E17-danielle-doberman-palliative-care
[00:00:00] Guest: When we bring patients to the hospital, we say, mother has shortness of breath. What do we say? We say, do you want CPR? Does mother want CPR?
TJ's mother went intubation and people are like, Oh, okay. If that makes the shortness of breath, go away, give mother that you had a side of pressors with that, a little dynamic, this family she's like, what the hell?
 Welcome to mastering Medicare. I am here today with our cohost Alex Mohseni and me Amy Schiffman. We are back for our 2021 debut of mastering Medicare, Alex. Welcome back. Yeah, good to be back. How's your COVID going awesome. I just love COVID so great. [00:01:00] Um, so I apologize to all of our listeners, we've taken a little bit of a COVID pause, but we are back with what I would consider to be a highly anticipated podcast.
Alex, I've been so excited for this podcast. Did you know that I've been thinking about this podcast for like about a year? Yes. Danielle didn't know that. So now traditional there's no pressure. Yeah. Okay. So I would like to welcome to podcast Dr. Danielle Doberman, who is not only an unbelievable doctor and amazing person who has like a really long title that I'm going to get to in a second, but a really good friend who I've known for 20 years since she was a year ahead of me in med school and residency, uh, she is.
Very very renowned in her field. Um, Danielle is, well, I should call you Dr. Doberman. Dr. Doberman is the clinical medical director for palliative medicine at Johns Hopkins Johns Hopkins hospital in Baltimore. She's also the fellowship director for the palliative medicine program. Did I get it right? You got it right?
Oh [00:02:00] my God. A lot of work, a lot of work. Unbelievable thing of actually almost saying John Hopkins hospital. Can you imagine like it's so no Johns Hopkins. I'm like an alumni. I can't even say it. Right. Okay. Anyway. So we are really excited to have Danielle here. Uh, we are going to jump right into a topic that I think everybody is thinking about.
Talking about, has a million questions about, so I am going to literally start at the beginning with you, Danielle, unless you want to like, sort of like, say more about yourself and Alex, if you have any questions about Danielle's training or anything like that, I think we're going to jump right on in, and it'll sort of like, I'll tell the tale.
Danielle, what is palliative medicine? So that's a great question. I think a lot of people are confused at times. Um, palliative medicine, um, is a sub specialty actually of internal medicine that focuses on what some people call total patient care. So [00:03:00] mind, body, spirit. What are the realms of, um, patient care that can be improved to prevent suffering.
So physical pain, nausea, shortness of breath, actual pain, um, as well as the practical issues of an illness. Um, if somebody let's say is a single dad trying to raise kids and they're diagnosed with cancer. Or maybe they're diagnosed with ALS Lou Gehrig's disease. How do they get through the day? How do they balance work and illness?
Um, and the field of palliative medicine works, um, as a team, not just as a physician or a nurse practitioner, but alongside social workers and chaplains to really help take care of that patient and whomever they identify as their support system. So family significant others. Um, whoever they identify as their [00:04:00] lived family.
To try to help support them, uh, as they make their way through life. So it's an added layer of support alongside the regular physicians who care for the patient. So I'm gonna kind of, that was amazing. And I think that was really well-described even for me, who has sort of like, sort of circled around the field of hospice and palliative medicine and geriatrics and emergency medicine.
I mean, understanding what palliative medicine is. Is a really critical piece here. Now, is this a hospital-based specialty or is this something you find out outside in the regular brick and mortar doctor world? Like, tell me, tell me where you find a palliative medicine. So that's an interesting question.
And I think it really depends right now on where you are in the country. So, uh, years ago, when the field was first developing, it tended to be very hospital-based. But now, as there's an understanding that really. [00:05:00] Everyone with a serious illness can benefit from palliative care, a more holistic view of somebody's treatment plan.
More and more palliative services are being offered in the community. So some people have palliative providers that come into their house because clearly if you have advanced CLPD or emphysema or advanced heart failure, It's hard to get out to the doctor's office. And so having a provider like a nurse practitioner or a PA or a social worker who can come into your house and help you is really important.
And also more and more, there are independent providers who are having clinics. So for those patients or those, um, family members who can travel to the clinic, There are now free standing clinics. Some of these are affiliated with hospitals. Some of these are free standing. Um, people who have hung out a shingle to provide the services.
[00:06:00] And some of these are affiliated, um, with, uh, sometimes with hospices. Palliative is totally separate from hospice. It can be provided at any age. So some children have palliative care, um, and it can be at any stage of an illness from diagnosis all the way through. So early stage cancers, early stage Parkinson's, for example, neuromuscular illnesses and early stages of other illnesses.
Like. Snatch up all their things dementia too, right? Dementia. Exactly. Alex has raised his hand, but all neurological illnesses, um, actually are great paradigms for having palliative care. So, um, um, my senior gravis, Ms. Parkinson's dementia, all of them, they are illnesses that people live with for many, many years, even decades, but often you have symptoms for many years.
And so having somebody who's an expert in symptom management, [00:07:00] And who can work alongside your regular physicians is very helpful. Yeah. So Danielle, that's a very interesting, uh, way you can hear me now. We can hear you better. Okay. Yeah. So, um, can you clarify a little bit, uh, for me then, Um, you know, with hospice, we have like a clear threshold as to who qualifies.
Um, you know, the, the doctor has to expect that the patient has less than six months to live. Uh, is there such a threshold for palliative care? No, and I think that's actually one of the myths of palliative is that you have to have some sort of threshold. Um, there's a very fancy, um, kind of, uh, jingle any age and any stage.
So palliative is any age. Um, and any stage and there's actually, um, perinatal palliative care. So sometimes pregnant women are diagnosed with a baby who may have a lot of genetic, [00:08:00] um, anomalies. And the baby is known that it might die very soon after death, after birth. Excuse me. And so there are actually hospitals around the country that will offer palliative services to, um, the parents to help them.
Uh, um, with their grief that will come at the time that the baby is born. And even knowing that that for the woman that she'll be carrying a baby, who's soon to die to help that baby have a passing that will have no symptoms and help the parents with that anticipatory grief. So any age, any stage of any illness?
Um, unlike hospice where we say, you need a certain diagnosis to qualify, and palliatively say you just need symptoms. And so sometimes those symptoms are things you feel in your body like cough or fatigue or nausea. And sometimes those are symptoms, um, like, uh, [00:09:00] emotions. Severe anxiety because of the pain that you have or knowing that your loved one is burdened by illness.
So can I ask my question? Yeah. Okay. I get to go first. Okay. Okay. So, I mean, I do kind of know the answer to this question, but you know, I think as part of the mastering Medicare concept, and I know the any stage. What did you say any age, any stage? You know, we focus so much on this podcast on Medicare, so that sort of implies an older patient population and we all have learned.
And, and Danielle, you, you well know this, um, hospice is a part, a Medicare benefit. If somebody is in palliative medicine, they are receiving care through part B. Correct. Correct. So you can, um, your, the part B, so what you would charge going to clinic or what somebody, the fee for service [00:10:00] bills that your, um, nurse practitioner or your, uh, social worker who would visit and charge, um, back to Medicare, those would fall under part B.
