The PalliEM Podcast:
Episode 2 – Developing Processes to Integrate Palliative Care in an Academic Emergency Setting
– with Dr. Audrey Tan, DO
In this episode, I meet with Dr. Audrey Tan, DO, an emergency medicine/palliative medicine clinician, researcher, and educator. We discuss processes she has explored in the emergency department which help to identify patients who are likely to benefit from palliative care support and advanced directive guidance.
EPISODE 2 SPEAKERS:
Audrey Tan, DO, and Justin Brooten, MD
Audio Editing Assistant: Kevin Yu
Justin Brooten: Today I’m joined by Dr. Audrey Tan. She’s the medical director for the inaugural Division of Emergency Medicine palliative care at NYU Langone health. She’s a clinical associate professor in the Ronald O. Perelman Department of Emergency Medicine and the Department of Internal Medicine. Her area of focus is the integration of palliative care in the emergency department. She’s also involved in developing novel clinical solutions, and addressing educational needs to improve palliative care delivery in the ED. Her work is focused on improving quality of life for patients with advanced chronic or life-threatening illness, in hopes that every patient with serious illness within the emergency department can receive excellent compassionate care that encompasses their physical, psychosocial and spiritual needs. Dr. Tan, thank you so much for joining us.
Audrey Tan: Thank you for having me. I’m excited to be here.
Justin Brooten: So my first question is because this is kind of a unique field, what led to your initial interest in the combination of EM and palliative medicine?
Audrey Tan: Yeah, I get that question a lot. You know, I have to say, I went into emergency medicine, with no thoughts of palliative care, really, and it was only towards the latter part of my training, you know, I was in a sort of gritty, inner-city program. I just really felt like there were certain patients, you know, those patients with chronic illness that would come to the ED over and over and I just felt ill equipped to really help them in, in a real way. So, you know, I kind of then had some great mentors at SUNY Downstate, in Kings County in Brooklyn, who were EM/IM and actually intersected with palliative care that sort of showed me the ropes and introduced me to palliative care, and it really kind of, it clicked for me to sort of integrate it into what we were doing, you know, it just made so much sense as the door to the hospital and the specialty that was really doing the interventions, you know, doing the intubations and resuscitations that we also had to have the skills to talk about it and sort of the knowledge to navigate that. So I think it was, you know, kind of those revelations that really pulled me towards palliative care.
Justin Brooten: I really appreciate your response, because you highlight something that I’ve noticed is that in clinical emergency medicine practice, you’re just going to encounter situations with patients where that skill set is very helpful, and it’s interesting that came to the surface in your training. I went into emergency medicine with already having an interest in palliative care. But I think that’s why a lot of physicians, when they start off, they do realize they’re they have both that resuscitation knowledge, but also you have to be able to apply those skills in real time and under a lot of pressure. Now, your leadership positions kind of uniquely places you to oversee integration of these principles in the emergency department. How are you using both skill sets in your current professional roles?
Audrey Tan: Well, you know, I really love both specialties. I mean, I sort of was very adamant about keeping my foot in each door. You know, there are things I love about emergency medicine, there are things I really love about palliative care. So I am grateful at NYU, that they really gave me the opportunity to do both. So I spend a good amount of my time in the emergency department, and then also spend some dedicated time on the inpatient palliative care service at NYU. And my nonclinical time has been focused on really integrating palliative care and emergency medicine and innovating and developing some novel solutions to really improve the care of ED patients and address their palliative care needs.
Justin Brooten: That’s excellent, and I’m glad you’re able to use both skill sets. Because I find it’s the same thing you if you like both branches of medicine, you want to keep your skill sets, and you want to interact with patients in both arenas. One of the things that I appreciate about the interventions you’ve developed is you’ve looked at ways to help both integrate palliative care for patients on an inpatient pathway from the ED and also those who are going to be discharged need outpatient support, and the ED is kind of uniquely suited to address both needs. So can you tell us about some ways that programs can help address palliative care needs for both people who are headed to be admitted and they need inpatient needs and those who are being discharged who need outpatient resources?
