare professionals through the crisis. Connect with Dr. Meier here: https://www.linkedin.com/in/dianemeiermd  Find out more about CAPC here: https://www.capc.org/ 

In this podcast we talk about all things heart failure - from the culture of cardiology, how to impart palliative care on trainees, and practical tips on helping predict prognosis and symptom management. For more reading be sure to check out Haider's article in JPM on Top 10 Tips for Palliative Care Clinicians Caring for Heart Failure Patients and his article with Diane Meier in NEJM on Serious Illness 2.0 - Meeting the Needs of Patients with Heart Failure.

Dr. Diane Meier is the director of the Center to Advance Palliative Care in New York City. As a palliative care specialist, she has an intimate view of how the coronavirus pandemic is affecting patients and their loved ones. Meier shares her Brief But Spectacular take on showing compassion during COVID-19. PBS NewsHour is supported by - https://www.pbs.org/newshour/about/funders

Is the coronavirus pandemic generating a mental illness crisis? We talk to psychology professor and writer Andrew Solomon; Renowned palliative care specialist Dr. Diane Meier on the pandemic's impact on families when loved ones must battle COVID alone.

In this episode, Marie Cleary-Fishman, vice president of clinical quality at AHA is joined by Diane Meier, director of the Center to Advance Palliative Care and faculty at Mt. Sinai Health Systems in NYC and MacArthur genius awardee to discuss COVID-19’s impact on caring for seriously ill patients.

The cross-over episode is an American tradition that is near and dear to my heart. My childhood is filled with special moments that brought some of my very favorite characters together. Alf crossed over with Gilligan's Island. The Fresh Prince of Bel Air crossed over with The Jeffersons. Mork and Mindy crossed with Happy Days and Laverne and Shirley at the same time. To honor this wonderful tradition, GeriPal is crossing over with the Surgical Palliative Care Podcast for this weeks podcast! The Surgical Palliative Care Podcast is hosted by Dr. Melissa "Red" Hoffman. Red is both an acute care surgeon and hospice and palliative medicine physician in North Carolina. She has been podcasting since this beginning of this year and my goodness she has been quite busy in doing so. Her podcast featured some of the founders and the leaders of the surgical palliative care community, including Dr. Balfour Mount (the father of Palliative Care in North America), Robert Milch, Zara Cooper, and Diane Meier. That's an amazing lineup. We also welcome Joe Lin as a co-host for this topic. Joe is a surgery resident and palliative care fellow at UCSF. We talk to both Joe and Red about - How they got interested in the intersection of surgery and palliative care - How the culture of surgery and palliative care differ (and the misconceptions that both fields have of each other) - What the day in the life of a surgical palliative care physician looks like - A recent article in JAMA Surgery titled "Palliative Care and End-of-Life Outcomes following High-Risk Surgery" - What palliative care skills all surgeons should have (primary palliative care) - And lots of other topics! So take a listen and check out Red's Surgical Palliative Care Podcast (https://thesurgicalpalliativecarepodcast.buzzsprout.com/)

#005 - Join host Dr. Red Hoffman as she interviews Dr. Diane Meier, a professor of Geriatrics and Palliative Medicine, as well as well as a professor of Medical Ethics, at Mount Sinai School of Medicine in New York City (listen for NYC ambulances in the background!)   Diane is the founder of the Center to Advance Palliative Care (CAPC) as well as a recipient of the MacArthur Foundation Fellowship (also known as a "genius grant.")  She shares about the early days of CAPC and describes some of the educational offerings available through a CAPC membership (go online and type in your email to see if your organization is a member!).   Diane also discusses the importance of tailoring your message for your audience and reminds us to be thoughtful about our language, particularly when we are attempting to define palliative care.  I learned so much about communication from speaking with her!  Enjoy!Learn more about CAPC here.To learn more about the surgical palliative care community, visit us on twitter @surgpallcare.

There are few names more closely associated with palliative care than Diane Meier. She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC). We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including: * What keeps her up at night? * Does palliative care need a national strategy and if so why and what would it look like? * The history of CAPC and the leadership centers * Advice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careers * What she imagines palliative care will look like in 10 or 15 years? * What is the biggest threat facing palliative care? We hope you join us for this great podcast!

These podcasts excerpted from a 2018 webinar shares strategies for skillful communication, recognition, and response to needs of beneficiaries and their families throughout the course of serious illness, and engagement of palliative care consultants as an added layer of support. Timely recognition of hospice eligibility and referral in the months before death may improve quality of life and reduce reliance on emergency departments and hospitals for crisis management. The speakers also help the audience recognize the signs of the active dying process to ensure that thoughtful expert care is available during this vulnerable time.

