The PalliEM Podcast:
Episode 11 –  with Dr. Melissa Red Hoffman MD, ND, FACS

Episode 11 Production:

Podcast Guest:
Dr. Melissa Red Hoffman MD, ND, FACS
Link to Dr. Melissa Red Hoffman’s MD, ND, FACS Website

Podcast Host:
Dr. Justin Brooten, MD

Podcast Production:
Michelle C. Brooten-Brooks

Transcript for Episode 11 with Melissa Red Hoffman MD, ND, FACS (recorded October 2023)

00:00:00:02 – 00:00:09:13
Justin Brooten, MD
This is the PalliEM Podcast, a production of PalliEM.org at the intersection of palliative and emergency medicine. I’m your host, Justin Brooten.

00:00:09:14 – 00:00:31:05
Justin Brooten, MD
Today on the PalliEM Podcast, I’m joined by Dr. Red Hoffman. Doctor Hoffman is a trauma surgeon and associate medical director of both hospice and palliative medicine in Asheville, North Carolina. She is one of approximately 90 U.S. surgeons currently board certified in hospice and palliative medicine, and is a clinical assistant professor of surgery at the University of North Carolina School of Medicine.

00:00:31:07 – 00:00:41:04
Justin Brooten, MD
She speaks and writes nationally and internationally about the intersection of surgery and palliative care. And her work has been featured in Jama, Doc Simone, Kevin, MD, and General Surgery News.

00:00:41:05 – 00:00:49:01
Justin Brooten, MD
Red is the founder and host of the Surgical Palliative Care Podcast, and is the co-founder of the Surgical Palliative Care Society.

00:00:49:02 – 00:00:54:19
Justin Brooten, MD
She is currently launching a new podcast called The Surgical Soul and is writing a memoir.

00:00:54:21 – 00:00:57:16
Justin Brooten, MD
Doctor Hoffman, thank you so much for joining me today.

00:00:57:17 – 00:01:01:20
Melissa Red Hoffman, MD, ND, FACS
Oh, thanks for having me. You can call me Red, by the way.

00:01:01:20 – 00:01:14:06
Justin Brooten, MD
I’m so glad we could finally meet, to record. I had had a chance to interview buddy in the past, and I really liked what he had done with our surgical team to teach them more about palliative care. And also,

00:01:15:04 – 00:01:33:21
Justin Brooten, MD
Just the Surgical Palliative Care Society. I know that I’d seen a lot of press about the society. So, I think it’s, it’s doing a great job of really highlighting the need for part of care in the surgical world. So, one thing I’m really curious about is tell me a little bit more about how you entered this world of surgery and palliative care, because that’s such a unique combination.

00:01:34:01 – 00:01:54:02
Melissa Red Hoffman, MD, ND, FACS
Sure. So, I actually had a very windy road, to get to where I am. I actually started my life, my professional life as a naturopathic doctor and a yoga teacher, and in the midst of my naturopathic training, went to India, to study homeopathy. Actually. And that was the first time I was in the O.R. and I fell in love with surgery.

00:01:54:02 – 00:02:11:03
Melissa Red Hoffman, MD, ND, FACS
And so, when I got back to the States, I said, oh, I think I’ve made a mistake. I want to be a surgeon. And when I, I was very lucky to go to medical school at OHSU in Portland, Oregon, where I was already living. And for those of you who don’t know, Oregon is the birthplace of death with dignity.

00:02:11:05 – 00:02:40:11
Melissa Red Hoffman, MD, ND, FACS
And OHSU, where I went to medical school, was the birthplace of the post form. So, where we practice, Justin, in North Carolina it’s called the most form. But it’s different forms all over the country. And so you know, palliative medicine like was just embedded into my medical training. And in my fourth year of medical school, even though I already knew I wanted to be a surgeon, in my fourth year in medical school, I did one month with the palliative care team, and it really it just like changed my life.

00:02:40:13 – 00:03:02:01
Melissa Red Hoffman, MD, ND, FACS
And I ended up going to residency in Arizona at the county hospital in Phoenix, and we did not have a palliative care team. And I saw an inordinate amount of suffering. I mean, so much suffering. And I spent a lot of time in the ICU. I always kind of found my way back there. And then also we had a huge burn center, which I always found my way back to.

00:03:02:01 – 00:03:18:02
Melissa Red Hoffman, MD, ND, FACS
And there are a lot of, a lot of suffering in the burn center as well. And, you know, I ended up doing a lot of primary palliative care, just the stuff I learned as a fourth-year medical student, because no one was doing much else, I have to say. But eventually I started thinking about how I really was very interested in trauma surgery.

00:03:18:02 – 00:03:44:01
Melissa Red Hoffman, MD, ND, FACS
My, my father was murdered when I was 19 years old, so that definitely led me into the trauma world. And, and also probably like the hospice and palliative medicine world and, at some point I started thinking, how the hell am I going to combine these two worlds? And, you know, thanks to the magic of the internet, I ended up finding, and Rosenthal, who’s I call her, the mother of surgical palliative care, and Jeff Dunn, the father of surgical palliative care.

00:03:44:01 – 00:04:04:19
Melissa Red Hoffman, MD, ND, FACS
I found them both on the internet. And there was really one, like, book that we all used at the time, and it was put out by the American College of Surgeons, and it was called, I think, a surgical residence guide. And it was all about surgical, palliative care. And that’s really, helped me start to shape what my life might look like.

