Full code to palliative care

[EMDOC17]

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Not really a question nor a thought provoking thread. More so a vent or even maybe a reaffirmation that this job can be very fulfilling at times; even in the smallest or ****iest way. I took two patients, and family’s, through the long process from “full code” to palliative care.

Pt 1: metastatic cancer, ascities, liver failure. Now septic although talking, and completely conversant. Still on “palliative chemo” per onc notes. Beginning of MOD’s with new renal failure. I get that patients/families don’t often here what we say and take their comments with a grain of salt; but state I am the first to to tell them the cancer was “terminal”. After a long discussion with son, daughter and patient about what I would need to do to treat they realized they all were tired of fighting. Got a hug from the entire family as they went up to the hospice floor.

Pt 2: elderly patient with ESRD who missed dialysis twice. K+ Was 7.6. Eventually increasing weakness/debility and was brought in for a fever. This was really initiated by patient. When family stepped out and I was talking to the patient they brought up that they missed dialysis because they were tired of it. Tired of the lifestyle and tired of living with that burden and was content to have lived a long fulfilling life. Very long discussion with the children and she was eventually discharged home with supportive end of life scripts. I don’t think all the children were happy but the son came up and gave me a genuine thank you.

Luckily both these were at the end of my shift when my patient load kept decreasing and I had the time to really go through options. Left 2.5 hours after my shift, but has been one of my most fulfilling. Both were documented full code PTA. No real medicine involved, no really tough decision making; but two patients I felt like I really helped and made a difference. I’ve got a beer in hand and the next 7 days off. I love the rescitations and the critical care but something special about walking someone through end of life.

That’s all.

 

[gutonc]

Not really a question nor a thought provoking thread. More so a vent or even maybe a reaffirmation that this job can be very fulfilling at times; even in the smallest or ****iest way. I took two patients, and family’s, through the long process from “full code” to palliative care.

Pt 1: metastatic cancer, ascities, liver failure. Now septic although talking, and completely conversant. Still on “palliative chemo” per onc notes. Beginning of MOD’s with new renal failure. I get that patients/families don’t often here what we say and take their comments with a grain of salt; but state I am the first to to tell them the cancer was “terminal”. After a long discussion with son, daughter and patient about what I would need to do to treat they realized they all were tired of fighting. Got a hug from the entire family as they went up to the hospice floor.

Pt 2: elderly patient with ESRD who missed dialysis twice. K+ Was 7.6. Eventually increasing weakness/debility and was brought in for a fever. This was really initiated by patient. When family stepped out and I was talking to the patient they brought up that they missed dialysis because they were tired of it. Tired of the lifestyle and tired of living with that burden and was content to have lived a long fulfilling life. Very long discussion with the children and she was eventually discharged home with supportive end of life scripts. I don’t think all the children were happy but the son came up and gave me a genuine thank you.

Luckily both these were at the end of my shift when my patient load kept decreasing and I had the time to really go through options. Left 2.5 hours after my shift, but has been one of my most fulfilling. Both were documented full code PTA. No real medicine involved, no really tough decision making; but two patients I felt like I really helped and made a difference. I’ve got a beer in hand and the next 7 days off. I love the rescitations and the critical care but something special about walking someone through end of life.

That’s all.

Thanks for this. Both for the story, and for doing it.

It's no secret that I'm an oncologist, and also no secret that we as a specialty can really suck at these EOL conversations, or making that transition from "we're going to fight this" to "the battle is lost and the war is coming to an end". I like to think that I'm better than average at doing this (definitely better than average among my group of 14 docs), but I can definitely do better. And even when we do have this talk, it's sometimes hard for patients to hear it from "the doc that's going to cure me".

Sometimes a "second opinion" can be really helpful in these cases. It can come from the PCP, Pall Care or, less optimally, an ED or ICU doc like in this case. I often see this when I get patients coming to me for a 2nd opinion as well. It's very clear from their primary oncologist's note that they discussed stopping treatment/starting hospice, but they didn't agree with it or believe it. But they come to me, hear the same thing and make the switch.

Not trying to excuse or explain away the issue. Just adding perspective. And, again, thank you for doing this.

 

[killerleaf]

thank you to both of you. I can't imagine how hard it is on ya'll...I know how hard it is on this end. When Mom was diagnosed with lung cancer, my brother and I decided that hospice/palliative care was the best option. She had Alzheimer's, and was not communicative, not mobile without a wheelchair. He and I endured 3 months of "friends" and other family second guessing our decision to not treat the cancer, until Mom passed away. We just could not put her thru all of the biopsies and chemo and surgery. It would not help her quality of life..and it was debatable if it would have even extended the quantity. The hospice team were great, and took awesome care of her. The doctors were awesome, explaining all the options; and I am so grateful for that.