Dr. Tim Corbin joins the Integrated MD Care team. He shares his experiences as the Director of Palliative Care at Scripps Health and why working with terminally ill patients is so meaningful to him.     Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text.  We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Transcript Dr. Bob: Welcome back to A Life And Death Conversation. I'm Dr. Bob Uslander, and I'm here today with my good friend, Dr. Tim Corbin, who has recently joined the ranks of Integrated MD Care after working for many years in various capacities as a hospitalist, a palliative care and hospice physician. Tim, I'm excited to have you on the show, and I'm excited to have you as part of our team, Tim. Dr. Corbin: It's good to be here. It's been a journey to get here, and it's a really exciting future for me. Dr. Bob: Well, we've been talking about working together for quite a while now, and timing is everything. Just so listeners are up to speed on you and what you bring to our team, tell me a little bit about your background, your training, and the work that you've been doing up until now. Dr. Corbin: Sure. Well, I'm internal medicine trained through my residency and became board certified in internal medicine. I went into private practice for a few years. I had the romantic vision of being able to take care of my patient completely in my office at home, in the hospital. I realize in the changes of healthcare that that just wasn't practical. It became more difficult at that time to make a living doing that, believe it or not, with insurance changes, and the evolution of HMOs, and all those sorts of things. What I really loved, being in the hospital, taking care of patients who were facing more serious illness and ultimately became a hospitalist as that movement was developing, so spent over 10 years being a hospitalist and taking care of patients in the hospital. But all along I've been doing hospice medicine. There was just a part of me that identified with patients, and I saw that need, and it was very meaningful work, so always a percentage of my practice evolved around caring for patients on hospice and at home. Palliative care became one of the fastest growing specialties in medicine, you know, kind of in the last 10 years. Having done hospital-based medicine as well as hospice work, I was in a position to really gravitate towards that, and it really spoke to the style of medicine that I like to practice, and I again saw a huge need, and so began developing really hospital-based palliative medicine services, and started one in 2008, and then ultimately became the director of the palliative care service at Scripps Health for four or five years. Dr. Bob: It seems like you were in a really well positioned for palliative medicine, being internal medicine trained, having all that experience in the hospital, working with hospice. I think, like me, what you recognized was there's a gap, right? Dr. Corbin: Absolutely. Dr. Bob: There's a gap between treating people aggressively in the hospital and then sending them off to hospice, where the entire focus is comfort and essentially waiting until the end of life. There's this big gap there, where people still need more care. Dr. Corbin: Having done so much care at home, I think I would see in the hospital what patients were often missing. You know, they were receiving their care in the hospital setting, and I always thought about the possibilities of doing some of this at home, where patients prefer to be and can be more comfortable if we had the abilities to do that. That was clearly a huge gap that's been improving, but in my careers, that was a huge gap for families and patients, so I recognized that pretty early on. I always used to joke that hospital medicine, you know, being a hospitalist and internist, strengthened my care, caring for patients at the end of life, but the opposite was true. Me doing hospice medicine and caring for so many patients when they were dying really strengthened my ability to be a better doctor upstream, as an internist, seeing patients in a hospital or even in a clinic setting. Dr. Bob: So, can you expand on that a little bit? Why is that? What do you think that results from? Dr. Corbin: I think for myself, if I'm effective as a palliative care physician, I'm guiding patients through the process of end of life, if patients and families don't recognize that there was a possible issue that could have caused more pain, or suffering, or difficulty, but I've been able to help guide that that never becomes and issue, because I have kind of a prospective insight about what may be coming, and so part of it is a skill of anticipating when we may not have good outcomes or beneficial care and not providing care that doesn't provide that. The way you set what beneficial care is and what quality is is really having those conversations with patients and families so that you gear your care towards what best supports them as a patient and a person. Dr. Bob: Yeah. What they want, what their goals are. Dr. Corbin: What they want. Dr. Bob: It's so true. I think that most physicians who don't take care of people who are dying or who don't see them in their homes, the traditional office-based physician, really have no idea what those challenges are and what's happening with people once they're no longer able to come to their office. I don't fault them for it, but there's a certain amount of ignorance or just lack of experience. They can't anticipate it, which if they can't anticipate it, they can't do anything about it. ` Dr. Corbin: You can take a history and a social history and ask patients, but when you're in the home, and you see for yourself, you see aspects that will affect patients' medical care. Now we're getting in the realm of talking about the social issues and the emotional issues, even spiritual issues. You go in a house, and you can tell a lot about what's important to a patient, and you can immediately identify conflicts and what we're doing medically that don't align with that. Dr. Bob: Right. That don't support that. Sure. Dr. Corbin: In fact, many times I would say, "You know, let me come see you at home next week," and patients laugh out loud, or they're taken aback. They say, "Well, I can come see you in your office." I say, "No. I really want to come see you at home," because I anticipate that later I will need to come to their home–in a fair amount of time–but also, again, it gives me that insight, and there's something about being in a home environment, where you break down some barriers of trust. You can be open with each other to really talk about what's most important. I had a very elderly patient who had a lot of medical issues going on. I thought I was going to her home to talk about that, but her cat kept bothering us while we were trying to have our interview. What it came down to, one of her biggest stressors was, "What's going to happen to my cat? Who's going to take care of my cat?" These things were affecting her ability to make medical decisions about what she wanted and what choices she wanted because she was worried about who's going to help take care of her cat. Dr. Bob: If she were coming into your office, she probably wouldn't feel like that was worth your time, right, to bring that issue up. Dr. Corbin: Right. If I were really an astute clinician, I'd notice the cat hair on her maybe, and I would be able to ask those questions, but I'm usually not that good. Dr. Bob: The second part of that is that someone who's in the patient's home may see the cat, and the cat may come up in conversation, but they wouldn't really be so perceptive or be so concerned about that dynamic, so it's not just the fact that you're there. It's also the fact of who you are. Dr. Corbin: Too often what we see as important to physicians and clinicians is medically based. It's disease based. We don't often think about the social dynamic of patients and how that may affect their health and their decision making. I think that is so true in the hospital setting because patients become institutionalized. I mean, you're giving up your freedom in many aspects, because you become a patient, and you become a patient within a hospital that has certain processes, and rules, and you don't have access to your home. This is something that is tolerated, obviously, by many patients, and we give amazing care, but when you start having patients who that's not really the most appropriate place for them to be, then we have to start creating better solutions than using the hospital as a way to kind of take care of patients who really don't want to be there or don't need to be there. Dr. Bob: Right, or don't need to be there, or it's detrimental for them to be there. Let's segue into that. We'll go back and talk more about what you're doing now because you've made a shift, and you're no longer in that position of running the palliative care and hospice program at Scripps Health, much to many people's dismay over there and joy on our side. But I wanted us to talk a bit about the hospital experience, the gaps that people experience, the challenges, because me, having my experience of being an ER doc for so many years, seeing people coming in various states and conditions, you as a hospitalist, palliative care physician, hospice physician, I think we're in a unique position to help people understand some of the challenges and risks that they face when they are in the hospital dealing with complex illnesses. You can I could spend hours, and hopefully, we will, talking about the different challenges and gaps that people face and ways to help avoid being harmed by them. Well, let's spend a little time focusing on what happens in the hospital, what doesn't happen in the hospital, what happens when people are preparing to be discharged, and where are the gaps, and what can people do to help prevent any further turmoil or challenge? I mean, you mentioned when you're in the hospital, you're in an institution, right? You're in their territory, so you lose some of your freedoms. I think that people who work in the hospitals, they lose sight of that. I mean, they're busy. Everyone's working hard. No one's lollygagging around, for the most part. I will make generalizations. In general, I think that people in healthcare really do care. They really want to do the job, and they really want to take good care of people, so it's less of a personal personality issue, and I think more of an institutional system problem, that we just don't have enough staff. We don't have enough people to provide the kind of personalized, supportive care that people are looking for and need, and that's largely a financial issue, right? I mean, what's your perspective on that, having spent so much time in the hospital? Why don't people feel, in