So, um, somebody who comes to provide services in your house would get charged in that way. All right, Alex, you go. Okay. So I'm, I'm going to play the part of, uh, the, the lay person audience. Um, so because that's pretty much what I have often, so, okay. Let's say I'm a cancer patient and I may have anywhere from four months to 12 months to live.
What is like the algorithm that I should go through to try to figure out, should I become a hospice patient, or should I become a palliative care patient? Like, is there an algorithm? Like, what are the questions I should be asking myself? Or maybe my, my primary care doctor together with me, we should be asking to try to figure out because we can't really do both.
Right. There are [00:11:00] two separate avenues, uh, so can help us out through that. So, um, That's interesting. Um, what is lost, I guess, um, there, um, I, uh, many times agencies around the country that provide hospice, have palliative care. Um, I want to say arms or they have, um, um, service lines that also provide palliative care.
So for community-based palliative care, in some areas of the country, the vendor of the community-based palliative care is a hospice. Um, so I think as a, as a. Patient who's receiving the services, I don't think necessarily for you [00:12:00] and your doctor to choose the service line. I think maybe to go in and ask for all the information possible.
One of the challenges between palliative and hospice is that, um, One of the main differences in what is not funded by Medicare under palliative is the chaplaincy component. Um, so if you, um, are in the community and, um, would like to have the faith component of what is getting you through the day addressed and your own ministry is not able to do home visits or faith outreach, and you're not able to, um, maybe get to your.
House of worship with ease and they're not able to do zoom and times of non COVID. Um, [00:13:00] perhaps looking more at, at the hospice services might be better. Hospice under Medicare also is a very. I don't want to say fixed it's it's a very coordinated service benefit. So Medicare pays for all the medications related to somebody's illness.
They also will pay for home health aid services. These are, that is not paid for under. Palliative. They also will pay for durable medical equipment, such as a bed or a bedside commode, because hospice was created for people who do have a more finite life expectancy. So there are, it is a more robust set of services acknowledging that somebody might need a greater amount of support.
So palliative, um, [00:14:00] covers that same timeframe, but the awareness is also that somebody likely doesn't need the same degree of supports and that perhaps their family can still, um, uh, get back and forth to the pharmacy rather than having pharmacy deliver medicine. For example. So, um, would it be fair to say that if you are a cancer patient and you no longer want to be on chemotherapy or it's few tiles to be on chemotherapy and you have less than six months, then hospice would be a good choice for you.
But if you want to continue chemotherapy, given the nature of hospice being a capitative payment model, where the hospice would have to pay for your meds and chemo is generally very expensive. Then probably palliative care would be a better option because you could continue to kind of do them with the more aggressive and expensive treatments.
Is that valid or no? [00:15:00] Um, yes and no. This has gotten a little bit gray. Um, and that's why I hesitate. Um, I. Uh, depending on where you live in the United States, there are some very large hospices which can accommodate small amounts of what has historically been felt to be disease modifying treatment while under hospice care.
These are wealthy. These are wealthy hospices that have tons of cash. Cause they're still under a capitated model though, right? No, I wouldn't phrase it that way. What I would say is that science is evolving. And so when you and I went to school, [00:16:00] um, there were, you know, um, there was treatments where we said this treatment only.
Is used to cure disease and these treatments are only used to make people comfortable and nothing crosses. And now we know for example that, um, if somebody has a bone metastasis that, um, rather than giving people a lot of pain medicine, opioids, if we give them. A very few number of doses of radiation. We can get pain management, um, to that single isolated bone metastasis without causing a lot of maybe sleepiness from the medicine.
But it only is useful if people are going to have a life expectancy more than three months. So there's a cost benefit for a single individual. So it's, um, it [00:17:00] is worth, it is, um, Cost-effective if the patient has the stamina to get back and forth to the radiation scanner, to sit in place. Um, if they have the fortitude to not be negatively impacted by the radiation, um, there is a cost to the hospice for that.
There's a cost burden to the patient for that. Um, if the patient. Is known to have this metastasis in the last one week of their life. It does not pay too to offer radiation 30 bedridden, for example, right. They're still walking around and they've enrolled in hospice because their philosophy is they want to maximize time with their family and they want to avoid being in the hospital.
They want to avoid exposure to illness and COVID and everything else, maybe. Three doses of radiation. One dose of radiation [00:18:00] makes a lot of sense. Um, so there are now treatments. Um, similar if somebody is coughing up a lot of blood with lung cancer, radiation makes a lot of sense as well. There are things like, um, Um, drains in the abdomen, uh, for people who have what we call a site, these are fluid in the belly.
Hospices never used to pay for those. They're very expensive. Now they do, because the benefit on, um, people's quality of life outweighs. The cost of the hospice in certain times, intravenous antibiotics is another example. Hospices did not use to pay for artificial nutrition, artificial fluids. Now some smaller hospices around the country.
Elect not [00:19:00] to, um, utilize those agents still to this day. Um, there's other agents for heart failure, intravenous drugs for heart failure that not every hospice will use, but some do because they feel it helps my shortness of breath. So it's, um, It's also not necessarily just a cost issue. If a hospice chooses to support, say the intravenous agents for heart failure, their nurses need very specialized training, not just in how to, uh, they understanding of how the drugs work, but what to do.
If the Ivy line falls out, how do we troubleshoot that? At two o'clock in the morning. So there's a whole cascade that goes around it. So that's okay. So I'm going to jump in here cause I, I think Alex and I tend to veer towards what we call last mile, really nuts and bolts, [00:20:00] like what is real and what is sort of theoretical in general, some of this.
So let me ask a couple of really nice. Nice and difficult theoretic non theoretical questions. So palliative medicine sounds amazing and we've all heard of it. I mean, in the hospital setting, it's, it's fairly ubiquitous now. I mean, I haven't come across a hospital, um, in our area that does not have a in-house palliative physician, nurse practitioner, or a team that supports the patients when they're in the hospital.
And then, you know, let's just assume that the patient. You know, gets a palliative consult. If the hospitalist sees the, sees the light and makes the right referral or somebody, you know, has the wherewithal to do that, then it's time for the patient to get discharged and they go home. And now the family is singing this tune.
Well, we're in palliative medicine, we're on palliative medicine, but. In my experience. And Danielle helped me out with this. It sort of falls short once they go out into the community because everybody else is going, what do you mean now? You're back to your [00:21:00] regular care team, which is your internist and your cardiologist and all the ologists that are part of your care.
So help me to understand real terms. I am a patient. I am in the hospital. I have something that is. Potentially hospice appropriate, potentially not, but let's just say it's not or aunt or it is, but we're choosing not to go down that path. And now the family comes home and they're like, we're on palliative care.
I have, it's a twofold question. Number one is Medicare. Doesn't see that patient differently. They're just still a part B patient. And the second question is how would a patient continue with quote unquote palliative treatment once they leave? If there's no palliative team available as the outpatient. As an outpatient.
So I think each one of the, one of the lovely parts about palliative treatment is it's self-defined right. So, um, Population [00:22:00] health is, you know, everybody should have a colonoscopy. Everybody should have a mammogram, blah, blah, blah. Palliative care is individually defined. So if you and I both have the same congestive heart failure, what you define for yourself as I'm on a palliative treatment plan might be different than what I define as a palliative treatment plan.