00:04:05:05 – 00:04:10:01
Justin Brooten, MD
Wow. That is a and I thought I had a winding path. You had a really winding path.

00:04:12:18 – 00:04:28:18
Justin Brooten, MD
And I can’t imagine going from, like, naturopathic, homeopathic, principles to, like, being in the operating room. I mean, that is, I don’t know of a more stark contrast to actually palliative care and surgery. We’re actually not much of a problem, not really much of a leap at that point, because you had already taken a really big leap to begin with,

00:04:28:19 – 00:04:30:05
Melissa Red Hoffman, MD, ND, FACS
Right? Yeah (Laughing).

00:04:30:07 – 00:04:56:11
Justin Brooten, MD
What was you know, it sounds like it was it was really out of necessity. And the other thing you mentioned that I think I’ve just encountered often is that people who gravitate towards palliative care have had to deal with some kind of loss, and they’ve had to deal with something really profoundly impacting them. And I think that that’s almost it’s almost necessary in a way, to be able to emphasize with kind of the pain that some of our patients and their families go through.

00:04:56:11 – 00:05:19:00
Justin Brooten, MD
And I think it’s just a unique trial by fire that I feel like many of us have had in a different way, that prepares us for that. Do you feel like you have? I’m just curious, knowing going from the ED side, I feel like I definitely kind of people are like, oh, that’s unusual. You know, combining the two of these, and it seems like you were able to just it was just part of being a surgeon and just a normal part of what you did when you were in training.

00:05:19:00 – 00:05:33:22
Justin Brooten, MD
Because there wasn’t other consultants there to help. You just had to develop those skills. Have you ever kind of come across scenarios where you had, you know, other surgeons who really kind of didn’t understand the context of palliative care or you kind of felt like you were swimming upstream. Just curious.

00:05:33:23 – 00:05:40:05
Melissa Red Hoffman, MD, ND, FACS
Sure. I think at the, in the beginning, people couldn’t wrap their heads around it.

00:05:40:05 – 00:06:01:15
Melissa Red Hoffman, MD, ND, FACS
I will say, you know, my field of surgery, acute care surgery, which is that mix of trauma, emergency general surgery and surgical critical care, it lends itself so well to hospice and palliative medicine. When you think of what we do, and I think there’s, other fields of surgery that may lend themselves more towards, towards that, as well.

00:06:01:17 – 00:06:30:09
Melissa Red Hoffman, MD, ND, FACS
So, what I found for me was there were certainly people in, say, when I was training who were really questioning, what is this going to look like? And, and that was, for me, one of the reasons why I wanted to do a fellowship, I, I always tell people, I mean, the vast majority of us, whether we’re in or surgery or any field, we’re not going to do a hospice and palliative medicine fellowship, and that’s fine because there’s not enough hospice and palliative medicine doctors, and we all need to be practicing primary palliative care.

00:06:30:11 – 00:06:46:04
Melissa Red Hoffman, MD, ND, FACS
But for me, I felt like the fellowship, I really did it at the beginning because I felt like it was going to end. A lot of, lend a lot of legitimacy to like, my career path, but I found once I did, it was I thought I, I really knew a lot, and I just realized I just knew the tip of the iceberg.

00:06:46:04 – 00:07:06:09
Melissa Red Hoffman, MD, ND, FACS
And I just it was really one of the more like, profound years of my life because it really allowed me to slow down. Right? Because the pace is so different than than the rest of our training, whether it’s arm or surgery. And it just really showed me, oh, God, how much I didn’t know about communication and, just taught me, taught me so much.

00:07:06:09 – 00:07:29:13
Melissa Red Hoffman, MD, ND, FACS
And now so even so, one of the things that I was very blessed with is, like, I did my palliative medicine training, my fellowship, where I ended up practicing surgery. And that has led to like such a beautiful career for me. But at the beginning, when I started my surgical attending career, I’m like, come to the ICU and the nurses would be so confused because they knew me as a palliative care fellow for a year.

00:07:29:13 – 00:07:55:05
Melissa Red Hoffman, MD, ND, FACS
So, they’d always ask, like, are you wearing your. They used to ask, are you wearing your palliative care hat or your surgical hat? And I’m like, that’s not how I think I am, like one being offering the full spectrum of care. And of course, now, years later, no one’s offering me that. And I always joke like, you know, if I can’t save your life, then I am going to try as hard as I can to give you and your family a really good experience around death and dying.

00:07:55:13 – 00:08:02:17
Justin Brooten, MD
That is so that is so awesome. And it’s, it’s so it’s so interesting. I can relate from the standpoint of somebody who really likes critical care.

00:08:02:20 – 00:08:26:03
Justin Brooten, MD
One of the things I’m curious about is what you would say, so what you would say to somebody where you really benefited from fellowship, you think it’s really shaped your career, taught you a lot of things that you wouldn’t have known otherwise by kind of that challenge. What, what would you say to the person who’s kind of on the fence between, like, do I want to just maybe do, like a short course and maybe learn a little bit more?

00:08:26:03 – 00:08:37:23
Justin Brooten, MD
Or am I really thinking about a fellowship? But I feel like I could try to answer that question. But I want from your perspective, like what you think makes it a sanction between somebody who should consider a fellowship versus maybe a short course or some additional resources.

00:08:37:23 – 00:08:43:11
Melissa Red Hoffman, MD, ND, FACS
So, I think it’s important to think about what do I want my life to look like now?