Audrey Tan: Yeah, I mean, I think there’s a variety of ways, I think, certainly what I would say is that you really need to be in tune with your sort of institutional needs. I think that’s one thing I’ve really sort of learned early on is that aligning yourself with leadership at your institution is critically important. But you know, there’s a lot of I think one of the ways that is often utilize are triggers. And that has to happen sort of on the backbone of education, of course, but triggers that sort of help us side Identify amidst the sort of chaos of the ED, quickly identify patients that have unmet palliative care needs in the ED. We have taken that a step further, I think one of the programs I’m most involved with is part of a bigger research project called PRIM-ER and Corita Gruzden is the principal investigator, and I had the opportunity to develop a clinical decision support tool that was embedded into the PRIM-ER research project, and it’s now actually at 35 different EDs across the country. It’s actually a four pronged intervention; that’s pretty cool. It involves some education for the ED attendings and ED providers, and really, education around communication, so kind of modeled off vital talk, and then the clinical decision support tool is really meant to identify those patients that have palliative care needs, but utilizing and really using the electronic medical records to do that, and every institution has different needs different culture. So it is kind of there’s a framework for it. At NYU, we actually use this clinical decision support to identify hospice patients that sort of have been discharged from hospice and then come back to the end, because obviously, we want to know about those patients fairly quickly. Those patients that have advanced care planning documents that are on file, we want to know about those patients fairly quickly, especially if they come in in extremis, which is sort of that feared scenario for every ED provider, right? Like the patient that is like an ESI one or two kind of peri-arrest, and we don’t know what their advanced directives are, or there’s kind of conflict around advanced directives. So it really pushes that information out to the provider. And then we have also developed one tool, one alert that attempts to identify patients that have novel palliative care needs. So all to say, you know, those different alerts help the ED provider, you know, again, sort of amidst the chaos that we work in down there to identify those patients quickly. So, you know, those patients are typically destined for the inpatient world, and we bring them, you know, we bring the palliative care team down more rapidly with these triggers. And in addition, you know, the ED provider with those skills can sort of negotiate advanced care planning and goals of care discussions more expeditiously.
Justin Brooten: That’s excellent. And you mentioned, you know, using the information that’s already in the EHR, because there’s lots of information there and leveraging it in a time sensitive way is helpful. One thing I’m wondering, how is the receptivity, when you try to change practice, or give people an extra step? How do you overcome maybe the obstacles that people have to thinking this is going to affect my workflow? This is going to make me slower, that can be tough. How do you address that?
Audrey Tan: Yeah, I mean, that comes on the background of a lot of education. Right. I think a significant component of the whole PRIM-ER initiative is the education not only around like, distinct tools around how to have the conversation, but sort of, you know, why are we doing this? Why is this important talking about those cases, getting people on board? You know, I really think that culture change is like a significant part of what this ED, what you and I and our colleagues are doing in terms of just shifting how ED providers think about palliative care. It’s not like an upstairs job. It’s not an outpatient job. It’s actually our job, too. And so as part of sort of the culture change, I think it’s really just getting people to get it, right, like talking to people about those cases that are challenging. And if you had these skills, you would be able to navigate that right, you wouldn’t be kind of stressing and shaking in your boots. I think that’s often, you know, the patient and an extremist again, that’s like, got conflicting goals of care, you’re just not sure you don’t think they’re going to benefit from resuscitation, but you sort of feel obligated to do it. How do you navigate that? You know, these are the tools that we can give you to help you move forward. And I have to say, I think there’s different you know, I think like, certainly newer residents get it, and/or the residents just in general get it and with your attendings sort of a tendency with older attendings sometimes there’s some resistance, but I think, you know, again, it’s part of this sort of changing of the culture, changing of our mindset, in the end to really embrace these skills.