general, like they're well cared for? Or do you think that they do? Dr. Corbin: I think in many cases they do, and in many cases, they don't. I think one of my family members, in their personal experience, made a comment that in the hospital they felt like they were a cog in a wheel, where there's this path of workup, and diagnosis, and treatment that is on a course of, you know, kind of standard medical treatment that, again, a patient gets put into. A patient's in a bed. The physicians discuss having, "Well, we need to get a CT scan." It's ordered, and all of a sudden someone shows up to the patient, and they're whisking them to the radiology, and the patient doesn't understand why. When you sign yourself up in a hospital, you're signing yourself up and agreeing to the treatment that needs to be done for your particular issue. As physicians and clinicians, we're trained to treat that condition. You know, there's kind of a process and an algorithm to that, to a certain extent, and we don't often go off course. To not do something could risk missing a diagnosis or risk of there being downstream harm, and physicians are very sensitive to that, whether it's from the standpoint of malpractice or not providing a standard of care. The standard of care becomes doing everything, which is not always appropriate. It's not always beneficial care. I tell you, patients often recognize that, and they understand that and are willing to take that risk, if you will, so there becomes this disconnect between what the treating teams are doing and what the patients really want. The patients, it's not that they don't want to be hospitalized. They may say, "You know, I'm weaker at home. I'm 90 years old, but my quality of life's pretty good, so I don't mind coming in and getting treated for pneumonia, but I'm not really up for getting a bunch of CT scans and being poked and prodded and this sort of thing," so where is that balance? In many ways, it's the physician's job to cure and to treat fully, but we're not always taught how not to do everything, so I think patients need to recognize that. There are many times patients bring up the fact and want to have this conversation. So, in the last 10 year, palliative care teams have developed in the hospitals, which are multidisciplinary teams made up of physicians, and nurses, and social workers, and even chaplains to really address patients' emotional, social, spiritual needs, as well as their physical needs, but really it developed as a support team to help support patients with serious illness through the hospitalization, which is kind of crazy when you think about it. Our technology and ability to treat patients is so, you know, high tech and the ability to keep patients going and keep patients alive is so extended that we need support teams to help- Dr. Bob: To protect them. Dr. Corbin: ... to help fend off, you know ... It's kind of like the ability to turn off your cellphone and ways for patients to connect with you. It's very interesting when you start thinking about the ... I always joke that I hope I don't have a job as a palliative care doc one day because that means that our healthcare system is treating patients with the values and the principles of palliative care that we don't need specialists in palliative care to do this. I think we'll always need our expertise and specialty, but there's so much work to be done in that realm of taking care of patients holistically. Dr. Bob: So, a huge issue that we touched on is that when people are in the hospital, sometimes the care is appropriate, and then there are times when it just goes beyond what they would want or might seem necessary because that's just the way it's done. My sense is that it's the path of least resistance. A person is in the hospital. They've got a condition. Something else might be identified. Then they get a consult with the kidney specialist, and they get a consult by the cardiologist, and a consult by the infectious disease guy, and the pulmonologist. Everybody gets a piece of this patient. Everybody gets paid, but everyone's ordering the tests that they feel are appropriate, potentially the treatments that they feel appropriate, and then before you know it, there are six different physicians treating the patient, and they're now a week into it, and they've been tested and treated way beyond they may have ever wanted, because those conversations are not happening. Dr. Corbin: Let's think about each of those physicians who are seeing those patients, who are amazing clinicians, really good docs, want the best for the patients, want the best outcomes, so intentions are all perfect and good, but in today the chances that any one of those physicians has a long-term relationship with that patient is almost zero. We now have sub-specialists, who do nothing but round in the hospital for their group. We used to have just hospitalists. Now we have cardiologists that are hospitalists. We have GI docs that are hospitalists. We have neurologists that ... when you get admitted to a hospital, you have this new team taking care of you, and no one has had that relationship over time. If you, as a patient, have defined what is most important to you and what your true goals are for your life, what gives you dignity and respect, and how you want your life to go as you become sicker, no one has appreciation for that. That's one reason we have palliative care teams, because we sit there for three hours and try to understand this, so we can affect what we decide to do with patients. If you don't have those conversations, as my family said, you become a cog in a wheel, where we're going to treat whatever's going on as we do everybody, and there are tremendous pressures to then get you out of the hospital. You know, we always want a shorter length of stay. Dr. Bob: We do everything- Dr. Corbin: When I first started as a hospitalist, patients stayed in the hospital five or six days. Now it's down to below four days, three days average length of stay. Tremendous pressure to see patients, make a diagnosis, start treatment, and then get out of the hospital. So, you don't have the luxury of time to sit there and think about what you want, or you don't want, because people are coming up to you constantly saying, "We need to do this next and this next." So, it can be completely overwhelming. Families and patients get in a crisis mode. You know, I tell families and patients, "It's really not a good place, in a hospital, to be making life or death decisions, when you're in a crisis mode, where you're emotionally stressed. You haven't been sleeping well. Family's flying in from out of town everywhere, and you're being asked to make decisions that hugely impact what your future is going to look like. You really need to try to have these conversations earlier." Dr. Bob: Very critical information, the timing of that, when you do it, but a lot of times it's not being done. Dr. Corbin: Absolutely. Dr. Bob: So, we now find people who are facing this. They're in the hospital. They're being asked or kind of demanded to make a decision about what's next for them, which may mean going home with certain treatments. It may mean going home and being in hospice. It may mean going to a nursing facility. But they're being pressured, because of what you were just describing, where there's pressure on the physicians to discharge patients and get them out of the hospital quicker, which in some cases is appropriate, but it puts this new sense of time pressure on families to make decisions, and they're getting it from the hospital discharge planners, and the case managers, and now the doctors. So, what do you do? Dr. Corbin: Yeah. You started this conversation talking about gaps in care. I think the gaps are that, you know, our healthcare system's kind of in silos. You see your primary doctor. You go to specialists. When you're in the hospital, you have your hospital team. When you leave the hospital, you may go to a facility, like a skilled nursing facility, which has its own team. So, the patient needs to speak for themselves. We talk about healthcare now should be more patient-centered and family-centered, where the patient should have the autonomy in decision making to make decisions that are best for them, but they're constantly facing a new team. I once looked at social workers' touches on a patient who had cancer very early in their diagnosis all the way through to the end of their life, and they had five different social workers over the course of like a two year period. You know, they had a social worker, outpatient oncology social worker. They had a home health social worker. They had a social worker in the hospital. The palliative care team had seen them eventually, and they had their own social worker. When they ultimately went home on hospice, they had a different social worker. So, you can see that families and patients sometimes complain about having to tell their story again, because they're constantly having to tell their story again– Dr. Bob: Over, and over, and over. Dr. Corbin: ... and reiterate what's most important to them. You know? It's almost like telling my story fatigue. They just get tired of that. So, there are the gaps where there's not that support. Dr. Bob: The continuous support, the continuity. Dr. Corbin: And often it's about explaining to families and patients what their options are and how to be prepared for those things. It's much easier to do it when you have a little bit of time and space. It's very hard when you're told, "You need to figure this out within two days, because they're being discharged in two days, and we need to know if they're going to a skilled nursing, or are they going to go home with more support, or whatever the case may be." Then patients often, depending on what kind of support they need, they may ... For example, hospice, which is by definition for someone whose prognosis is estimated to be less than six months of life. With that, you get a hospice service, and you get kind of this comprehensive care that's paid for through a hospice benefit. It's great support. You have 24-hour care for nurses, a triage available. They can come to the home as needed. Medicines are often delivered to the patient. You have a social worker, physician's visit, do home visits. I mean, it's an amazing program, but it's for the more very end of life. I see a lot of patients who are kind of really I wouldn't say pushed, but one of the options is to go to hospice when maybe it's questionable whether they may qualify. It's questionable whether that's what they truly want. They're not maybe ready for that, but they get the support because everything else is breaking down, that they're kind of pushed towards that, and then patients get better because there's not another alternative. The