00:08:43:11 – 00:09:04:16
Melissa Red Hoffman, MD, ND, FACS
I, well, I could never have imagined what my life has and looking like today, but I will tell you, because now I only work part-time surgery. Because I ended up with a chronic illness. Having this fellowship was great because it really allowed me to shift and really make the case to have all this administrative time to do all these things.

00:09:04:16 – 00:09:30:17
Melissa Red Hoffman, MD, ND, FACS
So, I do ask someone, like if there one true love is the O.R., like, let’s say I think of my friend who’s like a CT surgeon and like, they just want to be in the O.R. all the time. I don’t think having a yearlong fellowship is going to add a lot to them. I really don’t. But then I think of, like, my, friends or colleagues who are very interested in that world of acute care surgery where you’re spending at least a third of your time, usually in the ICU.

00:09:30:20 – 00:09:51:00
Melissa Red Hoffman, MD, ND, FACS
I mean, it lends itself so well, the ICU. And again, I have great colleagues who are not fellowship trained to work in the ICU too. But like to me, that’s where I might actually say it’s going to really work out well for you. And then the other people who like May have spent some time in hospice at some point in their life and they know they want to go do that.

00:09:51:00 – 00:10:14:06
Melissa Red Hoffman, MD, ND, FACS
Now, you can certainly get a hospice job. I mean, hospice deep hospice jobs will hire you without a hospice and palliative medicine fellowship. But if it’s something you’re really interested in, like you could see yourself doing a part-time surgery and part time something else. And I think it’s another great, a great idea. And I say to like, I was older, I mean, I, I finished my training when I was 44.

00:10:14:08 – 00:10:33:02
Melissa Red Hoffman, MD, ND, FACS
I’ve always known, like, I’m going to need an exit ramp, like I just knew it, you know? And so that was also like part of my planning in advance was like, I’m going to need an exit ramp that I know is going to be there. And so, I knew that I could end up being a hospice medical director at some point and be very happy.

00:10:33:04 – 00:10:52:06
Melissa Red Hoffman, MD, ND, FACS
So, I think it’s all about what you want. And then also like how much debt you have, how young or how old you are, you know, is that an extra year of training is, you know, more, more loans that you’re not really repaying. And, you know, a whole year of salary that you’re not making a 401 K that you’re not getting.

00:10:52:06 – 00:10:54:08
Melissa Red Hoffman, MD, ND, FACS
So, you have to think about it.

00:10:54:08 – 00:11:10:01
Justin Brooten, MD
Well, the other thing, too, I feel like, is you have it gives you the skill set to educate others, I think, as opposed to let me just get some skills for myself. So I feel like you’re doing it, you know, and I also that’s going to segue to my next question about the Surgical Palliative Care Society.

00:11:10:03 – 00:11:21:09
Justin Brooten, MD
But you’re doing that working with the surgical palliative care society. You’re kind of disseminating some information about the field. So having that fellowship training I think is really, is probably really helpful for that role.

 00:11:21:10 – 00:11:32:06
Melissa Red Hoffman, MD, ND, FACS
Although, again, I will say I always think of, of my friend and colleague, Mackenzie Cook at OHSU, who is like, I just think such a leader in the field of surgical palliative care.

00:11:32:06 – 00:11:51:01
Melissa Red Hoffman, MD, ND, FACS
And he did not do a fellowship. And he’s also an excellent surgical educator. So, it’s like there, there are people out there. But then I think, you know, the benefit of Doctor Cook is like he he trained at OHSU. So, like the whole surgical department is steeped in palliative care. And then he did a fellowship at U-Dub.

00:11:51:01 – 00:12:08:02
Melissa Red Hoffman, MD, ND, FACS
And like so many leaders in the field of surgical palliative care and palliative care in general came out of U-Dub. So, it like it really depends on like what your base of training was to I mean, from where I was sitting, like I said, I didn’t even have a I didn’t even have a palliative care team where I did residency.

00:12:08:02 – 00:12:10:04
Melissa Red Hoffman, MD, ND, FACS
I really needed to do a fellowship.

00:12:10:04 – 00:12:28:09
Justin Brooten, MD
Now that makes a lot of sense. And I, and I definitely see that we, our palliative care team gets, we have residents, or we get medicine residents that rotate through our service routinely. And then, when I work with the E.D. residents, I get a mix. Some of them are like, I have never seen this before, you know, and others, others, you know, went here and they they already know me.

00:12:28:09 – 00:12:46:09
Justin Brooten, MD
They know me as a medical student. And, so you’re right, the there’s a still a very, very wide ranging experience that people are going to get in training right now. Hopefully at some point it will be more homogenous in the sense that there’s going to be more exposure to that routinely across the board, but it’s definitely in the, it’s definitely not the case.

00:12:46:09 – 00:13:01:02
Melissa Red Hoffman, MD, ND, FACS
Yeah, And I’m sorry to interrupt, but I hope like for my I think my residents, by the time they’re done are going to be so great a palliative care like we’ve only graduated two years of resident so far, but like, I think they’re just going to be incredible.

00:13:01:20 – 00:13:12:14
Justin Brooten, MD
I’m curious to hear a little bit more about the development of this surgical palliative care society, kind of your role with that right now and what you’re what you’re accomplishing through that organization.

00:13:12:14 – 00:13:33:18
Melissa Red Hoffman, MD, ND, FACS
Sure. So, the idea for that was born in, October of 2019, myself and my two co-founders, Doctor Buddy Martyr and Doctor Pringle Miller, were at a very small dinner on the last night of the, annual clinical Congress of the American College of Surgeons.

