EPISODE 1 SPEAKERS:
Kei Ouchi, MD, and Justin Brooten, MD
PRODUCTION:
Audio Editing Assistant: Ben Highland, Transcription Assistant, Ryan Hilton
Justin Brooten, MD:
Today I’m joined by Dr. Kei Ouchi. Dr. Ouchi is an assistant professor of Emergency Medicine at Brigham and Women’s Hospital and Harvard Medical School. He’s an upcoming researcher with multiple publications in the field of emergency medicine and palliative medicine integration. He is also an associate faculty member of the Department of Psychosocial Oncology and Palliative Care at the Dana Farber Palliative Care Institute. Dr. Ouchi, thank you so much for joining me today.
Kei Ouchi, MD:
Thank you so much for having me.
Justin Brooten, MD:
So, my first question is what prompted your interest in researching this unique topic of emergency medicine and palliative care?
Kei Ouchi, MD:
Well, so when I was in training, I was always thinking that whenever I save a life, when someone comes in with, let’s say, acute respiratory failure, I thought, wow, emergency medicine, when I intubate somebody, it’s really lifesaving. And this was a really important moment for me to, kind of, appreciate what emergency medicine practice is all about. And, I trained in internal medicine as well, and when I switched services to internal medicine from emergency medicine a few weeks later, sometimes I found patients who are older and I intubated actually still in the hospital. And we had this one case where the patient’s family member told me after a few weeks of coming out of ICU that he would never wanted this had he known that this was the outcome after the intubation. Well, this is when I started to think twice about whether it’s always the right thing to help people with acute respiratory failure with intubation, especially when patients are older and having serious life-limiting illness.
Justin Brooten, MD:
Yes, it’s so true, you mentioned, you know, we think about the interventions we can do. But then after the fact, you see what the outcomes of that is, and how much it would change decision-making. You’ve done a lot of work in that area of trying to improve communication in the emergency room because it’s a unique environment. What–in that same vein, what are some of the unique issues that arise when you’re trying to address critical illness and end of life care in the emergency room?
Kei Ouchi, MD:
Mm-hm… well, I think we have to kind of think about this in perspective, because traditional emergency medicine training doesn’t really address this directly. So, the fact is, there are more–more and more older adults that are presenting to the emergency department in our society in America. And, this is because human beings have never lived this long before. And, we know that, as a result, practice in emergency department is slowly changing, not only from acute trauma-like care, to also have to address goals of care for patients who are living with serious life-limiting illness. And this is apparent because 75% of older adults visit the emergency department in the last six months of life. And as they get sicker, they come to the emergency department more often. When thinking about this context, we have to also be mindful that everything that we were taught in emergency medicine training is not necessarily sometimes aligned with what patients would actually want. And it’s up on us emergency department clinicians to figure out exactly how patients want to be treated when they’re facing a medical crisis.
Justin Brooten, MD:
Absolutely, and one of the things that you’ve spent some time on is looking at the outcomes that people have. As you mentioned before that family member noted that their family–their loved one–would have made a different decision possibly if they had known what the likely outcome was. And you mentioned the frequency with which older adults go to the emergency department in the last phase of life–what kind of patterns have you seen as far as say respiratory failure? When an older person over age 65, or older than that, presents to the ED and is in respiratory failure, what kind of outcomes can they have from that that are maybe less than desirable?
Kei Ouchi, MD:
Thank you. So, when older adults with serious life-limiting illness come to the emergency department in acute respiratory failure, that’s already–and if you’re considering intubation is one of the interventions that might have to be performed in the emergency department, that’s already pretty bad news because we know from literature that about one in three of those folks will likely die in a hospital after intubation. So, when you’re considering this intervention in the emergency department, it is a critical moment for patients and their surrogates to really grasp the situation. But at the same time, emergency physicians must grasp the situation too, an outlook of what you’re about to perform. Because patients who are lucky enough to survive, most of them don’t end up going home. In fact, most of them will end up in a nursing home or long-term acute care hospitals where they would have pretty limited functional status at that time. And we have to think about whether that’s something that patients would have actually wanted in his or her life. And in the emergency department, we’re faced to complete this conversation where this decision-making has to be rapidly decided. And we’re asked to basically complete a conversation that’s harder to do than any other situation in clinical medicine.
