Solving Healthcare - Ottawas Department of Medicine

Solving Healthcare Podcast

Hosted by
Dr. Kwadwo Kyeremanteng (learn more)

Dr. Kwadwo Kyeremanteng cares for the sickest of the sick in the Intensive Care Unit (ICU) at the Ottawa Hospital. His research focuses on making the ICU more efficient and improving access to palliative care services. To achieve this, he founded the Resource Optimization Network, a multidisciplinary research group working to reduce health spending in this area without compromising care. Dr. K, as he is fondly called, is a leading contributor helping the department to achieve its vision of shaping the future of Medicine.

In association with the Ottawa Department of Medicine and the Resource Optimization Network, Solving Healthcare is a podcast series featuring interviews and discussions on topics related to improving healthcare delivery in Canada based on the values of cost-effectiveness, dignity and justice in healthcare. The podcasts will challenge the status quo and explore gaps, assumptions and different perspectives in the pursuit of finding solutions to the problems in Canada’s healthcare system.

Listen to the most recent episode:
Surviving Pancreatic Cancer & Living Your Best Life, with Sindy Hooper

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12/03/2019

Episode Notes

Sponsored by BetterHelp

Sign up today: http://betterhelp.com/solvinghealthcare and use Discount code “solvinghealthcare”

Book recommendation:

Man’s Search for Meaning by Viktor E. Frankl: https://amzn.to/2pqQH2O

Resource Optimization Network website: http://www.resourceoptimizationnetwork.com/

Follow us on twitter: @Kwadcast

Like our Facebook page:

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Please send your comments/feedback to kwadcast99@gmail.com

Listen More | Episode Archive

Surviving Pancreatic Cancer & Living Your Best Life, with Sindy Hooper

Minicast: Lessons From The Ottawa Patient Safety Conference 2019

The Opioid Crisis, Humanizing the Homeless & More, with Dr. Jeffrey Turnbull

Over Parenting: Pushing our Kids into Mental Illness, with Dr. Adrienne Matheson. Part 2

Over Parenting: Pushing our Kids into Mental Illness, with Dr. Adrienne Matheson. Part 1

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11/05/2019 | Sponsored by Medical Scribes of Canada

Episode Notes

Why are we seeing more children with depression, ADHD, & anxiety? What the heck do we do about it? The next two episodes tackle these issues. If you have a family or are starting one, you NEED to tune in. Dr. Matheson has sound, practical advice to help our kids to be more resilient.

Take home points:

Legislators/Administrators: Early interventions works! We need the infrastructure and policy to make it happen.
Clinicians: Intervene early to have the most impact.
General public: Let go of the reigns. Kids sense our anxiety. We got to let kids be kids! Remember kids WANT to be good.

Dr. Adrienne Matheson, Ph.D., C.Psych., is a Licensed Psychologist practicing in Ottawa, ON. Dr. Matheson has been working with young children and their families for the past 8 years. Dr. Matheson works with children, teens, parents and families that are struggling with a wide range of challenges including anxiety, aggression, bullying, trauma, separation/divorce, ADHD, self-harm, OCD, sleep, feeding and sensory regulation challenges. Dr. Adrienne Matheson completed a Ph.D. in Developmental Psychology from Carleton University (2009) and a Masters in Counselling from the University of Ottawa (2004).

Dr. Matheson also provides support to families that are going through divorce and separation by providing information, support and consultation. Further, Dr. Matheson conducts Custody and Access Assessments for the courts.

See more on her website: https://mathesonpsychology.com/

This episode is brought to you by Medical Scribes of Canada. These guys reached out to us after hearing episode our with Dr. Duane Hickling. They do amazing work. Co-founded by Dr. Peter Graves, an emerg physician with over 25 years of experience, & his son Stephen; they have established a group of scribes that can improve your work environment, efficiency and most importantly the patient experience. If your organization is looking to improve any of the above, please contact them at medicalscribesofcanada.ca

medicalscribesofcanada.ca

Recommended Books:

Raising a Secure Child: https://amzn.to/2JLBEYB

The Whole Brain Child: https://amzn.to/2PPG6sW

https://www.booker.io/u/@adrienne/

Resource Optimization Network website: http://www.resourceoptimizationnetwork.com/

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Please send your comments/feedback to kwadcast99@gmail.com

Note: As an amazon associate, I earn from qualifying purchases.