00:13:33:18 – 00:14:08:23
Melissa Red Hoffman, MD, ND, FACS
And, just started talking with a group of people, and and it was actually born, born through that. And, it took about two years to it was a very long gestation period, and a lot of learning. I mean, we started this whole organization by ourselves with no help. And, Pringle had actually started another organization. So she had a little background, but we it was such an experience to, like, hire a management company and get a 500 and 13C and learn how to fundraise and build a website and and then be born.

00:14:08:23 – 00:14:30:19
Melissa Red Hoffman, MD, ND, FACS
And we did have a lot of support at the beginning from general Surgery News and from the American College of Surgeons. And I had a podcast at the time, so we just got a lot of a great press. So, we had our first, conference last year and our second conference coming up this year. And it’s been really interesting.

00:14:30:19 – 00:14:54:07
Melissa Red Hoffman, MD, ND, FACS
You know, we tried to build the organization in one, buddy, really, you know, doctor Marsh here, he is a beekeeper, and he is very interested and in how the hive works. And it’s really a community. And he really wanted to build this organization based on how the hive works. And really also, you know, when you think of how, how a well-functioning palliative care team works, right?

00:14:54:07 – 00:15:16:18
Melissa Red Hoffman, MD, ND, FACS
This interdisciplinary team, we’re so different than, say, surgery where the surgeon, it’s a team, but the surgeon in the end of is the captain of the ship, like, palliative care. Remember being so touched in my fellowship? There is no captain of the ship. The physician is just as important as the chaplain, who’s just as important as the social worker, who, if you have a pharmacist, is just as important as the pharmacist.

00:15:16:18 – 00:15:55:13
Melissa Red Hoffman, MD, ND, FACS
And so, we really tried to build it like that, which, right, like brings up its own, it’s, it’s very beautiful and then could be really challenging because then in the end you’re like really making decisions as a team, which can take a long time, you know? So, it’s just been an, a very, interesting experience. And, you know, the purpose of the whole organization was one to, to obviously educate the surgical community and then, and to build fellowship and, and, to was to just kind of nurture that next generation of surgeons who are coming up.

00:15:55:13 – 00:16:13:17
Melissa Red Hoffman, MD, ND, FACS
We’re going to be the next leaders in the field of surgical palliative care, because, like I said, when I was interested, it was like one little book on the internet, and now we want it to just be so easy to find us so that anyone who’s interested can reach out and kind of start planning their career. And what is that going to look like for them?

00:16:13:17 – 00:16:28:00
Justin Brooten, MD
The press that I’ve seen about the surgical palliative care society, it sounds like there’s really been a lot of, uptake of that. So that’s exciting. I feel like that’s going to be impactful. Like you mentioned, it’s, you had a, you trained somewhere that that was just part of what you did and it was part of your experience.

00:16:28:00 – 00:16:45:20
Justin Brooten, MD
But not everybody has that. So I think this is, has a chance to really, let a lot of other future surgeons or surgeons in training know, what’s out there. Speaking of that, and thinking about your experience as a trauma surgeon and also thinking about the people that listen to this, that are that are working in the EDI or working in palliative care.

00:16:45:22 – 00:16:52:08
Justin Brooten, MD
I’d really love to know some of your pearls that you’ve learned about dealing with, the patient and the trauma bay.

00:16:52:09 – 00:17:09:06
Melissa Red Hoffman, MD, ND, FACS
Sure. So, when I think of, you know, say how trauma intersects with palliative care, I really think of four different things. I think about care of the patient, care of the family, care of the team, and care of the self.

00:17:09:06 – 00:17:43:04
Melissa Red Hoffman, MD, ND, FACS
And I can kind of go through each of those a little bit. But, you know, when we think about care of the family, I mean, our, sorry, care of the patient, you know, right up front, obviously, if if it’s a trauma patient and they’re actively dying, you have to do what you have to do. And so, I often say about trauma and about ICU, I mean, we cause a lot of pain for our patients, but if the end result is going to be worth it, which is to me, a life worth living, whatever that means to an individual patient, then you know that pain is sometimes part of the picture.

00:17:43:04 – 00:18:11:11
Melissa Red Hoffman, MD, ND, FACS
But I think, with our trauma patients, it becomes clear often rather quickly, whether this is going to be, a resuscitation that’s not going to go well or it just doesn’t go well. You know, we try to resuscitate them or do, resuscitate of thoracotomy and it just doesn’t go well. Or say, in the case of a head injury, we get the patient to the CT scanner, they come back, and it’s just what would be considered a devastating brain injury with, like, impending herniation.

00:18:11:13 – 00:18:43:00
Melissa Red Hoffman, MD, ND, FACS
Then I think that flip starts to, that switch starts to flip for me a little bit, and then I’m like, okay, I can move more into this approach maybe, based on comfort and totally on symptom management. And so, I do a couple of things there because one, even our to some of our trauma nurses are not always comfortable with, the amount and the different medications that it takes to really comfort someone in their dying process.

00:18:43:00 – 00:19:11:06
Melissa Red Hoffman, MD, ND, FACS
So, I do a lot of education with them. I think it’s really, important if you’re writing orders, you know, everyone has like, their orders said that we have this palliative care order set for the imminently dying that we use. I think it’s really important to talk to the nurses, since they’re the ones administering the meds to make sure that they’re comfortable giving an opioid a benzo and sometimes an antipsychotic all at the same time at the doses.