So for you, you might say. I never want to go back to the hospital, except for if I need intravenous antibiotics. And for me, I might say, I want to go back to the hospital and I want to go to the ICU, but I don't want to be put on a ventilator again. And so one of the challenges I think is that, um, for patients who have not yet enrolled in hospice, palliative care really is about.
Educating the patient and their support [00:23:00] system to be advocates within a complex healthcare system. And that's really what has happened to medicine right now. Um, people who get care at one hospital, we know they get discharged. To, um, a rehab center. If they get called nine 11, they go to a different hospital, right.
Patients really have to be their own advocates, unfortunately. And it's our job to really teach them. So how does home health, how do internists, how to cardiologists, how do we all work together to support that patient and family? So it's about goals of care. It's about everybody getting on board with the same goals of care.
Now we all know that right. Patients do not tend to be great advocates for themselves. They get caught up in the sort of the churn of healthcare. You know, you walk in and, you know, we do have a HIE, a health [00:24:00] information exchange here where we practice medicine, but you know, it only tells so much it doesn't like put a big red.
Thing at the top, when you look at them saying, Oh, this patient has chosen a palliative path. I mean, and so everybody's a nail and all the doctors are hammers. And so everybody just starts going at it and going at it and going at it, you know, in the emergency department and internal medicine. So people have to be able to stand up for themselves.
So, I mean, I guess the question really is, in your opinion, is there is room. For sort of more structured scaffolding to support Hollywood of medicine outside of a hospital setting. So when that same patient comes out, they really might feel supported by a palliative practice that could sort of lay on top of the care that they already have to kind of like.
Keep the bad Juju from coming back in, you know, to some degree. Right. And I see that Alex raised his hand again. So he's so proper sound robust, [00:25:00] the raise hand button. That is what I've actually figured. Hold on. I'm going to start doing some reactions. So we'll do some thumbs up and stuff too. And before we ask Alex, when he raised his hand about it is about goals of care.
The challenge is that as physicians. What we error. What we make an error on is we say to a patient. Do you want, and then we talk about technology, right? So, um, I know squat about my car when, when my car, when I take my car to the car dealer, and this is what I teach the fellows. When I take my car to the car dealer, I go the car squeaks and they go, okay, ma'am, we'll take care of it because my goal.
Of care is make the squeak go away, right? They don't say, do you want a new fan belt? Do you want a new serpentine? I don't know what I want. I want the squeak to go away. Right? When, when we bring patients to the hospital, we say, mother has shortness of breath. [00:26:00] What do we say? We say, do you want CPR? Does mother want CPR?
TJ's mother went intubation and people are like, Oh, okay. If that makes the shortness of breath, go away, give mother that you had a side of pressors with that, a little dynamic, this family she's like, what the hell? Like it makes the shortness of breath go away and give her all that. Right? What we need to ask her, what her mother's goals mother's goal is make the shortness of breath go away.
Maintain cognition maintain ambulation. Right? Mother's goals are functional. They're not attach a lot of tubes and lines. And so we have to learn how to have conversations that are functional conversations. There is a wonderful document called prepare for your care. It's a living will it's free online and you can Google it at prepare.
For F O R your care. And it's a very user-friendly document. It's legal in the state of [00:27:00] Maryland. And there w there's Virginia versions. There's DC versions. There's Maryland versions. There's a Spanish version. It was actually created in California and utilized in the VA system in a study. And they had much greater, um, rate of completion in the VA.
Um, because it's literacy level is about fifth grade. Um, and it very clearly articulate. Um, what would people want in terms of, um, maintaining. Function. At which point would you want convert to convert your care plan to comfort? If you could no longer walk or talk or things like that. And that's what we have to do when patients are released from hospital is say, at what point would you want us to return you to hospital?
If you are so short of breath, [00:28:00] Um, that sort of thing. Oh, Alex went away on my screen, but his hand is still raised. Yeah. I'm here, I'm here. So I, I'm still a little fuzzy Daniel on the Venn diagram. Uh, and maybe you can help me understand it of the Venn diagram of palliative care, which based on what you're telling me, basically sounds like an internist who has additional tools in his or her tool belt for addressing.
Um, complex and end of life, uh, medical issues like head-on as opposed to many internists who just don't want to deal with some of those things. Um, so what is the w w help me with the vendor Graham between palliative care and geriatrics, uh, forgetting for a while that palliative care can be any age, but for the, for the elderly, for the Medicare population, um, is it basically.
Geriatrics for those who have really complex end of [00:29:00] life issues. Um, like what do those, what is the end? What is the Venn diagram there? And then why have a follow-up question after that? What we'll do one at a time. Right. So, um, yes, it is actually a Venn diagram. So every, every person who goes to medical school has to be able to manage hypertension, you know, manage a little bit of diabetes, but not all of us become cardiologists or endocrinol.
Right. So we'll have to learn that in emergency medicine. I just wanted to let you know, we don't actually have to learn how to do either of those two things, clarifying theory that may have been a goal. Right. Triage had met. So it's the identification of the problem. And then we. Scanned it away, somebody else coming manage.
Right. So yes, every single person does need to be able to discuss a little bit of end of life. Um, a little bit of goals of care, discuss, um, be able to do some [00:30:00] pain management, nausea control. So yes. Palliative medicine is a sub-specialty. So every geriatrician, every internist has a skillset in end of life and discussing goals of care.
Palliative medicine is a specialty. So when that gets a little bit outside of, um, the, the comfort zone of an internist or a geriatrician, they would refer to palliative care. Um, so people who have. Very challenging to control pain or very challenging to control nausea, shortness of breath, maybe somebody who has dementia, who then in addition has cancer and it's unclear should they have treatment or maybe they've started a little bit of treatment and now their dementia has a florid delirium, and it's unclear.
Um, if the F maybe half the family wants to continue with treatment, but others in the family don't. So, um, it might take having a lot of intensive [00:31:00] family meetings, that sort of thing, a lot of time, um, uh, dependent. Communication and mentor doesn't really pay for all of that. I mean, that's, that's sort of part of the problem here.
And I don't care that Alex has raised his hand. It seems like Medicare doesn't always pay for all that. Excellent care though. Under part B like part a is like set up because it is built as a team-based. Like part a hospice is built to accommodate that, right? The number of patients that each nurse takes care of and the total amount of burden that any individual agency will have per unit person is sort of understood.
But under part B Medicare is not necessarily set up, at least in the outpatient setting. I think maybe in the inpatient setting, it is, but in the outpatient setting to have these extensive family. Dynamics conversations. It just, it boggles the mind because we know that's the right way to do it. So the, um, outpatient, the physician, the nurse practitioner [00:32:00] and the social workers can all be reimbursed under fee for service.
There are the new value-based models, which are coming through Medicare. Um, you can. Um, there are some of the models of, um, direct contracting which are coming through. Um, there is actually a. For profit capitated palliative care model, which is called aspire, um, which is just one of the models out there, which, um, has contracted with some of the insurance companies to provide palliative care.
Um, To members Medicare advantage. Yep. It's generally the Medicare advantage thing. Yep. Yep, exactly. Um, because. The way that those palliative care, and it's not just aspire. There's several [00:33:00] others, the way those palliative care models work and the way it works for some of the hospice companies which are doing home-based palliative is those tend to be social work and are N driven.