 

[evilbooyaa]

One thing I'll say is that a patient with malignant ascites isn't necessarily on death's door. I just googled the definition of terminal cancer, and I think the connotation for terminal means "on death's door", which most metastatic patients are not at. I do realize now that my bias towards the word terminal doesn't make change the textbook definiton of it, which is just 'incurable'. Many metastatic cancers have come a long way in terms of duration of life, sometimes on the scale of median survival in years in the right patient and diagnosis.

Obviously when the first patient presents to you in the ED with new, onset renal failure and severe sepsis, yeah they're in a worse place than they were before during the chemotherapy. Metastatic cancer is (generally) a death sentence, it's just a matter of how far we can kick the can down the road.

Some of the toughest conversations to ever have are when to stop aggressively fighting the cancer and focus on QoL. Patients (and more often than patients, their families) feel like they're "giving up" which can be psychologically difficult to process.

 

[EMDOC17]

Thanks for this. Both for the story, and for doing it.

It's no secret that I'm an oncologist, and also no secret that we as a specialty can really suck at these EOL conversations, or making that transition from "we're going to fight this" to "the battle is lost and the war is coming to an end". I like to think that I'm better than average at doing this (definitely better than average among my group of 14 docs), but I can definitely do better. And even when we do have this talk, it's sometimes hard for patients to hear it from "the doc that's going to cure me".

Sometimes a "second opinion" can be really helpful in these cases. It can come from the PCP, Pall Care or, less optimally, an ED or ICU doc like in this case. I often see this when I get patients coming to me for a 2nd opinion as well. It's very clear from their primary oncologist's note that they discussed stopping treatment/starting hospice, but they didn't agree with it or believe it. But they come to me, hear the same thing and make the switch.

Not trying to excuse or explain away the issue. Just adding perspective. And, again, thank you for doing this.

By no means do I feel I am “good” at this. Although like I said it is fulfilling to me (in a weird way) especially when I feel like it is the best for the patient.

I also am not calling out the oncologist. I am sure they have been told the state of the cancer it’s just patients don’t always understand or hear what is said. In some ways I think the perfect place for this is the ED/ICU. You see them when they are chronically sick. I see them when they are acute on chronically sick. They are also really not feeling well and may be at the point of being tired of the fight or really wanting symptom control more so then when they are stable.

“Despite what we do we may not be able to prolong your life. During this hospitalization to treat you I am going to have to make you symptomatically worse and you will not leave the hospital better, and likely will leave worse than you previously were.” I usually then go over options of do everything medically or so everything comfort focused or a blend of the two knowing it’s not medically the best treatment for their disease. I use some form of that reasoning when talking to patients. It seems to at least let them know what I’m concerned about.

I have no problem going full medical treatment and offer that but at least we have went over their options and started that discussion. When they get admitted I think it sets up the next provider to be able to continue that discussion if the patient so chooses or things worsen.

 

[gutonc]

By no means do I feel I am “good” at this. Although like I said it is fulfilling to me (in a weird way) especially when I feel like it is the best for the patient. I also am not calling out the oncologist. I am sure they have been told the state of the cancer it’s just patients don’t always understand. In some ways I think the perfect place for this is the ED/ICU. You seem them when they are chronically sick. I see them when they are acute on chronically sick. “Despite what we do we may not be able to prolong your life. During this hospitalization to treat you I am going to have to make you symptomatically worse and you will not leave the hospital better, and likely will leave worse than you previously were.” I usually then go over options of do everything medically or so everything comfort focused or a blend knowing it’s not medically the best treatment for their disease. I use some form of that reasoning when talking to patients. It seems to at least let them know what I’m concerned about.

I don't think any of us (perhaps other than our Palliative Care/Hospice friends) are "good" at this. I'm certainly not good at it, but I'm better than most.

But I think you nailed it in these 2 scenarios. And that's what we need. So thank you.

Just yesterday, I had the following patient:
65F w/ CTEPH and HF, on 4L home O2 at baseline with a recent dx of likely pancreatic cancer which was an incidentaloma on imaging for abd pain/diarrhea. Had EGD/EUS with "suspicious" findings but GI and Gas said she'd need intubation for another procedure and might not come off the vent afterwards. Not obstructed and symptomatic only from her cardiopulmonary issues. Recommended that we just forget about the pancreatic thing unless she became symptomatic. Half the kids were totally on board, the other half wanted me to "do something". I told them the thing I really wanted to do was not kill her. They seemed OK with that plan.

Best patient of the day.