00:19:11:06 – 00:19:31:20
Melissa Red Hoffman, MD, ND, FACS
And I’m asking them to give, I try. So, one, if they’re not comfortable, then I try to find another nurse to help them, or two if I have time. I really like to spend time in the trauma bay when the patients are, dying because like, to me, that’s another part of my job that I think is, you know, really precious time that I like to be a part of.

00:19:31:22 – 00:19:54:23
Melissa Red Hoffman, MD, ND, FACS
And then two, I’m a real big fan and of I’m actually just rewriting the order sets right now, especially for our new nurses with so many new grads who are just shoved into these, like, really intense positions, to give them really objective day to, to use. So, I’m like, all right. I just tell them, listen, if the heart rate’s greater than 100, knowing full well that some of that might be due to hemorrhagic shock, but I just use that hurry.

00:19:54:23 – 00:20:17:16
Melissa Red Hoffman, MD, ND, FACS
Greater than 100 or, respirations greater than 16 or any, non like verbal indications of pain, whether they’re grimacing or grunting or just kind of reaching out and being really agitated like this is when we’re going to treat. So, I try to kind of help guide them because it’s hard, you know, they’re used to using these pain scales that are like 1 to 10.

00:20:17:16 – 00:20:25:08
Melissa Red Hoffman, MD, ND, FACS
And you can always ask someone that. So those are kind of the things that I try to do to help take care of the patients.

00:20:25:08 – 00:20:41:15
Justin Brooten, MD
So, one of the things you mentioned, that I think is really interesting, is you’ll kind of notice as you’re in the process of a resuscitation or you’re thinking about the kind of injuries the patient has, sort of seeing that signal that, that we may need to transition from resuscitate of care to comfort measures.

00:20:41:15 – 00:20:59:03
Justin Brooten, MD
And sometimes that line is very apparent, you know, devastating head injury or non-survivable, you know, penetrating trauma etc.. But, there’s times where I’ve had patients where they, they may have a survivable issue, but the outcome, at least for the patient, would probably lead to something unacceptable.

00:20:59:04 – 00:21:18:23
Justin Brooten, MD
I’m just curious if you’ve encountered the same thing and how you approach that, because sometimes we can see something that we think is going to be an unacceptable outcome for the patient, but if they’re still going to survive, potentially, that still is a very foreign concept of transitioning care, even when survival is possible. But under very specific circumstances. I’m just curious,

00:21:19:00 – 00:21:47:00
Melissa Red Hoffman, MD, ND, FACS
like my care, my personal care of patients in the actual trauma bay downstairs in the Ed. I think if I see someone who I know is going to have like, say, that devastating head injury, that’s an easy that’s a bit of an easier call. I think what I’ve found with situations like that is one loading the boat, like bringing the neurosurgeon with me so they can hear from from two specialists that like this is likely going to be an awful, awful outcome.

00:21:47:00 – 00:22:09:14
Melissa Red Hoffman, MD, ND, FACS
But I’m a real I talk a lot about this idea of decisional burden and my desire to relieve families of decisional burden. That’s about care of the family. Have to remember, as I’m a survivor of two different violent losses, and I know how, the way those losses kind of play out, can affect someone the rest of their lives.

00:22:09:14 – 00:22:25:20
Melissa Red Hoffman, MD, ND, FACS
And so I, I never, you know, I’m not offering any further resources. And a lot of these, I don’t ask, do you want I’m like, I just want to be clear. If their heart stops in this situation, I’m just going to allow a natural death. And I think it’s important to say that maybe 50 years ago it wasn’t.

00:22:25:20 – 00:22:51:03
Melissa Red Hoffman, MD, ND, FACS
But now everyone watches TV and is on the internet all the time. So you want people to know. I was thoughtful about this, but this is this is not an option. You know, it’s going to be, futile. Basically. So I think those situations are kind of, actually almost a little more straightforward. Those cases that you’re talking about where the likelihood of, of, of, life is not going to be great.

00:22:51:03 – 00:23:18:10
Melissa Red Hoffman, MD, ND, FACS
I mean, I’ve actually learned over time, I’ll say when I during my hospice and palliative medicine fellowship, and probably in my first two years of practice, I kind of leaned a little more towards death and dying. And over time, I’ve kind of come back to the middle and I’ve learned, that, you know, sometimes we just need to wait 72 hours to sort some shit out, to be honest with you, and kind of, like, let everyone catch their breath.

00:23:18:12 – 00:23:38:06
Melissa Red Hoffman, MD, ND, FACS
You know, if obviously if there’s, a big procedure planned during that time, we might want to talk about things, but especially in these head injuries, sometimes you just don’t know how it’s going to land. Or even in our multi-system trauma patients. You just don’t know. And so, I’ve actually, like, learned to kind of sit on my hands a little bit.

00:23:38:06 – 00:23:59:14
Melissa Red Hoffman, MD, ND, FACS
I think, because I want to I want to be able to trust myself that, my training, my palliative care training hasn’t, like, led me to only think about death and dying, because I also want to think about life and living and what that means, you know? And so, I also think if a decision doesn’t need to be made right at that moment, that why push someone?

00:23:59:14 – 00:24:16:05
Melissa Red Hoffman, MD, ND, FACS
Because again, the family’s just trying to catch up with everything. So yeah, I’ve become like a little more. I think I’ve just like, try to walk down the middle of the road a little more right now, rather than like pushing for a decision right away.