Um, Where, if you help assist with somebody staying at home and avoiding the hospitalization, you then are cost shifting and, um, you can reduce the overall cost to Medicare by keeping somebody out of the hospital. There are people who argue that hospice does not save Medicare money, that you are cost shifting out of the hospital.
You know, why. The average, if you stay in hospice for an entire year, it costs Medicare about 60 grand, which is considered to be a very expensive patient under original fee for service Medicare, like $60,000 a year is like [00:34:00] really expensive. But if you say to yourself, that person could have cost $120,000, then it is considered to be a savings.
Because the average Medicare, the average Medicare patient only cost Medicare about $12,500 per year. Like a 65 year old, healthy 65 year old. It's just as they kind of go through the system. An ICU stays a quarter of a million dollars. So like, if you divert enough, potential ICU stays into hospice. I could see that it would be cost savings because the readmission rate, once you're in hospice is only like zero to 4% or whatever it is, but you're right.
Like there is this weird thing that Medicare doesn't save a whole lot in terms of dollars necessarily under hospice. And it also depends on which, um, when you look at, if you divide cancer patients versus CHF versus dementia patients, the [00:35:00] dementia patients end up costing more because they stay on hospice longer.
I think it were dementia, but they, the, um, it, it, if you stratify by disease state, the costs are different. Oh, that's interesting. Hadn't thought about like that. Okay. I'm still stuck on. You should be in palliative care.
Right. So philosophically, philosophically people would say, if you haven't completed your treatment, you should stay in palliative, but this gets a little blurry. This, this does get. Blurry because, um, some hospices will accept patients who are on clinical trials because technically you have completed all treatment.
You're on experimental. And, um, people who are seeking a trial are technically not under treatment. [00:36:00] They are actively being evaluated to determine if they even can qualify for a trial. So there is a phase. Um, the other thing is that I have seen a lot of patients who. Well come to the hospital and, um, they are, they are diagnosed with, if we're talking cancer, they're diagnosed with a stage four cancer.
And um, many times the, um, chemotherapy is no longer started in hospital. You have to go to clinic. Be evaluated and then determined what chemotherapy might be appropriate for you. So to get a clinic appointment is seven, 10, 14 days to get an appointment in the chemotherapy center is another seven, 10, 14 days.
You're out two a month. So for somebody who has a stage four disease from time, zero to time chemo into the vein is 28 days. [00:37:00] A lot of discomfort and physical decline can happen in that time. Um, if a person is discharged from hospital with home-based palliative services, many of the area home-based palliative teams will do a visit once a month or once every two weeks often.
That is, um, That, um, may not be enough to adjust medications. If somebody with advanced cancer or advanced COPD, if their body is actively changing. Especially if you're 90, you may, uh, need check checking in more frequently. So if you have home health plus palliative, do you, you may end up returning to the hospital.
However, if you enroll with hospice, Um, you have somebody checking in much more [00:38:00] frequently and you're given a telephone number that you can call 24 hours a day and either talk to a nurse or have even maybe a nurse visit your house. So some family are nervous, they say well, but what if, what if dad wants chemo?
Or what if, what if the pulmonologist comes up with a medicine for his pulmonary hypertension? Well, To me personally, as somebody who does geriatrics, um, as well as palliative, um, I feel safer discharging my patients into that, the system that is hospice, um, with more wraparound services and then say, you know what.
God love you. Let's hope they find something in a month. Medicare will understand, and you can, you can disenroll from hospice. I know that's not what the government wants, but I think it's safer, um, than risking having an admission. Okay. So, [00:39:00] uh, I like to think algorithmically, so tell me if I'm thinking about this, right, Danielle.
So let's take, let's take a new patient who has a newly diagnosed terminal or likely terminal illness with poor, at least one very poorly controlled symptom. Let's say pain, for example. Is that like, so if you could narrow this down to one question, uh, to say, should you consider palliative care? Would it be something like that?
Would it be, is the question, do you have a likely terminal illness that has at least one very poorly controlled symptom or consequence? If so, Consider palliative care. And then maybe ask another question to see whether a hospice might be a better question for you. Am I thinking about this right? In terms of an algorithm, any you're on mute?
Everybody's like, yay. Can I just repeat back to you your [00:40:00] question Alex? Cause I just want to make sure I understood it. You're asking that if somebody gets an end stage cancer diagnosis and are they offering treatment that's chemo or are they not offering treatment? That's chemo. Um, w so the question I'm trying to answer is if I'm a geriatric care manager and the family saying, should we think about hospice?
Like, what's the question I should ask myself? And I think the question is not just like, do you have a likely terminal illness? Because most geriatric, regular geriatricians are dealing with lots of seniors with. Terminal illnesses. Right. But is there a something that's out of control, like pain or a mental issue?
Because if there's something that's out of control and the geriatrician or the internist is not able to handle it, I think that's, I'm trying to figure out what is the trigger to start to think about palliative care. It's the combination. I think what I'm hearing of some sort of likely terminal. Illness plus this, something that the current care team can't really manage well, that could probably be managed better by palliative care.
[00:41:00] What does that overlay, what did, what would this overlaying sort of layer bring to the table is what you're saying. Yeah. And then you should consider palliative care and probably consider hospice. And then if it's likely less than six months to live, and most likely you're not going to do disease altering treatment.
Right then probably hospice is your best bet. But if you're still thinking about some sort of disease altering treatments or it's possible, or likely that you would live longer than six months, then palliative care would be your better option. I'm just trying to create the algorithm. So the folks who are trying to think about this with geriatric care managers and others understand, like, what are the questions I should ask to figure out which one I should pursue?
So I think it's also the challenges. They're not all either ORs there. And so I think, I think your question of is the symptom uncontrolled is a good place to start. So if you have an internist, geriatrician oncologist, pulmonary doctor, and you have a uncontrolled [00:42:00] SIS, uh, uncontrolled symptom, um, I think then to say, Should I ask the providers if palliative care might be a benefit.
Um, and I think that is a good place to start, and it's not an either, or it would be an and bring them in to help us support the rest of the team. Um, I think that's a very good question. And I think that that's, that's the question. Well, I'm going to add to your answer and to the question, which is. It may not be on your menu in your geographical area to even ask for such a thing.
So, I mean, I, I sometimes feel like, you know, we could say, Oh, it's so nice if we have palliative. Well, it's really nice to want that doesn't exist. And that's been sort of, I mean, experientially, having been a house call provider for years and years, I can tell you. In some ways what we were doing, because we were establishing goals of care, [00:43:00] dealing with complex health issues, bringing people together in the part B world, we were essentially doing palliative medicine without calling it palliative medicine or a version of palliative medicine.
But if you say we need palliative medicine, Alex, I would say to you, where, w w who, who are you going to call? Like there's no Ghostbusters here in Montgomery County or Washington DC. That's easily accessible. Like. Those doctors are hospital-based providers locally, for the most part. I mean, there are some limited number of palliative programs, but this is not a robust, easy to refer to thing that is on everybody's menu.
Mostly because it may not. There's a restaurant may not be in town where do most referrals to palliative care come from? So, well, first of all, there is a website called get palliative care.org. It's an offshoot there's um, there's a national organization called center to advance palliative care. The acronym is CAPSI C a P as in Peter C, [00:44:00] like Charlie.