Justin Brooten, MD:
Yeah, it’s so true, it’s very time sensitive, and one of the things that you mentioned that’s interesting is you talked about how outcomes have changed and people are living longer. And one thing that I think is interesting is if you look at what people died from 100 years ago, and it was a lot of acute illness, infections, things like that, that people died very suddenly there wasn’t this long– prolonged process. And as we’ve advanced in our ability to treat things like COPD and CHF, people get to a much more advanced state of disease, but then they’re in and out of the hospital, sometimes with a significant illness –whereas people used to have some big catastrophic event and that was the most likely cause of death. Now, we have some of those events still, but we have these periods of time where people go through this prolonged chronic illness with superimposed acute illness. And you’re right, a lot of them end up in the nursing home, if they end up surviving the hospitalization, they end up with a very big change in their functional status. So, as you mentioned it’s very time sensitive, we’re having these conversations, and we don’t have a lot of time to be able to talk about these things. What are some other barriers that you see to trying to provide palliative care in the emergency room?
Kei Ouchi, MD:
Well, in terms of this particular decision-making about whether to intubate someone or not, and whether that is aligned to patient’s values and goals, there are many different barriers to successfully come up with this shared decision-making. First, the patient’s really sick, and we have to make a decision quickly, so we have a very limited time for making this decision, which also results in heightened emotion for patients and surrogates about what to do next because they are really sick, and they’re scared, or anxious, or something is going on in their lives that is prohibiting rational decision-making – that they would usually be able to do in other circumstances. And third, there’s a lot of clinical uncertainty about prognosis. Yes, one in three people may die in the hospital, and yes, most people may survive and will have a prolonged course recovery with limited functional abilities. And how certain can we be at describing these prognoses? So, these are all different things that could make this decision-making very difficult. And we haven’t been able to systematically train our trainees in having these conversations yet in the emergency department.
Justin Brooten, MD:
You bring up a good point where you talked about there is uncertainty in prognosis, it’s early on and while we do have data that suggests potential outcomes that someone may have that’s older adult with a critical illness. One of the things I think you touch on is–really it’s somewhat about informed consent. Because to me it seems like, so many times, there’s so many other things in medicine, where there’s kind of a rigorous informed consent process, and, in this case, we think of life support and other interventions as sort of a default, and we don’t necessarily think about it as informed consent in the same way because we may be getting somebody through an illness, but again, there’s a potential functional outcome at the end of that that may be undesirable. So, I wonder–I want your thoughts on this, but to me it seems like, by having the conversation, regardless of what the patient or the family member ends up choosing, they are likely getting a more informed understanding of what the possible outcomes are, and which way they decide to go on the matter, they’re at least prepared for an outcome–for the range of outcomes that are possible. What are your thoughts on that?
Kei Ouchi, MD:
Well, that’s what we would hope. And in reality, what gets in the way of informed consent is those things that I mentioned – the clinical prognostic uncertainty, as well as heightened emotions about decision-making, basically about life or death. And, no, those things will definitely get in the way of informed decision-making. And, what happens in these crisis moments is that a true informed consent, meaning, explaining what are the benefits, potential harms, and alternatives of a treatment decision-making is, and asking people to make a decision, sometimes it’s really unfair, given that the patient might be so sick and they’re in a heightened emotional state. Therefore, we would recommend a shared decision-making with patients or surrogate and the clinician. And the clinician has to be able to sort of, kind of understand where patients might be coming from and what his or her values and goals are in life and incorporate medical decisions that would actually make sense in his or her head and make a recommendation about exactly what might be aligned with patient’s goals. This is not exactly informed consent, it’s definitely a shared decision-making where clinician has to also take the burden of this difficult decision with the patient or surrogate.
Justin Brooten, MD:
That’s very true and I was thinking about the piece that you had in Annals of Emergency Medicine that goes through having these conversations with patients who present in respiratory failure and having these critical, time sensitive conversations in the emergency room. And, there’s a process that you go through in that article about ways to ask questions, and you use typical palliative care principles and how to ask these questions to get to the–kind of the heart of the matter of making these decisions. What are some of the ways we should ask questions of these families and these patients in the emergency room that maybe aren’t our typical approach?
Kei Ouchi, MD:
Typical approach in emergency medicine, I think, in my mind, would be to ask patients and surrogates would he or she want x, y, or z. Now, what thoughts have you had about getting x, y or z, which are mostly procedures, like intubation. And, I don’t think that method of understanding patient’s preferences would work in this situation, given the prognostic uncertainty is still difficult even for clinicians to describe. It would be unfair for us to expect patients and surrogates to understand that at the same level that we do in this given short amount of time that they have to make this decision. So, the typical way of asking for preferences like this, I don’t think would be helpful in these situations. Instead, we would recommend that we ask for patient’s and surrogate’s understanding of where he or she may be today, and, you know, go through other palliative care principle questions that I outlined in the manuscript in Annals of Emergency Medicine.