A Nursing Perspective on Futile Care and Moral Distress

Understanding Grief, with Heather Bousada

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10/21/2019

Episode Notes

Dr. Alan Wolfelt’s website:

centerforloss.com

Resource Optimization Network website: https://www.resourceoptimizationnetwork.com/

Like our Facebook page:
https://www.facebook.com/Solving-Healthcare-with-Kwadwo-Kyeremanteng-103665294393881/

Please send your comments/feedback to kwadcast99@gmail.com

Transcript for this episode:

Kwadwo: 00:37 Heather Bousada, welcome to the podcast. Thank you very much. Um, do you remember how we met? Gosh, that was a long time ago. Long time ago. Cause if you off the hook, I don’t actually remember how we met, but I do remember how I met your husband. So to the listener, I was playing hockey game and he, he didn’t know, he didn’t know who I was and I, I approached him after the game after a hard fought game, which I think we won by the way. You guys were dirty. We were done. And I approached Chris and I said, Hey, I know your wife. And he’s like, what did you just say to me? Oh I really know your wife.

Heather: 01:31 And then he did recognize you. Yeah. And that I explained that to everybody in the teleconference one. Yes. Unknowingly.

Kwadwo: 01:40 Well thanks for doing this Heather. It means a lot. And so maybe we could start off with what does a day in the life of the Heather Bousada look like, whether it’s at the hospital doing what you do or in your work with grief.

Heather: 01:57 Yeah. Uh, well it’s busy. It’s very busy, but, uh, most of my time spent in the palliative care and the palliative care team and I also work in medicine and I’ve worked with you in ICU, but, uh, I, you know, my love and passion is palliative care and grief. So a lot of my days spent with the palliative care team, meeting families and patients and talking about terminal illness and impact it has on the family and their goals and their hopes and their dreams and basically what’s happened to them and providing them support through that very difficult time

Kwadwo: 02:32 and crazy hours long days is that

Heather: 02:36 they’re long days, they’re long days. And sometimes I walk out of here pulling my hair and other times I’m like, wow, I feel like I was able to make a difference, you know? And that feels good. Yeah,

Kwadwo: 02:45 absolutely. One thing that I do appreciate that you guys do is, you know, I run into, I’ll have a family meeting or two in the afternoon and I feel emotionally I’d, no, I actually just physically, emotionally and physically exhausted. You’re doing this every day.

Heather: 03:05 Yeah. Well we all are in healthcare, aren’t we? We’re having really difficult conversations all the time. I don’t think, I think, uh, one of my colleagues I was talks about if we only had a GoPro, I don’t think people would believe what we go through in a day in terms of the conversations that we have. They’re really detailed. Intimate people are at their worst times often, right? And trying to make really serious decisions, um, on, not sometimes for themselves, but oftentimes families are having to make that for their loved one and they, they’re not sure what to do when they’re feeling stressed and scared and they’re not understanding how, or, you know, looking for support. And feeling in a world that’s not part of their typical day. Right? Yeah.

Kwadwo: 03:49 Imagine you literally can’t imagine being in the spots that and, right. Like, it’s not something that you think about, dream about, it’s just,

Heather: 03:58 well, people don’t get practice at this right now, let’s say to people like, it’s not something you sign up for. And then all of a sudden you find yourself in the hospital having to have conversations about end of life, either for yourself or your family. And it’s, it’s a, it’s, you don’t get practice at it. Right? Yeah.