00:24:16:12 – 00:24:33:12
Justin Brooten, MD
One of the things you just mentioned that I wanted to touch on, because you talked about kind of the the four big prongs of the way you look at caring for these, for these difficult situations was care of the family. So, you talked to some about the transition for the family. So tell me, tell me more about kind of the things you do to take care of the families in these situations.

00:24:34:00 – 00:24:54:22
Melissa Red Hoffman, MD, ND, FACS
Yeah. So, I have to say, you know, probably the reason that I got very interested in hospice and palliative medicine because was because of my, grief experience after my dad was killed. And I just thought it was such a it was such a profound, lonely time where I didn’t really have the language to talk about how I was feeling.

00:24:54:22 – 00:25:16:21
Melissa Red Hoffman, MD, ND, FACS
And also, when I found the language and I would tell the story. My my dad was killed by a terrorist in Cairo, Egypt, 30 years ago. And it’s a crazy story and, crazier because of all the things that happened after it. And when I would tell people this story, like they didn’t know what to say, and I didn’t find a lot of people were able to hold space for my grief.

00:25:16:21 – 00:25:41:02
Melissa Red Hoffman, MD, ND, FACS
And so, I really got interested in this medicine of course, I want to help patients, but I’m really interested in how the families are dealing with what are sometimes like these insane stories. And so, I spend a lot of time with the family, like just holding space like I am. I will just say out loud, like, I just want you to know whatever you say is not too much for me.

00:25:41:02 – 00:25:56:20
Melissa Red Hoffman, MD, ND, FACS
Whatever reaction you have is not too much for me. I’m just. I’m just here to. I’m just here to be with you. And you can say whatever you want. So that’s one thing. It’s just that idea of holding space. And sometimes that’s a lot of silence. Right? So, one thing we learned in fellowship is to be silent.

00:25:56:20 – 00:26:17:03
Melissa Red Hoffman, MD, ND, FACS
And because in that silence is where all the emotions start to bubble up, that people usually push down or avoid. If you’re quiet long enough, people are start. It’s amazing. People really do start talking and sharing. And then that I again, that idea of allowing them to avoid decisional burden. And I think that there’s two ways to do that.

00:26:17:03 – 00:26:42:06
Melissa Red Hoffman, MD, ND, FACS
One, not offering non beneficial treatment. So, we’re not offering resuscitation when we know that it’s going to be at least quantitatively futile. Sometimes it’s qualitatively futile. And you may offer it. But so, we do not have to do that as physicians and don’t have to, offer futile treatment. So that’s one way and two, instead of asking the families like, well, what do you want?

00:26:42:08 – 00:26:59:12
Melissa Red Hoffman, MD, ND, FACS
I love the question that we learn and in fellowship, which is, well, if your dad was sitting here with us, what would he say? So really putting it back on him, bringing him back in the room. And again, it’s amazing. People are sitting around, they don’t know what to do. And then you I just had this a couple weeks ago where I said, well, what would your mom want right away?

00:26:59:12 – 00:27:24:12
Melissa Red Hoffman, MD, ND, FACS
They’re like, take that effing tube out. That’s what she would have said. And so, I’m like, well, there’s our answer, you know what I mean? And so that I said that was literally from the horse’s mouth, you know. And so, I love that idea of just really, trying to make it as easy for them as possible. And then, you know, I think we just mentioned, like, this idea of kind of taking that middle path.

 00:27:24:12 – 00:27:46:14
Melissa Red Hoffman, MD, ND, FACS
Well, you know, that middle path, I think is sometimes great for patients and families, but it can be really distressing for the team members. I think sometimes the nurses are like, they just can’t wrap their minds around it. And sometimes I will take the time to talk to the nurses who I know are having their own distress and just reminding them, this is not about you, this you’re going to in two days.

00:27:46:14 – 00:28:02:23
Melissa Red Hoffman, MD, ND, FACS
You’re going to forget about this day. And this is like the beginning of this family’s grief journey. And so, we have to honor it. And yes, and may be like a little uncomfortable. And these orders may be a little weird. And I am here to talk to you. I, everyone has my phone number, and I can call me whenever you want.

00:28:03:01 – 00:28:25:06
Melissa Red Hoffman, MD, ND, FACS
But we’re still going to do this because this is what’s best for the patient. And, you know, during those times, really for the family as well. So just making sure that, the family just feels really supported it. It’s just so important to me. And I think for people, you know, there’s a lot of, thankfully, I think a lot of young people I work with who, who haven’t had their big grief event yet.

00:28:25:06 – 00:28:46:00
Melissa Red Hoffman, MD, ND, FACS
And so, I’m like, you know, you’ll get it. One, they’ll get it right. Everyone gets it at some point and they’ll understand. But for me, I know, that this is the beginning of their grief journey. And again, it can, it can change someone’s life. A good grief journey. The beginning of a good grief journey can really set someone up for

00:28:46:00 – 00:29:16:04
Justin Brooten, MD
I really appreciate hearing you talk about that, because I think we get so,so much of our training is, how do I deal with the nuts and bolts of the medicine? How do I deal with, you know, mitigating this person’s disease process? And we do play such a big role in how the family is going to deal with that situation afterwards. Tell me, I’m curious. You’re so tuned into the patient, the family. Tell me a little bit about you do with the teams, because that’s another big one. These patients are not just tough on us, and they’re tough on our colleagues and they’re tough on our other people were leading. So, tell me about that.