alternative home is often home health, which doesn't give the same amount of support. If patients' preferences are to get home, one of the huge gaps is enabling patients to get home with the kind of support they need. By default, if we don't have that, they have to go to a skilled nursing facility many find it very difficult to participate, but they're supposed to participate with a certain amount of therapy. They prefer to be at home. You look at a healthcare system that's looking at ways to be more cost-effective and to give beneficial care. You know, you have a situation where patients prefer to be home. That's where they want to be, yet there's no infrastructure to support that, yet it's inexpensive care when you compare it to a skilled nursing facility, or you compare it to going back in the hospital, and yet we haven't, as a healthcare system, figured that out yet. There have been improvements there, but it's a gap. It's a problem. Dr. Bob: Yeah. I think one of the reasons that it continues is because the people who are making the recommendations and facilitating the discharge, physicians, discharge planners, case managers, they have a hard time thinking outside the box. They're looking at what is the most efficient. They're looking at multiple factors. They're looking at what's in the best interest of the patient, what's going to allow them to get the patient out most efficiently because they have pressure to discharge the patients, and then what they're familiar with. How do you facilitate it? Unfortunately, what's in the best interest of the patient or what's most aligned with the patient's goals and values drops down the list of priorities, and people, patients, and families don't know to question it. They don't question the doctor. When the doctor says, "You need to go to a nursing home," well, that's where you need to be, but many times, as we both know, that's really not what's in the best interest of the patient or the family, and so everyone continues to struggle. Dr. Corbin: We should always question, as patients and families, if possible, just not question, but understand. If I'm going through a test or if I'm being sent somewhere, you know, why? What's the purpose, and what is the outcome, and what's the endpoint? What is my goal? I often tell patient and families, "Let's understand who you are as a person, as a patient. What's most important to you? What gives you the quality of life and meaning? And let's align the medical care we provide and the support we give with those goals." It's approaching the patient from a completely different perspective than what we're really taught in medical school, which is really disease based, you know, history and physical, if you will. Diane Meier, who's a leader in palliative care, had a quote. I don't know her exact words, but basically, she said, "You know, palliative care is about matching patients' goals with the medical care we provide." Dr. Bob: It needs to be driven by that, and it's not. And patients still, especially the older patients that we get to take care of, they're intimidated. They don't feel empowered to question what's going on. They may, in some cases, and sometimes there's a family member who will stand up and advocate, but too seldom does that happen. We, I think you and I recognize these gaps. We're working towards trying to fill them in our way, in our community, but what I'd like to do is to give a couple of, I guess action items, a couple of things that people can do to take away from this discussion when they have a patient, a family member, or themselves admitted to the hospital who is then going to be discharged. What are the couple of things that we would recommend that people could do? I'll start by saying, in general, if possible, you should never allow a family member to be in the hospital alone. Whatever needs to happen. And I know it's not always easy. It can be very challenging. Sometimes it's costly, but when a person is in the hospital, they are sometimes sedated. There's the potential for medication errors. I had just a patient who was a 31-year-old woman, who was on pain medication for an intestinal disorder that made it so that she couldn't eat anything. She was being fed through feedings going through her veins. She got an infection. She was hospitalized. A well-meaning nurse, but a relatively new nurse, instead of giving her five milligrams of Methadone, gave her 50 milligrams of Methadone, which is a huge, potentially fatal error. Those types of things happen all the time. It's not just the errors. It's the feelings of loneliness, of isolation, of needing to get somebody to come in and help you get to the bathroom, to understand what the doctors are saying when they come in on their rounds, which could be whenever. People need advocates, and I will never allow a family member of mine to be in the hospital at any point without somebody there to advocate for them, so I would strongly encourage people to find a family member, friend, or even if you have to to pay someone to be there with you. Dr. Corbin: Yeah. I would agree with that. You know, things in the hospital happen fast. We used to round as a team once a day, get all our tests, round the next day. Now we're rounding multiple times a day on a patient. You'll round, get some tests. You'll round again in the afternoon. Things happen quickly, so for a family to get real-time information is challenging if you're not there. I also tell families, "You know your loved one best. What are you seeing?" Subtle confusion or changes in their cognitive abilities, which is very common when you're hospitalized, particularly when you're older, may be missed by someone who doesn't know the patient. If you treat that early, you can kind of help prevent some of that, so there are lots of reasons to have an advocate for a patient there, for sure. That's one of the risks of hospitalization. I mean, it's well documented, medical errors, and hopefully, there's been an improvement in protocols, but the reality is is that, again, you're institutionalized. There are processes, and as much as there are checks and balances to avoid mistakes, mistakes can happen that can cause harm. It's been well discussed in medicine as an issue in our healthcare system, as well as infection risks, and often hospitalization tends to lead to more treatment. One thing leads to another, so you have to define what your purpose is in the hospitalization. You may know this. What an ER doc told me once, "As soon as a patient comes into the ER, the first question I have, 'Am I sending them home, or am I admitting them?'" I mean, that's the first question they ask. You know, as a hospitalist, I would say, "Okay. When am I discharging this patient?" It was all about the discharge. It's, "What do we need to do to get the patient out?" That doesn't mean we're not concentrating on treating, but there's such pressure to get patients out. So, another thing of having someone be there with the patient, be an advocate, is really advocating for what the vision of the patient needs to be in transitioning out of the hospital, back home or wherever that might be. Dr. Bob: Right. You alluded to this, the experience and the perspective of an emergency physician, and I think another tip for people is really thinking about whether you need to go to the emergency room or not. Give some serious consideration to that, because when an elderly person or a person with complex illness ends up in the emergency room, it's far easier to admit them to the hospital than to discharge them. Whether that's in their best interest or will ultimately result in improvement, or the opposite becomes kind of secondary. Speaking from the perspective of a physician who worked in the ER for 20 years, when an ill or elderly person comes in, ideally we could assess what's going on, determine what needs to happen, and determine if we can safely allow them to go home, which is where they'd rather be, and in many cases that's the safest and best thing for them. But because that takes more time, energy, and puts more risk on us as a physician, the path of least resistance is to call the hospitalist and say, "I've got a 95-year-old who's maybe got a touch of pneumonia and a little fever," and they might fight you, because they don't want to do another admission, but you're going to push that. Then you're going to order all the tests and order all the x-rays to cover yourself. So, there are times when we pick up things, and that kind of a workup and approach is valuable, but there are many times when it's not. Dr. Corbin: Another thing for patient families to realize, is that most physician offices are open from 8:00 to 5:00, but it's often 9:00 to 4:00 or something like that. After hours, and weekends, there's more chance that you're going to have an issue off hours than you are during regular business hours. Our human bodies function or not function 24/7. But one question for patients and families is, "What do I do after hours or on weekends if I have a medical problem?" Unfortunately, by default, if there's an issue after hours, and if you have any kind of significant medical history with advanced illness, no one's going to take the chance that something is missed–so they say, "Go to the emergency room," or, "Go to Urgent Care." That's just what we do. We impact our emergency rooms. It's very expensive care. Most of the time, if you have significant illness, the ER doc's going to feel uncomfortable sending you home, because they don't know you, and it's complicated, and so you end up getting admitted. As a hospitalist, I felt I did a lot of admissions, which were unnecessary. If someone was there to coordinate care at home, and kind of have an oversight, and there was that plan of what to do if it was after hours. That's amazing thing of your service with integrated MD care is that someone who has that layers of care, you know, all this is kind of planned out, and you have that support, and patients are really satisfied because you're not just ... Patients aren't just being sent back to the emergency room, and you get, again, into that cog wheel of treatment, where many patients don't want to be, which is another point. One of the risks of hospitalization is when you go, the medical records, you know, your history, what's been done, there are often duplicated care. You get more imaging tests, and you get more workup that you don't really need. I really advocate for patients and families to take a medical history and have that with them. If you come with a full binder, no one's going to look at it or read it, so it needs to be kind of done by someone with some medical knowledge to very succinctly put the diagnosis and what treatment's been done, so it's well understood, because- Dr. Bob: A summary. Dr. Corbin: We