Kwadwo: 04:15 So we’ll talk about some of the details of, you know, these difficult conversations in a bit, but you have a expertise in grief counseling and what are some of the things that you wish more people knew about the grieving process?

Heather: 04:34 Yeah, that’s a, it’s a huge topic. You know, it’s, it is my passion and not only for patients and families, but expecially for health care providers. You know, one of my passions lately is that, uh, as healers, we need to be okay, right? We need to, we’re doing some really serious work here. And if we’re not understanding, you know, for having to go through our own grief and mourning through loss of a family member, you know, I see it all the time, I see at the hospital and people are coming to me and you know, oftentimes they feel like what is going on. You know, I used to be able to take care of five, 10 people. Now all of a sudden just taking care of one person, I feel like completely overwrought and I don’t know what’s going on with me. Right. And sometimes just having conversation about what it is and what’s happening to them, to their body, to their mind, um, really kind of helps take off.

Heather: 05:21 Oh, OK. Cause we’re not only a death denying culture, but we really, um, you know, there’s that whole, whether it’s implicit or explicit out there that you got to buck up, right? You got to buck up, you got to get on with it. Um, you know, have a stiff upper lip and you know, people are looked at as courageous if, Oh, they look so strong. They haven’t even cried. Not everybody cries, but there’s that sense of, you know, if you’re only being strong, if you’re, you know, just keep moving forward. But the interesting part about grief and mourning is it’s not about moving forward. Everything we do in grief and mourning is about going backwards. So I mean, if you look at grief and mourning, and I think that’s an important part, I, well one I want to start with a lot of my approach degree from morning is from dr Alan Wolfelt.

Heather: 06:06 He has a companion and approach and that’s where my training is from. Um, as a social worker, I’ve also, I’ve gone down, there’s a center for loss and life transitions and it’s actually really a wonderful approach. And I, I heard dr Wolfville years ago and you know, just working in this field, I, when he talked about what grief and mourning as in going from the head to the heart, really it was what it’s about. And it’s that, um, that journey that we experienced that it just resonated with me, but it’s throughout our system, right? So like if you look at brief families or the hospices, the Canadian military, the American military, they have also adopted this approach because it’s a, it’s meeting people not from the head and the intellect. It’s meeting people with the heart, right? It’s companioning somebody and companion is means to break bread and it’s like sitting down with somebody and actually saying, you know what, I’m not necessarily the expert in what your relationship was with that person or what you went through, but I have some tools and I have an open, compassionate heart to be able to explore. What was that loss like for you? Right.

Kwadwo: 07:11 I feel like that’s a big fear for a lot of people. It’s like when you know somebody has experienced a loss, I can’t count how many times people say, I do not know what to say to them. I do not know what to do. I don’t know what to bring. I, you know, it’s, it’s awkward for awkward for some people, some people, and even as a palliative care doc that in certain circumstances where it’s like, you know, I literally, I’m not sure what to tell this person.

Heather: 07:41 Yeah. And there’s actually, we can talk about that a little bit later, but I think it’s important to start off with like, you know, there’s a lot of jargon out there, you know, brave man grief, mourning, like people throw out the words, right? But it’s really, it’s important to understand what the concepts mean, right? So that you can make some sense of it. So when you’re looking at at, for instance, bereavement, it’s a loss of a loved one. But what, what’s really fascinating about the word is it actually means that the Latin root word of it means to be torn apart. So, um, you know, it’s amazing whether it’s here or people would call me when I was doing my private practice with grief counseling and in some shape or form, they would be describing that their world has been blown apart. Right. Um, and that’s basically what it is, is that your world’s been torn apart.