Justin Brooten: Yes, you’re absolutely right about culture change. And one of the things that comes up when we talk about these situations, and we talk about difficult cases where you are having to make decisions really quickly. The thought is either these patients that come in, they’re chronically-ill or they’re having repeat ED visits. When someone starts that conversation when that patient is cognizant and can weigh in on what’s important to them; that doesn’t have to be a long conversation, but that may really help your colleague downstream or help you downstream when that patient returns and now they’re in extremis, like you said, and at some of those things have been written down. I’ve had that happen, where somebody that I’ve seen on palliative consults comes back to the ED, and it’s pretty amazing, but we’ve actually had a chance to address some of those things ahead of time. And now in the acute situation, we’ve actually got some guidance. So to get to see it on both ends is not common, but I’m hopeful that the work that we’re doing is affecting other providers as it comes back around, because it is a time investment, and you’re right, seeing that utility in it. And the uptake, I think it’s now that it’s becoming more of a commonplace thing and ED resident education, it’s not such an unusual topic anymore. So one other one other question I have for you, so your nurse telephonic program. So I think this is really a wonderful way to you mentioned outpatient, you know, sometimes it’s not even just the conversations that’s going to happen in the ER, but it’s identifying these patients who need outpatient resources. So how does that program work? And what were some of the beneficial outcomes you saw through that, or you have seen, I’m sure it’s still in progress.
Audrey Tan: Yeah, we are still in the midst of sort of continuing this program. But this is part of a PCORI funded program. And it’s been really cool to work on this. So these patients are patients that come through the ED and either have end-organ disease or advanced cancer, and they’re actually randomized to standard outpatient palliative care clinic, or the program that I’m working on, which is an outpatient, nurse led telephonic palliative care program. And what happens is our nurses work with these patients for six months and call them while they’re at home and kind of address their palliative care needs over the phone. And I have to say we’ve had a lot of success with helping with advanced care planning, especially for you know, this particular cohort of patients, I think it’s particularly beneficial because they’re not then tasked with traveling in for a clinic appointment, or, you know, like yet another doctor to see, as many of these patients already have so many doctor’s appointments, they can do this at home. And we found with talking about advanced directives, that when they’re at home, they have sort of the liberty to talk about these things. And we can often pull in their healthcare agent or their surrogate decision maker, because they’re sitting right next to them. And so we have certainly had successes that way. You know, it comes with as every new program, there’s certainly some challenges as well, you know, is that the right cohort? Is there a better way to identify those patients, we’re still figuring all of that out, again as we sort of continue to analyze what’s happening with these two programs. But it’s been really fun. I think it’s been really cool to sort of think about how to do this telephonically, and also, with nurses kind of having and spearheading the initiative. I think they’re often an underutilized resource. And as you know, palliative care needs grow, realizing that, you know, relying on our nurse colleagues and our social worker colleagues has also been really beneficial to kind of navigate all of this for our patients.
Justin Brooten: Yes, I agree. And it’s one of those things that’s different culturally, because we do see so much more nurse engagement in palliative care traditionally. The other thing I like about this is you’re taking something you’re generating a resource that now all the ER physician from what I can tell, depending on how your system works, their job is to identify this introduce this to the patient. What have you noticed with downstream engagement in advanced care planning, and the conversations that were generated? What did that result in with the initial group of patients you’ve looked at?
Audrey Tan: Yeah, certainly, we’ve had successes in just having the conversation. And then what we found anecdotally is that our nurses are always sort of tracking the patients on our caseload. So when they go to the hospital, they’re often able to intersect with the inpatient team. And the nurse will be like, “hey, guess what, I had that conversation, and we talked about this, and they want this intervention, but they’re really ambivalent about that intervention. So I would touch base with them before moving forward”, you know, just kind of giving the inpatient team a heads up, and just having that initial information on file has been really I think, helpful. Certainly, there are some cases that stand out in my mind where we’ve been able to make a big difference?
Justin Brooten: That’s excellent, and I think ACP applies at multiple levels. I think one, just bring up the conversation, and that’s one of the things that’s unique about the ED. I was talking with someone else and they pointed out what you mentioned before, that we talked about this being an upstairs job or an outpatient job and when patients come into the ED and they’re dealing with something, you know, maybe not horribly ill, but they’ve had enough of a disease exacerbation that it kind of puts them on our radar, that is a good time to bring this stuff up and just find out have they even thought about it, have they talked about it. So I think on multiple levels you start the conversation, potentially you have a medical decision maker there and you guide them through a little conversation, get them plugged in with a resource. And if they make it to having a hardcopy Advanced Directive, great, but even if they don’t, I mean, I’m sure you can recall numerous times where a conversation that you had with a with a patient who needed a care transition was dramatically changed by the fact that they had had some conversation with their family about “what if I’m really sick?” It can make a huge difference on the decision making and the comfort level of the family and trying to make those decisions on their behalf. So I think that’s excellent.