Um, and they have a, um, consumer website get palliative care. Dot org. And they have a website that if you are a loved one is in a skilled nursing facility or in the community. It lists all of the facilities that provide palliative care. So Amy is correct. In the community, um, like having palliative care, like going to a clinic is probably the hardest place to find palliative more and more of the skilled facilities.
So when some, a loved one goes to rehabilitation, for example, or if somebody is in a nursing home, More and more of the skilled facilities are actually having palliative care because they're contracting with either hospital-based providers or hospices to have nurse practitioners or social workers provide consults in the facilities.
Um, hospitals have [00:45:00] palliative care and they are offering now. Uh, clinic-based palliative care. Sometimes those clinics are closed. So you have to maybe be a patient in the oncology practice or a patient in the cardiology practice, that sort of thing. Um, and there are some free standing clinics around Washington, DC, Virginia, et cetera.
Many of them are listed on this website. So I think if you're a patient, I think also starting to ask about it. While you're in the hospital though. So like, I, I feel like it's also part of that spectrum of, can we, you know, in previous podcasts we've talked about how part a is really about sort of marching through from sort of the time that you're hospitalized through potentially, you know, rehab then out into home health or hospice where it sort of bifurcates.
So if you're in the hospital and you're getting palliative, And you get discharged to a nursing home or rehab post acute. Um, you can [00:46:00] stay in re in palliative. It's just at that moment when you're going to be going home. That, that sort of question Mark seems to always come up. So like, I would want our listener to be like, huh.
Okay. So I was under palliative care in the hospital and then I did get some nice palliative services when I was. In the nursing home. So how do I continue getting palliative care in the community? And so to your point, Alex, you know, it's nice to say I have advanced cancer, but. And what do I do? But if one of those bifurcating questions is palliative versus hospice, you almost need to know what you have at your fingertips.
To Sunday. We had a little bit cynic in that regard. Pardon me for that? The part that I was going to say, many of the home health companies are starting to offer. Palliative care as well, because they're already sending nurses out and in the state of Maryland because the, the MOLST has to be completed.
And in Virginia, there's now, um, people that are piggybacking [00:47:00] on. Goals of care conversations and palliative care visits into the home health companies, like part B nurse practitioners that are attached to home health agencies, part a home health agencies that are sort of. Uh, huh. So, cause they can bill for the, um, advanced care planning codes and ENM codes as sort of a, an add on to palliative.
I mean, hang onto the services that they're already providing. Got it. Right. And because, because the home health companies can do infusions in the home, there's a lot of home health companies that are becoming more medicalized and with some of the up-and-coming Medicare, um, Um, um, what I want to say, the, um, the projects, some of the value-based stuff like direct contracting, et cetera.
Yeah, exactly. A lot of the, a lot of the, um, I think a lot of the field is [00:48:00] changing very quickly. And there's a lot of things that I think are a foot to change very quickly. So that's what I was starting to say. If, if somebody feels they had a positive experience in the hospital, we're finding people are calling back to our department.
They're asking our social worker for referrals, but I also know that people are calling, um, Like cardiology. And they're asking for the services. People are reading it online. Many of the websites for major illnesses, like the Alzheimer's association, um, et cetera, will suggest that patients and family members seek out palliative care, which is how the get palliative care website was developed.
Um, and so I think. There has to be a grassroots movement of people who request this, so that then the community-based services, um, You know, follow. So in the [00:49:00] regular hours patient world, um, when a, when an internist, um, has a complex cardiology GI case, right. They refer out to the GI cardiologists. Um, are you saying that in the palliative care space, most of the referrals are actually not coming through that kind of standard mechanism, but really originating in the hospital.
And if so, um, What happens post discharge? Um, if there does continue to be a relationship between the patient and the primary, um, uh, and the palliative care doctor does the primary care doctor say, like, who the hell is this lady? Like? Because there's some overlap in that Venn diagram between what palliative care is offering and what a primary care doc.
So is there, does there tend to be conflict or is it the opposite? Do the primary care doctors say. Oh, thank God. Goodness. Cause I didn't know what to do with that lady. Like her symptoms were too complex for me to manage. So, uh, how are primary care doctors responding and interacting with, with palliative care doctors?
Usually very favorably. [00:50:00] So, um, you know, we'll have. Follow up phone calls, people get the discharge summaries. Um, if a patient is referred into hospice, often it's back under the care of the primary cares, the coordinating physician under hospice care. Um, I've had primary care doctors call me and say, Um, you know, John DOE Jane DOE is now out of rehab.
They'd been under my care for three or four months. Um, he's taken a turn for the worse. He got influenza. He got COVID. He doesn't want to go back to the hospital. I'd like to enroll in hospice. Can you give me some advice? You know, it's just like, um, you know, just like a GI doctor or cardiology doctor, uh, where the primary care might say, listen, you, you saw him in consult a year ago.
Things have gotten worse. He's 90, he's saying, you know, he's led a good life. He wants to enroll in hospice. Do you have some suggestions on, you know, his, [00:51:00] his heart failure with preserved ejection fraction? You know, should I, should I titrate the Lasix right before I send them in, you know, blah, blah, blah, blah, blah, that kind of thing.
So, um, We have a, we actually at the East Baltimore campus of Hopkins have been trying to grow our outpatient clinics because we know that there's a demand. Um, and, uh, for, for outpatient, um, palliative, um, We have multiple weeks worth of waitlist for, for, for patients. Yeah. Like almost like six, eight weeks.
So, um, you know, and, and it is hard. We would like to actually partner with the internists because, um, You know, sometimes people have had 30 year relationships with their patients. Um, and you know, we might have symptom expertise. They might have the, the personal expertise and knowing the name of the dog and the dog before the [00:52:00] dog and, you know, and all the grandchildren's names.
And sometimes also it's hard for the internist. To say, you know what, maybe, maybe it's time to shift to downshift. Sometimes the internists are having a hard time, um, acknowledging end of life, you know, and, and it's easier for that patient family to have the conversation with us. Wow. So I think that that's actually a really good moment to just sort of say for a second, um, palliative sometimes can fill a role.
For some of those difficult, um, patient physician relationships that may be difficult for physicians to handle, you know, it's sometimes possibly easier to talk about palliative to talk about as opposed to talk about hospice. Now, palliative has a weird name too, right? Like everyone's like, Ooh, hospice, that's scary.
But now palliative has become scary, um, to some people. And now we hear the word [00:53:00] supportive care, right? Only in the cancer world, only in the cancer world. Although I think some of the palliative programs are starting to call themselves supportive care. So, um, only the cancer was
cancer. Cancer term is cancer. Palliative term is supportive care. Yeah, but so only the only the ones in the cancer centers will use the, um, supportive oncology or palliative and supportive care. And they've actually done studies on it. And after a couple months, um, when patients go to like the pain and supportive care, they realize it's palliative care.
And they're kind of like, huh? I said the same thing, but palliative care is not pain management, right? Like that was like one, five second conversation I wanted to have for our listeners, which is, um, I was part of a home health agency in a hospice agency that had implemented one of these, uh, [00:54:00] palliative programs into overlaid on top of their services for pre hospice.