Heather: 08:28 But the, the, the grief is important cause it’s the grief is there are internal thoughts and feelings. So unless you’re a sociopath, you’re gonna feel that loss, right? When you love somebody, I mean, grief and love are the flip side of the same coin, right? Cause if you love somebody, you’re gonna feel that loss. So it’s the thoughts and feelings. But where we get stuck is people just have that feeling, right? They have that feeling, but they’re not sure. So they’re not sure how to process it. Right? And we don’t get taught that and everybody’s teaching them to, Oh, just move on. Right? But where the real work is in the morning, right? And that’s the part that, um, that I tried to help people understand and, and how to kind of go about doing that. Like the morning is the outward expression of that grief.

Heather: 09:11 So emotions need motion. Um, so the more that you, it’s a social, a shared response to loss. Sometimes it can be specific to one’s culture or rituals that you might do. But unless you’re sharing that loss and expressing it and um, and I see it all the time with patients and families, once you get them to start talking about that relationship and who that person was, you can see the movement, right? It’s a natural unfolding. You know, people think of it as like mental health. It’s grief and mourning is a natural thing that we all go through, right? Unfortunately we like to avoid pain and suffering, but we will experience it and it can’t get people around it. You got to go through it. But in that journey is as a really kind of beauty in it in terms of recognizing what you’ve experienced and how you then integrate it. I mean, grief is, if you really look at it, it’s, it’s moving from one of physical presence, um, to one of memory. That’s the ultimate shift that what you’re doing in the morning work, right? So again, you’re moving that from physical presence to one American memory and you’re integrating that into your new life, right? There is no new norm. There’s a new normal now, right? You can’t go back to the old normal as a new normal. So you’re integrating that.

Kwadwo: 10:28 Wow. So there’s a lot there. So one thing actually, so Heather maybe talk a bit about what to expect when you’re going through that process. Yeah. Obviously there’s going to be a lot of distraught pain, you know, there’s that new normal as you described, but what are some of the things that people might expect?

Heather: 10:57 Yeah. Like for yourself and other people. Yeah, and that’s what I find fascinating is um, people don’t understand, like people think, assume it’s a, it’s just an emotional response, right? But it’s the totality of your whole being, right? It affects you physically, cognitively, socially as spiritual ritually. And especially if, if I make reference to the healthcare workers, we need to be game on, right? So like as yourself, as an ICU doctor, you need to be there. You need to be present. But if you’re going through a lot, us, you are, um, not only physically your body, you get extreme fatigue. Uh, you exhausted your appetite. You know, 80% of people lose their appetite, 10% gain another 10% that are neutral sleep disturbance. You know, so often people will tell me, you know, they’re quick to go to bed to sleep cause they’re so exhausted, but they wake up frequently, right?

Heather: 11:53 Um, so you’re not getting a lot of sleep. Your immune system’s down, right? Cause you’re in this critical state, like you’re in this hyper arousal because you’ve got this in either an impending loss or a loss, right? So, um, physically it’s affecting you emotionally. You’ve got like multitude. There’s no, you can find many different feelings at once and it comes in waves, right? Um, and cognitive is, it was interesting part, especially with healthcare is that healthcare workers is you, you know, we multitask, right? We’re constantly multitasking and, and life and death. Like you’re making life and death decisions. Um, and you all of a sudden you’re, and it’s, there’s a lot of research on it and uh, people will start to, uh, you’ll find it’s difficult to concentrate. Um, it more irritable. Uh, the multitasking often goes right out the window. Um, so all of a sudden you’re like, wow, you know what’s, and that’s where people often in healthcare come to me and say, I don’t know what’s going on, but you know, I was used to, I would could do this with my eyes closed.

Heather: 12:54 Now I can’t even, um, you know, concentrate on, on two patients that I have. Um, I mean I, for a personal example, I remember I’ve been in palliative care like for 19 years and I remember when my own mom was, um, uh, terminally ill and she was in the hospital and I went with my team to go meet a patient and the doctor and the nurse and myself when we sat down. And sometimes you’re not aware of it, right? Cause you’re so in grossed and what’s happening that you’re not really aware of how difficult it is for you. So I remember sitting there listening to the nurse and the doctor talked to the patient a conversation I have every day and I couldn’t even process what they were saying. At least I had the wherewithal to go, wow, I shouldn’t be here. Yeah, I need to step back.