Justin Brooten, MD:
One of the things you touch on there that I think is really important is – what was their functional status? You know, what would their–you know, if they were here with us, what would they think if we could give them the same information that you have right now? I think those are really helpful to touch on. And, you know, one question I have too is, you know, these conversations can be challenging, and they can be kind of time consuming. What would you say to the physician who’s worried about, well, yeah, I can engage in these conversations, and I see that it’s important, but how am I supposed to have this kind of a conversation in a time sensitive way while I’m also still managing a busy emergency room? What are ways that you can have a really meaningful conversation and it doesn’t necessarily have to be excessively long if the right questions are asked and maybe the family of the patient are a little prepared to discuss that.
Kei Ouchi, MD:
Well, I think one thing that we must all keep in mind as emergency department clinicians, is that our conversations in these crisis moments when patients are, for example, in impending respiratory failure requiring intubation, our primary task is not to explore everything that is possible to explore. But to really determine, you know, really identify patients who would consider outcomes after intubation really worse than dying, or something similar to that. That’s what we’re trying to identify. A lot of times when we talk to patients or surrogates, they have not really thought about these things before, and it’s really–they just need a little more time to figure this out, or think through this, and not in the heightened emotional state in emergency department. So, you know, a lot of these times, it’s unfair to push them to make a decision, and we just have to lean on the side of intubating them and having them process this information that you just shared with them. So that’s our task as emergency physicians. And, if you actually go through the steps that are outlined in the code status conversation guide, I think most palliative medicine clinicians would agree that it would actually save time to get to the bottom of how much decision-making is even possible in this situation. That’s what I would say about that.
Justin Brooten, MD:
Yeah, that’s a good point. It’s interesting to talk about this because I just had an ED resident yesterday, I was discussing this with and he’s a third-year resident so he’s thinking about, you know, how is his own practice going to work. And we were talking about this type of scenario. And I was telling him, you know, you’re gonna have situations where, like you said, they’re gonna need more time and you don’t need to push them to make a decision if they’re not ready to make a decision, or they’re not ready to de-escalate care even if the prognosis may not be great. And one of the other things that we talked about was you have patients who may have had multiple hospitalizations, they may have had multiple, kind of, recent events or recent decline, where the family is, kind of, waiting for that–waiting for the physician to, kind of, say, this may be a transition point, this may, you know, they’re getting sicker, and you’re not forcing a decision, but they’re kind of–they’re maybe a little more prepared. And those situations, like you said that if an outcome, if there’s a potential outcome after intubation that’s worse than death for them, like prolonged nursing care, or significant disability beyond what they’ve experienced before, then they may be a little more prepared, or the family may be more prepared to say, yeah, let’s maybe not go through with all this. But I agree, there’s times where we just–we need to do the aggressive measures and we’ve at least started the conversation, and they can think about it and whatever the outcome is, at least they’re a little more aware of the severity of the situation on the front end. And I agree too, I think that some of these questions, they can be very insightful and they don’t necessarily have to be lengthy conversations. I found that asking how they were doing before? Have they been sick a lot recently? Have they noticed a pattern of decline? I think in there, you talk about, you know, wishes, you mentioned, what outcomes would they consider that are worse than death? And I think it’s a pretty concise guide while still providing some really robust information, which I appreciate. So, along those lines, what do you think the general ED physician–what are maybe three things ED physicians can do better as a group to provide more goal concordant care to some of our sickest patients in the emergency room?
Kei Ouchi, MD:
Hmm, I think one thing we can do is definitely to pay attention to patients that you’re seeing and sort of determining which patients may benefit from either palliative care consults or interventions, starting in the emergency department. So that’s basically to identify which patients that you’re seeing, you’re seeing 30 or so patients in your shift let’s say, which of those patients may benefit from palliative care interventions? So that’s one thing that emergency clinicians could do to try to improve ultimate goal concordant care, maybe not within the emergency department, but ultimately for the patient. Because we do definitely see a handful of patients who would benefit from let’s say, goals of care conversations or symptom management in palliative care teams. That’s definitely one thing that you can do. The second thing that we could do in emergency department is to really improve the communications that we could do in determining patients code status. Because this is one time in emergency department that you, the emergency department clinician, will certainly dictate what will happen to the patient in short-term as well as long-term for patients living with serious life-limiting illness. Emergency Department intubation is a critical moment that will alter patient’s clinical trajectory, and, we have to pay attention to exactly how to have these conversations with the patients who are coming into emergency department for acute respiratory failure. The third thing that we may be able to do would be to try to incorporate principles of palliative care in geriatrics, into the practice of emergency medicine. I think we just don’t do enough to identify geriatric syndromes in emergency department because most of us think that they may not have immediate implications to intervene in emergency department. If patients are, let’s say, suffering from recurrent falls, or delirium, and because our society’s aging, and we’re going to see more and more patients who are older and having serious life-limiting illness in the emergency department, we have to create pathways for these seriously ill older adults to be appropriately triage and cared for from the emergency department by incorporating these principles in emergency medicine practice.