just reinvent the wheel. Again, this new team takes over, and they're kind of obligated to do the workup, and it's probably, in many cases, already done. It doesn't seem like a big deal, until you're in that seat, or you find those tests to be very difficult to get through. You know, to go through an MRI, if you've ever had an MRI, it's not a fun experience. I've had one, generally young and healthy, and it was really tough. Imagine if you're in pain, or have more advances illness, or if you're elderly going through these tests. We don't think about it. We think to go to the hospital; you just do what you need to do. You get these tests, but we don't understand kind of sometimes the physical and emotional toll that that takes on you. Dr. Bob: It's very easy to order the tests, right? It's very easy to order an MRI, or a scan, or another blood test, but even just getting blood drawn, these people, the folks, they're sick. They feel horrible. Dr. Corbin: I used to challenge my ... I used to come in as an attending, whether I had residents or teaching. It was like day number seven of hospitalization, and they had the same blood panel every single day. I'm thinking, "What are you going to see in this blood test that may change what we're doing in management?" I mean, we get in this protocol where we stop thinking critically, and we just start treating patients as a process, and- Dr. Bob: Yeah. And a commodity. Dr. Corbin: It's easy to do. You referenced it earlier, about how when you work in that environment, it's comfortable to you. You know it. When you're not in it, it's over. I remember the first time as a medical student I walked into an intensive care unit. I kind of stood back, and it was just kind of a, "Wow." It was kind of overwhelming. Well, you know, when I was a resident, and I spent a whole month being an attending resident in the ICU, after that month it was ... Even after a month it became pretty routine, and all those bells, and whistles, and machines, and tubes, and everything else became kid of normal, which is kind of scary when you think about it, but you've just kind of normalize to that. We always have to back up and understand it. That's what's so hard to have these conversations with patients and families, to really get them to understand what things may look like as they make different choices about their treatment. I say, "There's no right or wrong answer about the treatment." I think patients need to understand their choices and make the decisions that are best for them, and then we try to support them in that decision. I think to have a good history available with you, be prepared with what your true goals are downstream, so you can share that information with physicians and teams, if you change different healthcare settings, and then really having someone that can really coordinate that care for you. If there's someone in the family that can't do it, and you have the means to have someone else or hire someone to help coordinate that care, just like having someone be with you in the hospital, there's no doubt you're going to get better care. Dr. Bob: Yeah. That's critical. Unfortunately, I think once you're in the hospital, it's hard for outsiders to come in. You might have that. So, for me, we do this high level of in-home care and become very intimately connected with our patients and our families. We do a great job of keeping them out of the hospital, because we are available 24/7, and we address things as they come up, and we really try to encourage people to not just rush to the hospital. In general, we're pretty successful at that, but sometimes people end up in the hospital. Even though I have this very intimate relationship and the patients want me and my team to be engaged, the hospital doesn't want that. They don't want outsiders coming in, and it's very difficult to get much information. I'm able to communicate with the hospitalists with some effort, but you can't coordinate anything. It's very difficult to influence the care that's happening, so you have to be able to work with the families, to spend some time with the patients, and allow them to become self-advocating as much as possible. Then get them the heck out the hospital as quick as possible, right? Let's talk for a moment about palliative care, because it really can add a lot of value to the experience for people in the hospital and save them from some future struggles and help guide things more in alignment with their values and wishes. Is palliative care available for every patient in the hospital, or how does somebody get a palliative care team to work with them and support them? Dr. Corbin: That's a very good question. Palliative care, first off, is really available to any patient at any time in their medical illness. It's a whole-person, holistic approach to care, where we address patients' physical needs, but also, as I mentioned, emotional, social, and even spiritual concerns, and try to align our care with what their true goals are for themselves, knowing that those goals may change with time. So it's a fluid situation. But it's really having those conversations and supporting those patients in that goal. It's a team approach, so it's a physician, and a nurse, and a social worker, and often a chaplain, and also maybe sometimes ancillary services as well, so it's a team approach as well. There's a lot of talk the last year that unfortunately palliative care, someone gets palliative care by chance. We know that palliative care is beneficial. We know it enhances the quality of life. We know patients like it. There's less caregiver stress. There's better end of life experience in death when that time ultimately comes. Patients can tolerate their medical treatments better when they have palliative care involved. We know all the outcomes look really good. Palliative care across the board is inaccessible to all patients in every care setting, and so it becomes who do you know? It's, "Oh. Well, I know my neighbor's Dr. Corbin, who does palliative care. Maybe you can call him," and so, oh, I get involved. It's kind of word of mouth and by chance, which is fortunate. Hopefully, in the future, we get palliative care across the spectrum. Palliative care started in a hospital setting, and now over 70% of hospitals in the country have some sort of palliative care team. For example, Scripps Health has palliative care team at all five or their campus and hospitals. So, patients in the hospital can request palliative care consultation. Usually, it's up to the attending physician, whether that's the specialist or the hospitalist, to request a palliative care consult. Dr. Bob: Can a patient or family request a consult? Dr. Corbin: It depends on the hospital. For example, at one of my hospitals, where I started the palliative care team, we made it so anybody could request a palliative care consult, family, the patient. It doesn't have to be from a physician. In that setting, we sent a nurse in to really evaluate the situation, to see what was happening, and then to talk to the attending physician and say, "Can palliative care ...?" But it was a real challenge, in the beginning, getting in the door. Dr. Bob: I would imagine. Dr. Corbin: In many ways, we're seen as a threat, or we do another layer of care that then can be seen as getting more complicated, but the reality is is that we're working through all these issues that really are not discussed. So, that's in the hospital. Most hospitals have palliative care, so if there's a desire to have palliative care if you ask. Often you can look online or read about the hospital, and they advertise their palliative program. The big gap is outpatient palliative care, so what happens to the patient when they go home? If they go to a skilled nursing facility, most likely they don't have palliative care. If you go home, most likely you're not going to have home palliative care, although there are some programs that exist now. There are different levels of what that means. So, if you've seen one home palliative program, you've probably seen one home palliative home program in terms of structure. Some are just nurse-driven. Some are just physician-driven. Dr. Bob: Or physician assistant, but none of them have figured out the model so that they can really deliver. Dr. Corbin: And the barrier's really been about reimbursement, who can pay for that. Unfortunately, that hasn't been figured out. There are trends now with private insurances, as well as possibly even Medicare, starting to pay for kind of more home palliative kind of bundle payments towards that, which will hopefully gain more access. Dr. Bob: Apparently Medi-Cal, which is the California Medicaid program, as of January 1st, is now paying for some version, some form of palliative care. Dr. Corbin: I know Blue Shield of California is paying for home palliative services for some of their patients they identify that need that. So, the other is outpatient palliative care in clinics. Now that's the third tier, so it's been kind of hospital-based, an attempt to do more home-based palliative care, and now actually doing even farther upstream where patients in a clinic setting can get palliative care has been pretty rare. I started an outpatient palliative care clinic at Scripps, which we ran in a radiation oncology center, which is a great setting, and I saw patients in the clinic just to kind of see patients kind of farther upstream. The powerful thing of that is that we were having these conversations not in the hospital when you're in the crisis mode. Because what happens? You can have all of this great plan and this great conversation in the hospital and know what you want to do, but as soon as the patient leaves the hospital, it all falls apart, because there's not the infrastructure or process to support it. You go back into the same process of delivering medical care that we do, which is going to your primary office, going to your specialist, and after hours, if you don't have availability, you go back to the hospital. How do you break that cycle? Dr. Bob: Your family was trying to figure out how to find the right resources for you. Dr. Corbin: So, seeing patients in a clinic upstream is extremely powerful. I would encourage patients with any non-curable illness, whether that's heart failure, or early dementia, or Parkinson's Disease, or an advanced stage cancer,–even if you're getting full treatment, you expect to get treatment, your illness will hopefully be well controlled for years to come–still you should have a palliative care type conversation with a physician or a team that understands the longterm vision. One, you start to have conversations that you don't want to have in crisis mode, or you don't want to have way down a couple of years from now when you're being admitted to the