As part of their home health program. And what we found was is there was a tremendous number of chronic back pain referrals for pain management. But what I, I know you guys are saying it's not, but it seems like that is one of the functions of palliative care is to manage uncontrolled pain. Uh, I know there's stigma with ma you know, pain management stuff, but isn't that one of the main functions.
So it's what is the etiology of the pain? So, um, one of the challenges across the country with palliative care clinics is, um, the palliative care clinic is not a workman's comp clinic. Um, it is not a clinic for, um, there, there is a tremendous difficulty for people who have had. Prior substance use [00:55:00] disorder who then can tract, um, cancer.
Um, and managing pain in the context of a prior substance use disorder is extremely challenging and there are palliative professionals who are also, um, now becoming specialists in using agents like buprenorphine to treat both the cancer pain and the, um, prior substance use disorder. Um, but. Palliative clinics do not do primary substance use disorder treatment.
Right. And so especially, um, uh, palliative programs within the veterans system have, um, had wonderful support. The veterans system has supported, uh, palliative care way back in, into the early nineties. They actually, um, have a quality metric within the veterans system that anybody who dies, they want to do a look back for quality, um, initiative and make sure that that patient [00:56:00] was offered palliative care within the previous six months.
Um, and the, uh, the, the veterans system also has been very good at evaluating whether patient patients have PTSD or other, um, chronic pain disorders. So there's a lot of nice literature coming out to make sure that people who have chronic pain have had a lot of good biofeedback, um, pain psychologists, um, contracting, because if somebody has.
Is in, um, uh, remission from their cancer. Many times they can completely be weaned off their opioids. Now, occasionally you have a nerve pain. You might have chronic chemotherapy induced neuropathy, but usually people can slowly over many weeks or months come completely down off their opioids. So, um, Uh, the [00:57:00] survivorship clinics are important and some of those are run out of palliative, uh, programs.
Um, there's special needs of survivors that do overlap with palliative, such as, um, cognitively every time people need their followup scans, a lot of anxiety. Um, But pain, primary pain treatment, um, is there are overlaps with palliative, but, but what, what Amy is saying is palliative care is not, um, chronic pain.
Agreed, but I'm not. And so it's not a primary, like primary pain, like pain of unknown origin or that type of thing, but would it be fair to say that cancer patients with uncontrolled pain would be one of the most common type of patient profiles that would qualify for palliative care? Correct? Correct.
And, um, what also should be known [00:58:00] when patients go to palliative clinics is that many palliative clinics will also screen for, um, prior substance use. Challenges as well as emotional, um, because there's a huge mind body connection. So patients, um, will be screened for, um, prior depression, anxiety, mental health, um, alcohol use all different things because that's, that's very normal for us in palliative.
Some patients when they've come to palliative clinics are, um, sometimes. Semi offended to be quite honest because there's, um, opioid contracting at many of the palliative clinics. Um, because if we are, uh, some palliative clinics will write the opioid prescriptions, some will ask the. Oncologists to write them or the primary care, because for safety, you want a single prescriber of all of [00:59:00] your, um, opioids and, um, and Z Alytics of all your C2 meds.
Um, and so when palliative care doctors write them, they often will contract somebody for. For safety or, or we'll ask the patient to agree to pill counts and things like this. Um, and so these are, you know, this is the society we live in right now. And some patients who have stage four disease have occasionally said, they're offended.
By these, um, by these things. But, um, this is, this is, this is our society right now, right? Alex, do you want to, do you want to be like Alex Smith, any famous summary statements? I have one more topic. I want to raise in my research. Uh, for this interview, I found this thing that I had never heard about.
Called palliative sedation. And it seemed really interesting and unusual, and it seems like it raises a lot of interesting questions. Can you talk to us about [01:00:00] what is palliative sedation and some of the controversy around it? Yeah, so palliative. So I think one of the things that, um, has kind of come out a little bit today is that.
Um, palliative care and hospice are kind of on a continuum of services. Right? So, um, um, all of, um, hospice is technically palliative. But not all of palliative is hospice. Hospice is just the care that's given to people in the last months of life. And it does also focus on relief of suffering. And as we said, palliative is any age, any stage.
So, um, hospice doctors and palliative doctors use a lot of the same medicines, a lot of the same skills. For people who have, um, symptoms that are extremely hard to control. And when [01:01:00] death is, um, Likely imminent. If the patient can sense, you can slowly increase the medication to the point where somebody is sedated.
So palliative sedation is. Increasing medication with the acknowledgement that you will, um, reduce consciousness likely. Um, but your goal is to relieve unremitting discomfort. Usually it's pain. Sometimes it can be nausea, um, by doing so you often, um, Interrupt the ability of a person to eat and drink. And usually the person is no longer conscious because it's somebody whose pain is so [01:02:00] refractory to all the other medications that you're giving them that you basically are doing.
Um, in effect, conscious sedation. You're basically giving them the amount of medicine. Um, That, uh, usually intravenous opioids and intravenous, um, um, anxiety Alytics like lorazepam or verse said, um, that somebody is, um, is, is difficult to arouse. And you, you can't reduce them again because you'll unmask the symptom.
So this, so what you're saying is it expedites death? Um, No. No. Okay. I think that's the controversy
because the person is dying anyway. Right? So they're, they're not dying because you've medicated them. They're dying because of their [01:03:00] disease. Yeah. So this is a really sticky subject. I can imagine. Um, now it was hard for me to imagine where this would actually take place because when we give, like verse said, which I think is the most common medicine I saw for palliative sedation.
It's always, you know, in the ER room with monitors and you have to have another nurse and all, you know, all these, you know, all this stuff. Um, so is this generally only done in the hospital setting and then for how long? Like when, if, if, if a palliative provider decides to do palliative sedation, is it typically for like an hour or days?
Yeah. So, um, There are people who feel that you should have an informed consent contract signed by the patient before you engage in this, and it should be considered a procedure. Um, and, um, If the patient [01:04:00] is not conscious to sign, or I should say lacks capacity to sign that you have the medical power of attorney sign the contract.
Um, it should be considered a procedure. We teach the fellows, the medications, um, like a procedure, um, I have, um, I have done this on behalf of patients. A handful of times. It's not needed very often. Usually you can control pain with, um, more regular means and. Honestly, if somebody has this degree of pain, usually it is a cancer or eroding through a viscera, or it's a, um, a cancer creating, um, a cord compression.
Um, I've had a near carotid blowout. I mean, these are, these are the things that we read in the oncologic textbooks that are the oncologic [01:05:00] emergencies. Um, and so it's some, it's not somebody who you're going from zero to a hundred. This is somebody who you've been managing for days upon days. And you're, you're increasing your, your PCA and you're increasing your other oral medications.
And this is not a procedure which is entered into lightly. Usually patients who are on, um, Very high doses of opioids and benzodiazepines and sometimes barbiturates anyway. Um, and you would do it in the, um, in some kind of acute setting, either the hospital or an inpatient hospice, there is. Debate in the hospice setting of if you would do this in the home, because you need to continually titrate.