 

[EMDOC17]

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[dchristismi]

Ha, yeah, I'm good at that talk. I'm just not good at it in the ED when there isn't the time to really do it justice, hence my transition out of the ED to HPM.

I'm also good at explaining exactly what we do in the hospital, and how if your heart stops and if we are "lucky" enough to get you back, you probably aren't going to be at the same level of functioning, much less, still you. I had a patient & family the other night revoke a patient's DNR (at my hospice house, but he stayed on hospice.) I explained to him and his family, mostly his son, that he was a grown up and could still make his decisions, but that if his heart stopped for a reason that his AICD couldn't fix, he would be subjected to all of modern medicine, but they probably wouldn't "get him back." Wife seemed shocked at the idea that he wouldn't stay at his current level of functioning, and when I explained that "Usually, what happens *if* we get someone back is that they spend 1-2 weeks in the ICU on machines, and then the family has to decide to turn those machines off since the patient isn't going to get better."

Guy really didn't look that bad (I mean, this is hospice, so it's relative), but he ended up coding that night. And EMS took him to the ED, and they called it pretty quickly. I think in retrospect, his son really wasn't on board, and I don't *know* that he was harmed, so maybe that's what he/his family needed. I was pretty surprised when I found out the next morning.

Anyway, I have a talk that I refer to as the "Ice cream is good, chemo is optional talk." I explain fully that I love my oncology colleagues but they're the most positive, hopeful doctors on the planet... and that I'm a cynical ER doc at heart. Most of the time, my patients are already on board, but it's usually an adult child I'm guiding through the process.

But absolutely, it's fulfilling. Painful and drawn out and really hard to do well in the ED, but it's the right thing.

 

[gutonc]

Anyway, I have a talk that I refer to as the "Ice cream is good, chemo is optional talk." I explain fully that I love my oncology colleagues but they're the most positive, hopeful doctors on the planet... and that I'm a cynical ER doc at heart. Most of the time, my patients are already on board, but it's usually an adult child I'm guiding through the process.

Back in fellowship, I used to joke that my favorite chemo regimen was R-CHIP (a riff on the commonly used R-CHOP regimen for high-grade lymphomas:
Roxanol
Cocaine/Cookies
Hawaii
Ice Cream
Prednisone

Prescribed that to 2 of my met pancreatic patients on Tuesday this week.

 

[turkeyjerky]

This is a great thread.

As an aside, I really hate the battlefield analogies in cancer care. These don't do anything beneficial for patients and can be psychologically harmful.

Nobody talks about "giving up" in any other field of medicine, so why is it even in our (society's) lexicon for cancer.

 

[geripalgal]

As a palliatuve care and hospice doc, I really appreciate this thread and all the comments. I dont think anyone can truly be an expert for these kind of talks, but with more practice we can all, myself included, get better. Palliative care docs have that experience and have more luxury of time to have these indepth conversations.


In a way its a shame that my entire field arose, as in many ways its the byproduct of docs having way too many patients and having too little time to spend with each of them. While its true there are many docs with no interest and perhaps little skill in end of life discussions, there are many more docs who genuinely could do "primary palliative care" and do it well if they just had the time and some extra training.

And I love the r-chip idea (minus the coke part)

 

[enalli]

And I love the r-chip idea (minus the coke part)

What's wrong with Coca Cola?

Regarding code status, I recently read the phrase "CPR is for when your heart is the only thing that stopped working." I'm sure I'm butchering it, but it seemed beautiful in its simplicity.

 

[geripalgal]

What's wrong with Coca Cola?

Regarding code status, I recently read the phrase "CPR is for when your heart is the only thing that stopped working." I'm sure I'm butchering it, but it seemed beautiful in its simplicity.

I prefer pepsi 😉

 

[gutonc]

As a palliatuve care and hospice doc, I really appreciate this thread and all the comments. I dont think anyone can truly be an expert for these kind of talks, but with more practice we can all, myself included, get better. Palliative care docs have that experience and have more luxury of time to have these indepth conversations.


In a way its a shame that my entire field arose, as in many ways its the byproduct of docs having way too many patients and having too little time to spend with each of them. While its true there are many docs with no interest and perhaps little skill in end of life discussions, there are many more docs who genuinely could do "primary palliative care" and do it well if they just had the time and some extra training.

And I love the r-chip idea (minus the coke part)

We’re already giving them heroin, might as well make it a speedball.

 

[EMDOC17]

@gutonc I am very stingy with my narcs for the most part. When they go palliative/hospice the flood gates open. What can I do? Dilaudid; how much? Gin and tonic? Hookers and blow? I will see what I can do, you know, legally.