hospital. That's not the right time to have these conversations, to really, truly know what you want. It also relieves this burden. It's always the elephant in the room, you know, what do I truly want, and having these conversations. Frankly, having conversations about death, and what it may look like, and what your preferences are if you do that, it's not threatening when you do. If you do it when death is a real possibility– Dr. Bob: Death is looming. Right? Dr. Corbin: ... it's incredibly frightening and overwhelming. Dr. Bob: For everybody, including the physicians. Dr. Corbin: Including the physicians, so by fault, we don't have that conversation. So, the patients that can have these conversations, and they want ... Studies suggest that patients want to have these conversations. Dr. Bob: And experience would confirm that. Dr. Corbin: We just don't do a good job, as physicians or clinicians, having those conversations. We just don't want to have the conversation. Palliative care in the hospital, there is some in the outpatient clinic. For myself now, I have two days a week where I do outpatient palliative care, where I can see patients in a clinic setting. I'm working within an oncology group, but I'm open to more than just oncology, so if patients know about me, they can come and see me. The purpose is to say, "Hey. What's going on medically? What's going on in your life? Where are your stressors?" You know, I ask patients, "How do you feel your quality of life is? What is your distress? How are you sleeping? How are you eating? What are you eating? How is your nutrition? All of these are things that we generally don't talk about with patients. But it's all about how can we identify things that are important to you? I had a younger patient, with advanced cancer who, after a long conversation, two things in her life were missing. One, the ability to still do yoga, and two, she had some experience with acupuncture, and she was interested in trying that again, but she was kind of bummed that she tired and couldn't do yoga anymore. Through connections, and friends, and again, palliative care by chance, I called a couple of friends, and one goes once a week now to help her do restorative yoga, and another goes once a week to do acupuncture. She's just thrilled. She's thriving. Her tumor markers are decreasing. She's responding to her chemotherapy. Her sense of wellness is much better than what it was before. She has hope. She's confident. She's living with her cancer better. I guarantee you in a normal healthcare environment, that would never come up. If she didn't seek palliative care, no one would ever have the conversation about setting her up with home yoga or acupuncture. It just doesn't happen. Dr. Bob: It sounds like a great concept. I kind of wish I had thought of that. Dr. Corbin: And you did. You know, what you do, the services that you can provide through integrated MD care, for example, the music therapy or aromatherapy, or massage therapy, or acupuncture, many patients don't think about that being important, but it's incredible how that can help you tolerate treatment better, reduce stress, take away some of the fears that you have. Ultimately we're deciding what are you afraid of. Is it what's coming tomorrow? Do you make up a story in your mind of what your future's going to look like, or you make decisions based on that fear, or you have conversations about that? Do you understand the facts medically, from a physician and have someone who can tell you, "This is most likely what will happen, and there's evidence to support that,"? And you get rid of this stuff we make up that scares us, and then you start to trust yourself. You start to trust life to give you what you need, and patients start to respond to treatment and can tolerate things at a whole other level. Dr. Bob: If those things that would enhance your life, and those people, and those therapies are presented to you and through trusted sources, and you open yourself up to them, I've seen, as you are expressing, I've seen tremendous, tremendous transformations in people. I've seen people, who had a prognosis of a month, and they were being told that they've got a month or six weeks to live, open themselves to receiving these therapies and ultimately live for a year and a half with an incredible quality of life. The reason for that, it's multifactorial. Part of it is the actual therapeutic benefit. A lot of it is just this connection that happens with life through other people, who are there to reach into your spiritual being, to help bring out the joy. So, that's a powerful, powerful thing that there's really no way to really put any kind of value on. Dr. Corbin: It's really taking your life back from whatever disease you're dealing with. You think about it, you know, you're whole day. I saw a patient yesterday who wanted to come to my clinic, but he said, "You know, but every single day I have a doctor's appointment for the next two weeks. I don't know if I want to come see ..." I mean, your life revolves around testing, and diagnosis, and treatment, and you lose the things that were important to you, like yoga and massage therapy that you used to do. Dr. Bob: Or time with your grandchildren, or time at the beach. Dr. Corbin: Or time to read or whatever. So, if we can challenge patients to make space for that and to remain who they are as a person through their treatment, it's invaluable. You know, unfortunately, I was never taught that in medical school. We're not taught how to take care of that aspect of patients. It's been, you know, over 20 years since I've done that. I think the medical education system has responded to that in many ways, and it's getting better, but the reality is is that we don't ... We talked about this earlier. I'm taught how to do a history and physical, and the things that I ask in my social history, like, "Do you smoke? Do you drink?" You know, those sorts of things, but I'm not taught, "What is most important to you? How is your stress level now? How is your nutrition?" We just don't ask those questions. Dr. Bob: Yeah. Certainly not, "Where do you want to be when you die? Who do you want to be around you?" Because for me, and for you as well, the idea is starting with the end in mind. If you can get people to share what that experience, how they would like that experience to be, it tells you a lot about who they are, and then you can help to guide all the care that happens. Dr. Corbin: That conversation intertwines a lot of spiritual, religious, philosophy, all of these things, right? But it's not about that conversation. I mean, I can have a very religious person or a very spiritual person who still hasn't truly thought about the way they want their end of life to look like. Sometimes who I think might be the most religious or spiritual person struggles the most with that decision, because they haven't thought about it in the context of that. No matter what your belief system is, no matter what your support system is, if you're challenged to think about it, it's an exercise we should all do. Dr. Bob: And people will often spend a lot of time thinking about how it should be for others and what they're comfortable with, and what they believe. But it's very difficult for many people to actually go down that path and take it to the point of imagining and trying to identify what's most important for them at the time of their death. Dr. Corbin: So, we've covered a lot. Dr. Bob: Yup. Always. Dr. Corbin: We've touched on a lot of issues. I think, hopefully, this is really valuable for people to get some real, heartfelt discussion from physicians who have been right in the fray. Right? I feel like we have a kinship here. We both love medicine. We both love medical people. We have a lot of respect for the passion, and the heart, and the compassion of healthcare providers. We're sensitive to the fact that they are often working in environments that don't allow them to practice optimally, and it gets very frustrating and discouraging. We see how wonderful the medical technology is and what it can do for people, and at the same time, we see how that has created this propensity to use that technology, and wield it un-responsibly, and neglect sometimes what's really and truly most important to people which can be to encourage them to take a different path. Dr. Bob: We have a lot of experience. Hopefully, we've shared some things for people to think about, and I think we're going to have lots of opportunities to continue exploring, discussing the pros, the cons, the good, the bad, but I'm excited, because we, in our practice, get to fill the gaps. Dr. Corbin: Absolutely. Dr. Bob: That's why we started Integrated MD Care. That's why we're doing this podcast. That's why we're doing a lot of the things is we're responding, we're taking a risk, right? Dr. Corbin: Absolutely. Dr. Bob: We're stepping outside the norm, and we're facing some folks who don't quite understand what we're doing, how we're doing it, or why we're doing it, but I think we're both committed to the process and to serving people at the highest level. Dr. Corbin: Absolutely. I agree. At the end of the day, we need to listen to the patient, keep the patient in the middle, provide patients with the best quality and beneficial care, and that really comes from talking to the patient and understanding what gives them the most value. That's what it's all about. Then we need to help continue to push our healthcare system to give the infrastructure to support patients with that. It's really exciting to see the work that you've been doing, and the outcomes that you've had with patients and families and really helping patients be able to transcend those gaps to get the perfect alignment of care that they deserve. You know? And making it not about palliative care by chance or this type of care by chance, because someone happens to know you, but really hoping things like this podcast will start to trickle out there, so patients are aware of what is available. Hopefully, we'll push the expectations higher, and our healthcare system will start responding to that. Dr. Bob: Yeah. That's our goal. Dr. Corbin: Look forward to it. Dr. Bob: In the meantime, we're doing it, and we're letting people pay for it, to recognize the value that they receive. The non-profit foundation that's just been created, Integrated Life Care Foundation, will help to provide funding for people to receive this level of care when they don't have the resources to do it. I'd like to now officially welcome you to the Integrated MD Care team, as one of the providing physicians and one of the leaders of this movement. Dr. Corbin: I look forward to it. A lot of work to be done. Dr. Bob: Absolutely. Thanks for coming on the show, and we'll be connecting again soon.