So the only times it's done in the home are with hospices, which are [01:06:00] able to station a skilled provider, like a crisis care nurse, an LPN in the home to constantly do the titration. Danielle is it ever done for terminal respiratory illness? Because I know as an ER, doctor seeing patients who just couldn't breathe couldn't ventilate and fill up with fluid, it's one of the most horrifying deaths.
And it almost brings me to tears to watch somebody and some situations you can't do anything to support. Yes. Yes. One of the patients in whom I prescribed for was somebody who, um, Um, was a leukemic and, um, it was, had stopped, um, transfusions and was very much dyspneic and was in, was yeah, was in, it was fully consented.
That was part of the treatment plan we had discussed as a possibility when she was [01:07:00] alone and her family knew that that was a possibility. And, um, You know, I think it's a very controversial, or it seems like it's controversial from my review, uh, before our talk today, but I can't think of something more important in life than to have some say into, uh, your last moments on this earth and how you feel in those last moments and whether it's going to be defined by unbelievable suffering.
Uh, or not. Um, and the fact that, you know, we can, uh, impact that to some degree, to be, to have less suffering and, and more peace, I think is a wonderful thing. Well, and when you had people who are profoundly dyspneic and maybe CHF overloaded or ARDSM, or what have you, your toolbox in the ed is intubate or not intubate.
And if you don't intubate, what do you do? Right. So [01:08:00] if somebody has made a choice to pursue comfort and dignity at end of life, um, and is at a hospice or in a comfort care room in a hospital and has their family around them, The toolbox is wider and it is the medications to provide comfort. The phrasiology of, um, some people call it palliative sedation.
The, the preferred term now is proportional sedation. Some people like that, removing the word palliative from it because proportional, meaning you're not, it's not whack-a-mole, you know, it's like you're, you're meeting, you're meeting them where the pain is. Right, exactly. Portion to their pain proportion, to their just right payment, just comfort.
So if it's dyspnea, you're bringing that, you know, the person who stopped transfusions, you know, they're, dyspneic, you're, you're trying to get them comfortable. Um, you know, maybe they have LDL hemorrhages, like you're just trying to bring your meds up and your verse [01:09:00] set up to the point that they're comfortable with the family can be with them and allow a peaceful death.
Um, You know, what have you, and, and for, for some person who's like an 85 pound 95 year old woman, that's going to be different meds. And somebody who's like a 250 pound linebacker, you know, who's got, uh, you know, carotid blowout from their head and neck cancer. So, um, the proportional sedation concept, I think is the, is the right phrasing.
The goal in both cases is to allow dignified death and it can be done in an ed. Yeah. If you could, Danielle, just to kind of take it sideways a little bit, if you could, um, educate your colleagues. Not necessarily, I'm not talking about Hopkins, I'm talking about general colleagues in, in the medical world.
This includes, um, geriatric care managers, anybody in the senior serving community, what would you want them to know about palliative medicine that you feel as though may be [01:10:00] misunderstood? Uh, that's a good question. I do think it's the fear issue. Um, there's a very nice article that's called best case worst case.
And, um, uh, there's a YouTube on it, which you can watch. And it's about how do we discuss procedures in geriatrics P geriatric patient? Yeah. And I think too often, what we do is we discuss the, um, The, the good parts about the, um, the procedure and then the worst parts about the palliative. And we there's actually four lbs.
Right? So, so, um, if we let's say you have, uh, an eight year old patient with COVID who comes to the emergency room, right. So always say as well, if we don't do anything, you will die. Or we could intubate you. Right. But there's like these other prongs, right? [01:11:00] So like, um, we could, we, we could admit you and try to help you with oxygen and support you and use high flow oxygen.
Um, or we could send you home with hospice. Those are maybe the best case of comfort and the. Worst case of conference central home with hospice. And we have to be honest about prognosis with both, or we could admit you into everything, including intubation and here's the best case. Um, um, and then, uh, this, I got to do my other problem.
Let's see. Best case worst case of, of the, you want to do the best case and the worst case of the aggression aggressive treatment and the best case. And the worst case of the comfort care treatment is basically how it is. So if we admit you and we are very aggressive, here's the best case, which is we could intubate you and hopefully get you off.
Um, or we could admit you and maybe not get you off, or we could add, um, uh, admit you and. [01:12:00] Uh, send you, sorry, send you home and use, um, hospice, or just send you home with oxygen and not use hospice. That would kind of be how it would be. So I think when people talk about palliative, we only ever talk about it.
Um, super lovingly, or we ever talk about it, like really horribly, like there's no like comparison or contrasting there's no like middle ground. It's so interesting because I think that, you know, I mean, this is a very important time to be talking about palliative. Um, we're in a weird place in society. We have a pandemic where people are going into the hospital and, um, they may have been healthy.
Maybe they had some risk factors are no risk factors, but people are definitely getting sick and being forced to make choices. Are you finding that your day to day is very COVID filled? Um, [01:13:00] interestingly, um, people I'm finding that people are being. Um, pushed all the way towards full care and they're saying stay away palliative.
Um, we're a very aggressive hospital and in our space, people are saying that we get very confused with hospice. There, there are some floors where we are, um, Where people understand that it's okay to kind of have us walk along. And again, that speaks to what you're saying. Like what, what should people know that it's okay to hold uncertainty?
Right? So, um, if you get admitted with COVID, if you get admitted with pneumonia, if you get admitted with a new diagnosis of cancer, It's okay to have palliative walk along with you. We're we're not going to talk you into anything or talk you out of anything. Um, I think we're [01:14:00] about choices and making sure somebody has informed consent.
Right. Right. So along those lines then, so should patients be asking for palliative families should be asking for palliative when they come into a hospital? It shouldn't just be a console service that some other doctor or nurse thinks up on their own. It should be something that is more front of mind, potentially for patients when they come in.
Yeah. And that gets back to what Alex was saying before. You know, I think if you have any kind of serious illness and then you have a serious symptom, um, and that serious symptom might be covered with coughing or shortness of breath that I think it's reasonable to ask for a palliative consult, um, just to help support getting you through and help you understand your choices.
Uh, I think too often people introduce. Palliative care just at the, towards the end of the hospitalization. Um, and then, then, then, [01:15:00] um, the support which could be provided, even if that support is just more communication and greater understanding of your choices, um, you know, that, that, that goes a long way in the hospital these days, you know, then.
It's minimized. You know what I mean? I think the take home message that, uh, providers and geriatric care managers, uh, should know from this talk is the falling, uh, palliative care is not giving up. Right. I think that's the misconception. It's kind of like grouped into this. Oh, if you put going to God palliative care, you're, you're giving up and you're just accepting that you're going to die.
It's not that you can continue getting all your cancer treatments and all that. We're just going to spend more time making sure we, we, we manage the severe symptoms to an acceptable level and we're better trained and we have more resources to do that. And a lot of times we see patients and we really try to just make sure they have a true [01:16:00] informed consent.
Like I really have no skin in the game if I get. Kind of higher to talk about, um, should somebody have a feeding tube or should somebody, um, you know, undergo chemotherapy? I don't, I don't really care if you have chemotherapy or if you get a feeding tube I'm really invested in, have you heard, were you emotional at the time you were given the information?