Justin Brooten, MD:
Yeah, that’s really true about what you said about geriatric syndromes. And just, I think sometimes, and maybe this is just me, I appreciate it a lot more after I did my palliative care training, but just things like falls, where initially it seems like, well, yeah, this is just something that as people get older, their balance gets worse and they start to fall, but just the prognostic implications of recurrent falls, like you’re saying, and also what things need to be done to address the problem. So often, our thought is okay, do I need to scan this person’s head? Are they on blood thinners? Do they have a head bleed? And maybe this is just me, but I feel like we might look at their medicines, we might think about things that are contributing, but the sense maybe we just need to figure out if they’re injured and then get them back to wherever it is they need to go, instead of, what else can be done? Do they need physical therapy? Do they need something else that’s going to maybe even prevent that next really serious fall, or medication change if they’re on something that’s going to be contributing to their balance issues? So, I agree, I think there’s some preventative medicine that we can do in the emergency room that really actually doesn’t take that much extra time, but it can save us time afterwards and it identifies deeper needs for the patients. What are future issues that you think ED palliative care research needs to continue to address?
Kei Ouchi, MD:
Mm-hm. Yes, so… all these things that we have just talked about. They haven’t really been shown in rigorous clinical studies to demonstrate direct benefit to patients, for example, having better well-structured goals of care conversations to determine code status, will that actually change the patient’s care or outcomes? We don’t really know. These things clinically would make sense to do, and those who know more about this were trained in palliative care can see the clinical difference in their practice patterns as well as patient outcomes. However, they have not really been rigorously studied to show direct patient benefit. So, it’s really important for us to not only hang our hats on what we believe clinically is helping patients, but also, at the same time try to demonstrate a clinical benefit to patients by incorporating all these principles that we have discussed, and that has not been well established in emergency medicine literature or palliative care literature, and it’s on us to rigorously study these so that we know what’s going to actually help the patients, and that has not been done yet.
Justin Brooten, MD:
Well, and one of the things you and I talked about previously is that there are certain aspects of emergency palliative care that are difficult to study inherently. One thing that comes to mind, and that’s probably part of the reason why it’s difficult to assess benefit of some of these things, is just communication. For example, in a clinic setting, you can do communication interventions, and you can randomize patients and the acuity is not so high. So, you can get a sense for how different communication methods may directly impact decision-making or patient perception of care. But in the emergency room, especially when you’re talking about patients with acute respiratory failure, it’s very difficult to do any kind of randomized study in communication practices, because most of us for one, in emergency and when time is limited, we’re going to default to whatever practice we have, and it would be very difficult to get clinicians to, kind of, adhere to a particular model under those circumstances. In addition, I think randomization becomes a big issue. So, what are some ways that I know we’ve talked about it before, but what are some ways that you can analyze sort of the benefits of providing this education to patients and providers that kind of get around some of this inherent challenges of studying acutely ill patients in the emergency room?
Kei Ouchi, MD:
I think there are many different ways in which we can change clinical practice through research, and one of the ways is to conduct more pragmatic clinical trials, unlike randomization, based on individual patients or individual emergency departments. For example, I am involved in Dr. Corita Grudzen’s pragmatic trial study right now, that looks at educating emergency department clinicians in primary palliative care skills. And, this is done through a pragmatic design where unit randomization is time, rather than individual emergency department or individual patients or individual clinician groups. So that over time, if you implement these primary palliative care interventions in different emergency departments, if it does work, it should show a difference in health care utilization of patients that we care for. And, that’s one of the ways in which we can tackle this difficult problem of actually conducting rigorous studies that are scientifically solid. We, in clinical medicine, are sort of encouraged to do pragmatic design trials, where we’re moving away from individual level intervention or outcome assessment. Rather, we want to sort of do it in a pragmatic way, meaning in a real-world type of way, because if we want to make a difference, we can’t just do it in a really controlled, randomized trial setting, we have to do in real world to see if it’s going to make a difference. So more and more, there are study designs that are coming up that try to address at that problem of doing in the real world. And I think that’s the direction–the overall direction in which that, this, you know, palliative care and emergency medicine research must move towards as well.
Justin Brooten, MD:
Absolutely and that that makes sense because then your interventions are much more applicable, because it hasn’t just occurred in a vacuum, but like you said, it’s more of a real-world setting. So, it should hopefully translate when carried over to regular clinical practice. Well, thank you, Dr. Ouchi so much for joining us today and I really appreciate the work you’re doing and pioneering a lot of advancements in this field and impacting the way we continue to care for these patients. Thank you so much.
Kei Ouchi, MD:
Well, thank you so much for talking to me, really appreciate it and I think it’s a really important work to try to get this out to everyone.