I had a good experience in residency with HPM. They were great and taught me a lot. If you have <6 months to live I don’t care if you become an addict or get a high. When I leave this world hopefully I can try dilaudid for the first time and see what it’s all about.

I’m glad this has turned into a good thread when I was simply voicing a ****ty shift although made me feel good. I have always considered HPM. I would do it right now if it didn’t pay dismally for a physician. It’s my later life plan when I pay off loans. If those HPM docs that have replied could message me and we could talk a bit more that would be great. I see myself doing this in about 10 years.

 

[gutonc]

This is a great thread.

As an aside, I really hate the battlefield analogies in cancer care. These don't do anything beneficial for patients and can be psychologically harmful.

Nobody talks about "giving up" in any other field of medicine, so why is it even in our (society's) lexicon for cancer.

Yeah, I hate it too. But I'm pissing in the wind on that one.

I also hate:
Terminal: Life is terminal. You have an advanced cancer that will most likely be the cause of your death in the next X months.
Remission: Unless you have leukemia, you will never be in remission, even if your Stage I, low-grade breast cancer has been cured and you're disease free for 30 years.
"I want the most aggressive treatment": You're going to be offered the most clinically and scientifically appropriate treatment for your cancer. Sure, I could give you chemo that would completely destroy your bone marrow, but it won't do s*** for your metastatic gastric cancer. And just because you don't lose your hair doesn't mean I'm holding out on you.

Alright...I'm done. Back to enlisting your all's help in providing our patients with a good death. That's quite honestly the thing I'm most proud of in my line of work.

 

[EMDOC17]

Alright...I'm done. Back to enlisting your all's help in providing our patients with a good death. That's quite honestly the thing I'm most proud of in my line of work.

If it was that simple. Just an algorithm of A,B,C. Every patient is different.

I swear the ED gods throw me a flavor of the week. One week it’s CC with Intubations, central lines, pressors. The next it’s non diagnosable abdominal pain.

This week it’s cancer.

55 yo with shortness of breath. Looks, smells, and quacks like copd. Hypoxic. CXR grossley abnormal. CT c/a/p metastatic disease. D/C with albuterol and reluctantly with po Roxanol. I’m hoping our social worker can find his cabin and get that home 02 he needs after leaving the department.

 

[VA Hopeful Dr]

@gutonc I am very stingy with my narcs for the most part. When they go palliative/hospice the flood gates open. What can I do? Dilaudid; how much? Gin and tonic? Hookers and blow? I will see what I can do, you know, legally.

I had a good experience in residency with HPM. They were great and taught me a lot. If you have <6 months to live I don’t care if you become an addict or get a high. When I leave this world hopefully I can try dilaudid for the first time and see what it’s all about.

I’m glad this has turned into a good thread when I was simply voicing a ****ty shift although made me feel good. I have always considered HPM. I would do it right now if it didn’t pay dismally for a physician. It’s my later life plan when I pay off loans. If those HPM docs that have replied could message me and we could talk a bit more that would be great. I see myself doing this in about 10 years.

My residency hospital had beer and wine order sets for hospice patients.

Our pharmD did lots of church-based outreach to the local prostitutes, so we probably could've found a way

 

[austintr]

My residency hospital had beer and wine order sets for hospice patients.

Our pharmD did lots of church-based outreach to the local prostitutes, so we probably could've found a way

I think I'm gonna go ahead and just do CAM and try and get this beer/wine/ladies of the night regimen mainstream.

 

[thegenius]

I'm bumping an old thread.

I'm curious about the billing aspect of this. I spent about 15 minutes the other day talking about end of life with a patient and their family in the ED. Afterwards the hospitalist told me I can bill for this. Now I see hospitalists bill for EOL all the time in their notes, but I wasn't sure if this could be billed by an ER doctor. Have ER doctors ever done this in the ED? And if so...any specific considerations we need to know about?

I enjoyed reading this thread.

 

[NITRAS]

You can bill for advanced care planning. (If you spend 16 minutes doing it). You can bill I’m in addition to your regular charge. You can’t bill with critical care though.

 

[thegenius]

You can bill for advanced care planning. (If you spend 16 minutes doing it). You can bill I’m in addition to your regular charge. You can’t bill with critical care though.

Do you know specifically how that is done? What text needs to be put in? The coders need to be able to pick it up in the chart.

What if a patient comes in critical, I perform critical care of 45 minutes on them (say they are in septic shock), and then the family comes in later and wants them DNR / DNI / Comfort Care? At that point I might have a > 15 min conversation about advance care planning.

Why would I not be able to bill CC time and Advance Care planning in the same chart? Maybe simply because it's just a rule, but would like to know more about this.

It appears you are a hospitalist? Do you also do ER time too? I appreciate your input on this.