Do you understand all your options? I don't get paid. If you get the feeding tube or not, I only get paid to give you. The information. I don't get more or less money if you get the feeding tube or if you get the chemotherapy oncologist does, you know, but you know, I'm not invested in the outcome. I'm invested in if you feel comfortable with the outcome.
And so that's what I tell our fellows that, that we're invested in informed consent. You've done a good job if they can sleep at night. That [01:17:00] that's that's when that's the good job. Let me ask this question. Cause I think it's, it's so relevant to what you were just saying. In some ways I think of things as like.
Speed limits are like how fast you're going. What's the miles per hour. The different specialties are always going at. So let's say you're an internist or a hospitalist. As an example, you might have, let's say 20 patients on your service is that right? Per doc, like you love unit cost economics, Alex, like per this per that.
So the number of patients that an internist or a hospitals might have in the hospitals with 20. Am I being nice. Is it higher and lower? And then how about a palliative physician? How many will you have on service that you see per day? I guess maybe it's patients seen per day or like, I'm trying to like boil it down because obviously there's, there's money involved with each visit that you make within a hospital.
So does palliative make money? Does it lose money? And I guess there's a 15 questions in there, but I guess the first question is per day does a, [01:18:00] um, palliative. Provider see fewer or the same number of patients per day. What else? The palliative teams as a team are always in the red. They run 40 to 60% in the red because the fee for service in the hospital doesn't make up for the salaries and the benefits.
So palliative teams, um, Are they end up saving money to the hospital because they reduce length of stay the way that's not their goal. They're more is to assist with goal can coordinate care is what it is. So if I visit you and your family, And I help you to achieve the health care you want, and maybe you get discharged sooner, or, um, maybe instead of spending five days vacillating on whether you have the feeding tube, we just up and get it done, then your, your length of stay will be shorter.
And so that is, it's [01:19:00] a savings to the system. Um, and so it's a cost savings to the system. It's not at the individual level. Right. So, okay. Got it. So on a part, because we know that part BS, what pays physicians and nurse practitioners who serve the part a hospitalization. So they, it does not cover. The salaries because you guys are not churning and burning at 80 miles an hour, like the hospitalists are yours.
You're sort of the slow it down team to kind of say, Whoa, everyone just, there's an article. There's an older article. Now that says, um, across what, when you, it's actually a part, a savings about just over $3,000 per patient. Per hospitalization per hospitalization procrastinating. Yeah. Okay. That is like the most amazing data point.
Yeah. Wow. Um, and so that's why teams tend to be hospital sponsored teams. And it's also why [01:20:00] teams, um, if you have a more robust team with chaplain and social work and music therapy and, um, and key and all that. Yeah. But it's, it's the T is the entire team that can support a family to facilitate their, their goals and, and, um, I have amazing nurses and social workers and everybody on the team.
And you know, like you may have a mind blowing family meeting with the neurologist. You don't necessarily need me to be a doc again, you might just need one of the nurses to hold hands and just help you understand what, what you know, and just process, you know, um, uh, there was something else that. I just slipped my mind, what I was going to say.
Oh, number of patients on team, right. Um, number of patients carried, um, Um, so it takes somewhere about two hours, give or take [01:21:00] to process a new patient. If it's on the floor, maybe an hour and a half, if it's an ICU patient, maybe even three hours, you know, if somebody's been there two months, three months, right.
And the hospitalist is admitting a patient I'm like six and a half minutes. Um, you know, if we're helping with a really extreme case, you know, you might do. Like two cases in a day. Um, there there's, um, there's some information that's older that says people do, um, six to eight patients a day eight. If it's more follow-ups that are symptom management, if you're seeing more goal patients, goal oriented patients, do you do fewer.
You might see three to five, if it's more new patients, um, if you're doing more symptom control visits, you can push more patients. Then if you're doing a visit for [01:22:00] understanding that the goals of the patient helping them make a decision. Um Hmm. So, um, Yeah, that's so interesting. I mean, I, I guess no, are everybody's time is really valuable here.
I think I could always go on and talk to you for a really long time. Danielle, I think this topic is so apropos given where we are with the pandemic. It's giving people an opportunity to think about these things. Most people do not go through their regular day. I'm thinking if I go outside and somehow I get a.
A life-threatening illness. I could die. I mean, it is an odd time. Um, Alex Knight earlier did a very sort of rapid fire, um, review of how to fill out a MOLST form. I don't remember which episode that was. So, and my background, um, in emergency medicine and then in house calls and then in hospice is sort of like drives my interest in this topic.
And I think given that. Um, it's complex. It involves two [01:23:00] different parts of Medicare in some ways to really understand the difference between hospice and palliative. And that's like a very important distinction, despite it being, you know, financial. Um, I think that the idea that there are. Th that there's a spectrum of care that then switches how you pay for care and yeah, the different types of resources that you can get.
And it almost becomes this little weird switch where you're like, well, you could be in the pallet unit, the part B world, where you have to like get nickeled and dimed. And every time you need a hospital bed or some sort of side table, or, you know, You know, bedside commode, you have to fill out a thousand pieces of paper, versus if you choose hospice up, you're now your VIP and you get all this stuff.
And it's just sort of part of the wraparound services of hospice. And then the distinction of when you that switch gets flipped is, is often very, very tricky. And that on top of the fact that I think that there is a resource desert of palliative in communities, um, that it makes it so that the hospital becomes a [01:24:00] primary source for that type of thinking that often.
Sort of dissipates and tropically as people leave the hospital. And that's sort of very disturbing, but it's good to hear that, um, some of the home health agencies are medicalizing and that some of the hospices are, you know, bringing that in as part of their spectrum of care to get a little bit upstream of, um, Uh, folks that may eventually need hospice care.
So I think there's just a lot there. Um, and I'm, I'm never the one to wrap it up. I'm never the one to wrap it up, Alex. Well, I also, I'm very optimistic. And so I think, I also think that like, um, I think that we should ha you know, build it and they will come, or like how people ask for it and it'll get built, you know, like, cause I think people, you know, I hear that.
I think people should keep. Um, demanding what is needed, um, you know, and, and the whole switch to value-based care, I think. And Medicare advantage now, allowing for [01:25:00] hospice patients, um, Somebody told me they're like palliative. Okay. So it's like that old Supreme court definition of pornography you like, you know, when you're seeing yeah, exactly.
So, um, you know, I, so I think like, um, it's part of the spectrum of like house calls. It's better than no care, you know, like, you know, Palio, you know, it, when you see it, think people should just say. Like, all right. Here's what I want for myself. Or here's what I want for dad. He doesn't want to leave the house.
He wants all the care for him. How do we make it happen? You know? And like, just keep asking for it. Cause it'll it'll happen. I mean, it's Scotty, right? Like the whole world is aging. Yeah. Thank you, Danielle. This has been a most tremendous episode and thank you for being so open with us and sharing so much of your knowledge and expertise.
Uh, I, I learned so much, uh, this was really awesome. Thank you. Yep. So, um, yep. I think, um, I look forward to actually having you [01:26:00] back on at some point, uh, we like the part too sometimes. So, um, we're excited for that. Um, Alex, we're going to be putting, um, some show notes up for this episode on mastering medicare.net and, uh, 20, 21.
It's gotta be better than 2020, right? Yeah. All right, guys. Thank you so much. Bye bye. Bye. Bye bye.