00:29:16:05 – 00:29:31:14
Melissa Red Hoffman, MD, ND, FACS
The first time I really recognized, like, moral distress was when I was, a critical care fellow. And so really, I was at UNC, I spent almost the whole year just in the surgical ICU.

00:29:31:14 – 00:29:59:18
Melissa Red Hoffman, MD, ND, FACS
So, in, like, you know, huge room, right? But it’s still one big area. And, I was, so up close and personal with those nurses for almost a whole year, and I really got to see their distress. Like, on some of these patients, I think transplant, patients that a lot of them can suffer. And and it’s sometimes notorious how how long we all allow them to suffer for with hopes of a really good outcome, you know?

00:29:59:18 – 00:30:21:04
Melissa Red Hoffman, MD, ND, FACS
And so, I started to really appreciate, like, what the, the nurses were going through. And so, as a palliative care fellow and now as an attending, like I just, I feel like I do spend a lot of time just kind of checking in with the nurses. And then I’m really proud that we have a, I was able to get this amazing man.

00:30:21:04 – 00:30:42:21
Melissa Red Hoffman, MD, ND, FACS
Right now we have in our, in our ICU who is a marriage and family therapist who not only sees our patients, but also works really closely with the nurses and the nurse managers to make sure that, like, everyone’s doing okay with whatever’s coming in. So really supporting the nurses on that, on that level, like I said, like my phone number is posted in the ICU.

00:30:42:21 – 00:30:55:09
Melissa Red Hoffman, MD, ND, FACS
I’m, I tell them, you can always call me if there’s an end-of-life patient. And you’re just like, you can’t handle it, or you don’t know what to do, or you just don’t want to give them meds, right? Sometimes they don’t want to give them meds. They feel like they’re killing someone. That’s okay. Someone else will give them meds.

00:30:55:09 – 00:31:11:10
Melissa Red Hoffman, MD, ND, FACS
Like, you don’t have to do anything you don’t want to do, but what you can’t do, which I’ve also seen which really upsets me, is just ignoring the orders. And that you can’t do either. We have to like, be grown-ups and talk about it. But I am always here to back you up. Like as long as you’re reaching out for help, you know?

00:31:11:10 – 00:31:32:05
Melissa Red Hoffman, MD, ND, FACS
So, I think that’s like the nursing level. I think, you know, there’s this great man, Jonathan Bartels, who’s a, he’s a trauma nurse for a long time now. He’s a palliative care nurse in Virginia. And he came up with this idea of the pause, which is just taking a moment after someone dies, whether after a resuscitation, you know, or code, whatever.

00:31:32:07 – 00:32:01:05
Melissa Red Hoffman, MD, ND, FACS
Or just like a mess in the trauma bay where you just take a moment and, you know, one honor the patient to, like, honor the team and really thank the team for just going above and beyond. And then just like all taking a breath together. So, and then I also lastly, like, I really am interested in this concept of disenfranchised grief, which is, you know, it’s defined as, as grief that we don’t feel that, that we have the right to feel.

00:32:01:07 – 00:32:28:13
Melissa Red Hoffman, MD, ND, FACS
So, it’s that feeling you get, you know, we all have feelings after someone dies. And then then it’s like, well, why am I feeling this? This wasn’t my loved one. Why am I crying? I mean, like, that wasn’t the worst day of my life. So, it’s almost like your questioning yourself for your own feelings. And you know, recently I was talking to one of our respiratory therapists about this because I was in the room with a patient when she was terminally activated.

00:32:28:13 – 00:32:47:07
Melissa Red Hoffman, MD, ND, FACS
Her family didn’t want to be there, so I said I would sit with her and the rest. Joy therapist came in and he took out the tube, and it was just standing there. And I said, we’re just chatting. And I was like, this must be really intense for you. I mean, you’re really a huge part of so many end-of-life stories because you’re taking the tube out, which is really the beginning of their end.

00:32:47:08 – 00:33:06:12
Melissa Red Hoffman, MD, ND, FACS
Yeah. And, and I was talking to him about that idea of just disenfranchised grief and like that, it’s like we have to normalize feeling this and then like, being able to talk about it. It’s like it’s not dramatic to, like, have feelings, like it’s actually pretty normal to have feelings that you just contributed to the beginning of this person’s death.

00:33:06:13 – 00:33:25:23
Melissa Red Hoffman, MD, ND, FACS
And of course, the disease in the end is what’s killing them. But, you know, we all had a hand in it, right? I wrote the orders, the nurse pushed the meds, the RT took the tube out. And so, talking about that concept and then normalizing everyone’s feelings and, and lastly, I am just, so honest about my own feelings.

00:33:25:23 – 00:33:45:21
Melissa Red Hoffman, MD, ND, FACS
Like, I cry at the bedside. Probably every time someone dies, I cry and, I think that that just, I hope, sets the stage. If other people feel the need to cry, that they can cry to, you know, it shouldn’t get in the way of our work. You know, I’ve learned in fellowship. You shouldn’t be crying the loudest in the room, you know?

00:33:45:23 – 00:34:07:09
Melissa Red Hoffman, MD, ND, FACS
But I would I love, you know, I just like I hope that they see if the surgeon’s crying, that, you know, it is okay to have have your feelings. We have our feelings. And then we go on to the next patient. And then I talk a lot about being in therapy because, like, for multiple reasons. But, I mean, I think everyone who does any of our, either of our jobs.