Suzanne talks to Diane Meier, Director of the Center to Advance Palliative Care (CAPC) about a specialty that is not getting the attention it deserves yet- palliative care. Learn what it is and why we so desperately need to advance its use to help the many Americans with serious illness cope with pain in the United States, and save money in the process.

The post Episode 5: Diane Meier appeared first on Death By Design, End Of Life Planning, Pallative, Hospice. See acast.com/privacy for privacy and opt-out information.

Why palliative care is so important, not only for a seriously ill patient but for the entire family. A conversation with palliative care specialist Dr. Diane Meier.

eCareDiary's caregiving expert, Margery Pabst will speak to a caregiver panel and Diane Meier,  CEO of the Center to Advance Palliative Care (CAPC), about what palliative care is and what it means for patients, caregivers, and their families.

Palliative care has been a little understood aspect of our overall health care system even as it has become more recognized within that system as a valuable resource for patients and their families. Patients often have no education about how palliative care and hospice can serve them and ease the tremendous stresses of serious diagnosis. Thankfully, pioneers in the field have conducted an impassioned fight to educate, validate and increase access to this most essential care. Of all of these advocates, perhaps none has done more to increase the number of palliative care programs available than Diane Meier as Director of the Center to Advance Palliative Care (CAPC). Under her leadership these programs have more than tripled in ten years. What brought her to this work? What do we need to know about these services and when and how best to use them. How can we all support the effort to increase these programs where we live?