Audrey Tan: Yeah, I was just going to piggyback on that, I was going to say that, you know, our patients come to the ED for all sorts of reasons, right? I mean, whether it’s that some device that they have, is not functioning, a pleural catheter, whether it’s pain that’s sort of out of, you know, uncontrolled. I think every ED visit always serves as an opportunity to even just plant the seed. Again, like you said, we’re not going to always sort of ended up with that advanced directive signed and completed, but at least you can sort of ask the questions and plant the seed. I think it’s often unnerving for patients when you know that ED is going at 100%, at 100 miles an hour. And then they get upstairs, if that’s, you know, the disposition and the ICU was like, well, maybe this doesn’t make sense. Or this may not, you know, they’re the ones sort of introducing this idea of, of talking about goals of care where we never even alluded to it. You know, I think we’re certainly players in the whole conversation. So we should be also kind of alluding to it and planting that seed.
Justin Brooten: Absolutely. And I think too, we can kind of. Now obviously, patients, you know, benefit from all the other involvement of specialist once they’re admitted and get clarity on the condition if it’s not completely clear from the outset. But I think the words we use early on in acute illness, I think people will fixate on that. And if we use really vague language, that doesn’t really help point them in any particular direction, then then that can set up one mode. And if we use, you know, language, I’ve got a really sick patient, you know, even if we’re not on the stage of maybe palliative care or care transition, but I’m really worried about their condition, just saying, “I’m really concerned about your loved one”. You know, “they look really, really ill. And we’re seeing several things that are concerning”, even if we’ve got an aggressive route of care plan, I think it changes their opinion of what’s going on, as opposed to saying, oh, yeah, “well, we’re doing this and we’re doing that” and kind of nonchalantly addressing their illness. I don’t know if that’s been your experience.
Audrey Tan: Yeah, no, exactly. I am so in agreement, that just planting the seed and sort of saying those words, “I am worried about what may happen, we’re going to go ahead and do this. But we may need to have another conversation, we may need to pull in a team called palliative care down the road.” I think that kind of that warning shot. And hopefully, you know, it may not go in that direction. But if it does, then the family or the patient is a little bit more prepared to have that conversation.
Justin Brooten: Yeah, absolutely. And I agree, it’s like a warning shot, they kind of know, they know something’s coming. And I’ll try to leave it open ended. Like we’re hoping for a good outcome. But I’m pretty concerned and like you said, mentioned the thought of maybe palliative care being involved, kind of warm them up to that idea. If it looks like it’s going to be an appropriate intervention to consider. One of the other questions I have based on your leadership role, you probably have a sense of this. But why should health systems consider investing in these processes? You mentioned your intervention being rolled out at 35 emergency rooms? Why should health systems be thinking about these things? Because how does it affect downstream care from the global standpoint?
Audrey Tan: Yeah, that’s a good question. You know, I think there are certainly the studies support starting ED initiated palliative care interventions in terms of improving quality of life for our patients. But there’s also, you know, conversations around improved symptom management. And I think from an administration/administrator’s standpoint, I think there’s certainly benefits in terms of resource utilization, you know, if we can because of a conversation that we have down in the end prevents a patient from an unnecessary ICU stay, or you know, if that patient is there for unaddressed symptoms, do they really need something like hospice? And if we can do all those things at the door to the hospital? I think that makes a lot of sense.
Justin Brooten: Absolutely, and just being able to utilize the full scope of resources we have, instead of just assuming everybody needs to get admitted, or that they’re going to go, they’re going to get discharged, but we’re going to have to leave them hanging and leave some of these concerns unaddressed.