00:34:07:09 – 00:34:24:11
Melissa Red Hoffman, MD, ND, FACS
Right. Could probably stand some therapy at some point in their lives because we are all carrying this with us. There’s no doubt that this sits on your soul. I mean, how could it not? You know, even if you’re not naming it or where of it, you know, your body’s taken it in. So.

00:34:24:11 – 00:34:59:19
Justin Brooten, MD
It really is amazing. The window we get to see into to life and death. The, the other thing I was going to ask about you kind of talked about it is really your level of emotion and your level of investment that you have in these patients requires you to take care of yourself. And having having needed therapy myself for various reasons, I think there’s a big value in that. It makes me a better clinician, makes me better at taking care of other people. If I’m taking care of myself. But tell me more about, you know what, what you do to make sure that you can stay resilient even though you’re dealing with really, really tragic situations on a regular basis?

00:34:59:19 – 00:35:13:08
Melissa Red Hoffman, MD, ND, FACS
A lot. And, it’s just so interesting. I just listen to a great Ezra Klein podcast about self-care. And, you know, I think there’s been a great commodification or gentrification of self-care.

00:35:13:08 – 00:35:43:20
Melissa Red Hoffman, MD, ND, FACS
They call the goop-ification of self-care. Gwyneth Paltrow’s website. And, you know, when I think of and, and, you know, I think, on this podcast, they were talking about, you know, those things are fine to whatever you do, light a candle, do yoga. I mean, I’ve done all those journal, I’ve done all those things. But I mean, when I think of self-care, I think of like that really deeper work of self-care that I’ve, been invited to are forced to do the last, the last couple years.

00:35:43:20 – 00:36:17:00
Melissa Red Hoffman, MD, ND, FACS
And, to me, that’s therapy. I like, have been very blessed to have do some amazing work with internal family systems and then with eMDR, which is such trauma informed therapy. And then I’m a huge fan of ketamine assisted therapy has, it’s just like a whole nother level of going through those, those layers. For me, I work part time as a surgeon, one, because I, developed multiple chronic illnesses after getting Covid that make my life really challenging.

00:36:17:00 – 00:36:44:12
Melissa Red Hoffman, MD, ND, FACS
But it’s also, really forced me or invited me, to slow all the way down and, and so that sometimes looks like a lot of sleep and, looks like taking a bath every day and looks like saying no to a lot of things that I used to say yes to. And I think, like that idea of self-care is just going to look really, different for everyone.

00:36:44:12 – 00:37:03:15
Melissa Red Hoffman, MD, ND, FACS
But I don’t think that it has to be this idea of that. It’s like indulgent or selfish. What I have found in the end is like, and again, this is more because I was forced by the world rather than like what I wanted. But what I realized in the end was, if I don’t do this, I’m not going to be able to do any of my job.

00:37:03:17 – 00:37:33:03
Melissa Red Hoffman, MD, ND, FACS
And so now I think the idea of, self-care helps me to like when I do show up to show up. Well, you know, and I think the one other thing of self-care that I’ve learned in the last couple of years is really trying to figure out what your values are, which is actually a really interesting, hard. Like, it’s a really hard exercise to actually name, like the few things that you truly value and then making all your decisions based on those values like that.

00:37:33:03 – 00:37:57:19
Melissa Red Hoffman, MD, ND, FACS
I think a form of self-care that I didn’t really understand until maybe even recently. And not everyone around you going to like it is going to like it, because, you know, one of the values might not include working all the time, you know, or giving that 120% at work. You know what? If we all only gave 100, or sometimes we gave 80, and then our colleague gave 101 that one day, and then you switched.

00:37:57:19 – 00:38:26:10
Melissa Red Hoffman, MD, ND, FACS
You know what I mean? So yeah, there’s, there’s a, there’s a lot of a, a lot of, different concepts there. But I think they’re all important to talk about. I think they all have their place. And I, like I said, I, I really am very open and honest about, like, my journey because I, want other people to know, like, there’s all these options out there to get us out of, of some really, rough spots. And I just want my colleagues to be aware of them.

00:38:26:10 – 00:38:38:00
Justin Brooten, MD
It’s really been a pleasure to be able to talk with you. I’ve enjoyed it thoroughly. You are a fabulous person. And it’s and, and as as you say on your, as you say on your podcast, you heal with more than steal.

00:38:38:02 – 00:38:55:20
Justin Brooten, MD
So, I have really enjoyed this. It’s really, it’s been a lot of fun and, I’d love to I’d love to do it again. I think there’s more things we could probably discuss. Especially along the lines of of just being a clinician and, and self-care and, and also mitigating the effects on our team members when we’re, when we’re all kind of seeing these difficult situations.

00:38:56:07 – 00:39:11:21
Justin Brooten, MD
But thank you so much for what you do and for advocating for, palliative care in surgical settings and integrating these two fields together and really being a beacon to kind of get that that word out to your colleagues.

00:39:06:02 – 00:39:09:11
Melissa Red Hoffman, MD, ND, FACS
Thanks, Justin. It was so great to meet you. That was so fun.

00:39:09:11
Justin Brooten, MD
I’ve enjoyed it. All right. Thank you very much. And, we’ll have to do this again.

00:39:11:21 – 00:39:18:05
Melissa Red Hoffman, MD, ND, FACS
Awesome. Okay. Thanks. I hope you have a great day.

00:39:18:05 – 00:39:28:00
Justin Brooten, MD
You too. For more information on current topics in the fields of palliative emergency medicine, please visit PalliEM.org.