Palliative care has been a little understood aspect of our overall health care system even as it has become more recognized within that system as a valuable resource for patients and their families. Patients often have no education about how palliative care and hospice can serve them and ease the tremendous stresses of serious diagnosis. Thankfully, pioneers in the field have conducted an impassioned fight to educate, validate and increase access to this most essential care. Of all of these advocates, perhaps none has done more to increase the number of palliative care programs available than Diane Meier as Director of the Center to Advance Palliative Care (CAPC). Under her leadership these programs have more than tripled in ten years. What brought her to this work? What do we need to know about these services and when and how best to use them. How can we all support the effort to increase these programs where we live?

eCareDiary's caregiving expert, Margery Pabst will speak to a caregiver panel and Diane Meier,  CEO of the Center to Advance Palliative Care (CAPC), about what palliative care is and what it means for patients, caregivers, and their families.

Join Health Affairs Insider.A palliative care physician helps a cancer patient cope with her coming death, while her oncologist struggles to give up treatment. Read by author Diane Meier, originally published in May 2014.

Guest: Dr. Diane Meier

Guest: Dr. Diane Meier

Dr. Diane Meier discusses her new book on dealing with serious illness.

Interview with Diane Meier, highly regarded marketing professional, who has set the look for major luxury brands including Neiman Marcus and Saks Fifth Avenue. Diane is joining to tell us all about her debut novel, THE SEASON OF SECOND CHANCES. It's the story of a smart and irascible woman of a certain age and how she ultimately celebrates her sense of style and intelligence as well as her need for personal meaning and self-expression. You won't wanna miss this one!

Guest: Diane Meier, MD Host: Susan Dolan, RN, JD Hear Dr. Diane Meier, from Mount Sinai School of Medicine and the Center to Advance Palliative Care, discuss how to run a successful family meeting.

Guest: Diane Meier, MD Host: Susan Dolan, RN, JD hear Dr. Diane Meier from Mount Sinai School of Medicine and the Center to Advance Palliative Care, as she discusses the inner life of physicians who care for the seriously ill.

Guest: Diane Meier, MD Host: Susan Dolan, RN, JD Hear Dr. Diane Meier, the Director of the Center to Advance Palliative Care, as she discusses recent advances in palliative care medicine.

Guest: Diane Meier, MD Host: Susan Dolan, RN, JD Hear Dr. Diane Meier, Director of the Center to Advance Palliative Care, as she offers her best advice for starting a hospital based palliative care program.