Audrey Tan: Yeah, our clinical decision support. So we thought about that sort of very statement and that I think, so much of this has historically been provider driven, but we really sought to involve the entire care team down in the ED with our clinical decision support tool. So we have actually involved our nursing staff down there, as well as our social workers, our care managers, and really, again, made sure that kind of in a very palliative care inpatient way, involving a multidisciplinary team to address the needs of these patients in the ED, and if the Social Work visit, you know, if they get a sense that that patient may need hospice, then they’re the ones that sort of spearhead that and many times have, I relied on our social worker to help me navigate that down in the ED.
Justin Brooten: It’s so interesting when you talk about this stuff, because it’s not surprising. But even in dealing with situations at our own institution and trying to come up with pathways that are going to improve care, you’re right, it’s multidisciplinary, it’s kind of using as many eyeballs as possible. And it’s funny because one example that comes up, and I’m educating people on this, and it slowly changes, but when we have somebody who they need to be on hospice, but they don’t qualify for inpatient hospice care, and we’re trying to get in disposition somewhere and the physician is like, “well, I don’t understand why the hospice agency won’t accept them to the to the hospice house, I mean, they’re dying”, it’s like, “yes, but all the hospice patients are dying”, they have to meet certain criteria and little things like that. We’re just helping them navigate to where they can figure out how can I plug this patient in with a good resource that fits them, meets their needs, and it takes a whole bunch of other people who have the knowledge of how those processes work to integrate. So it’s interesting what you said, You’re absolutely right. It’s kind of a combined effort. The other kind of follow up question I have to that is with providing these pathways, what has been you mentioned culture change several times earlier? What have you seen with the residents and the attendings? As they’ve seen these processes at work? How do you feel like they’re responding to it? And do you feel like there’s been buy in?
Audrey Tan: You know, I think that some of our workflows have been more successful than others. And I definitely have some lessons learned, especially with the clinical decision support, it was interesting to roll it out. I think, certainly, if you’re alert is not well directed, and focused, and perhaps fires too often, you know, you can make people in the end mad pretty quickly, was the lesson I learned. So just really being very thoughtful and cognizant of how you’re using things like clinical decision support, it was really an important lesson. And it also needs to really align with current workflows. You know, I think if you’re asking a provider or resident to sort of go out of their way, for example, we started on video conferencing solution for our nighttime and weekend palliative care consults. So we had all this fancy equipment in the ED, you know, a nice lovely computer screen that would teleconference our palliative care provider at home when they weren’t in house. But I have to, say, getting providers to sort of go fetch that screen and bring it bedside, and even though you know, logistically, that didn’t seem like a huge ask, we could never get our ad providers to sort of enlist with it, because it was just like finding the screen, getting that to bedside, you know, that sort of additional ask was not something. That initiative unfortunately fell apart pretty quickly, because we couldn’t get people to take those extra steps. So just to say, it really has to be embedded in sort of your institutions workflows, pretty seamlessly, in order to get people to enlist. And then, you know, I think it’s also a process. It’s a stepwise process. So you know, even with the clinical decision support, we initiated a few things did some education, then as you know, the sort of understanding and engagement and acceptance of palliative care, these palliative care initiatives moves forward, I think you can then change, you know, push the boundaries and sort of try different things. But it has to be a stepwise approach, you know, I think in a lot of change management strategies, it’s a very kind of strategic stepwise approach, when you’re sort of the light at the end of the tunnel is really getting people to enlist and sort of embrace palliative care. But to do that, there needs to be many steps in between. So yeah, just to say it’s been a process, we’ve had some successes, and we’ve had some that have been less successful.
Justin Brooten: Well, it’s so true, what you said, if the workflow even like you said, slight changes in the workflow, it’s going to completely change people’s behavior, and they may not follow along with the intervention that you’re hoping for. And I think the other thing that points out too is if you’re going to try to change culture and change practice, you have to take risks, and sometimes those risks show that people are not ready for that transition or that they’re not ready to use that intervention.
Audrey Tan: I was going to say, I totally get it when I’m down in the ED, it’s challenging to do this work down there. So I try to be very cognizant of sort of ED colleagues and what it’s like during a busy shift to navigate all those moving pieces.
Justin Brooten: Well, thank you so much Dr. Tan for speaking with me and I really appreciate the work you’re doing in this space. So, I am thankful that people like you are doing that kind of work.
Audrey Tan: Thank you, thank you it’s a pleasure to be here