Heather: 13:42 And, and I did, I stepped back. I mean it cause it’s cognitive that couldn’t wrap my brain around it. Like what was going on, what was being said. Um, yeah. And this was fairly recent. Oh, about four years ago. Yeah. Um, and uh, recently with my dad. But uh, yeah, it, it, uh, it’s, it’s good to recognize it. Right? It’s important for, uh, for people in general, but especially for healthcare workers that they’re not doing a bad job. That there’s nothing wrong with them. They’re going to the natural processes of grieving. Right. Yeah. We talked a bit about this beforehand. It’s a very unique scenario for health care providers to try and take care of others. Yeah. You definitely, yeah. You know, like for the reasons you mentioned prior about how unique it is for health care workers, you’re literally taking care of people. You’re seeing death and dying every, yeah.

Kwadwo: 14:52 And then when they experienced the loss, when they’re not able to think as clearly when they see that emotional tie to their dad or their mom or whoever might have experienced loss, you know, I don’t know if we talk about that enough. I don’t know if we support each other enough.

Heather: 15:12 And I don’t think, I mean, I don’t think it’s through bad intention. It’s, again, it’s a, it’s a S a social, cultural Mileah of, of Western society in general. We don’t tend to talk about pain and suffering. Dewey, you know, we talk about being happy, being independent and um, eh, so to talk about pain and suffering, we don’t, when we don’t often teach our children about it either. Right? So I’m often talking to families about how do you help children through the loss or the are about to lose someone important to them because we’re not taught. Right? So all of a sudden when we’re faced with it, we don’t know what to do. And as health care providers in general, um, you know, whether your community or in a hospital, uh, we want to take it on. But if we’re not understanding, we should be the very role models and understanding because we’re going to be out there trying to heal others and if we are not healed ourself are not going to be up to speed. Right. Yeah.

Kwadwo: 16:06 It’s, it’s very much that cause the culture in medicine. Like I try not to get too personal, but you know, when I, I found out my dad passed away, it was a Thursday while I was on ICU and it didn’t even occur to me to get somebody to cover, you know, it was just sort of ingrained in me like that plug away. And I didn’t even tell anybody. Okay. I told them one person actually TP, just a just thing. So I just want it to have that kind of, um, security in case things became overwhelming during that time period. But, uh, yeah, it’s for whatever reason, it’s that culture, it’s that talk about it, let’s grind away at what we’re doing. Even, you know, healthcare aside, even had a conversation with somebody that, that recently relatively recently experienced a loss, you know, and it was kinda like you alluded to at the beginning where it’s like, I just want to do a bunch of stuff that keeps my mind off it and all I think about this and maybe it’s worth diving into more, what are the consequences of not letting things sink in of always running?

Heather: 17:34 Well, I mean, when you look at, um, the six central needs of mourning, like through the companioning model, one of the things is, um, acknowledging, um, the reality of the death, right? And they’re not stages, right? You can come back and forth, back and forth, but primarily initially you’re trying to acknowledge the reality of the death, right? And depending on the circumstances, um, that may take weeks, right? So like for instance, if people don’t actually get to see the body, you know, say somebody died overseas and they regret it, that acknowledging the reality, the reality of what that the person is gone. Again, remember, grief is about one of physical presence to one a memory. So you haven’t actually been there to see it. It’s hard to integrate it into ourselves. Right? So, um, and then, you know, and then we start to identify or start to, um, embrace the pain of the loss, right?

Heather: 18:31 And our body and our mind has this wonderful ability to be able to do that. So like it’s about encountering innovating. So it’s okay. Like our mind can’t take it all in at once. Right? So our mind has a guy call it nature’s anesthetic. So when we need initially have the loss of somebody, we, our body has this way of kind of numbing us a little bit and it’s just because it otherwise it’s too overwhelming and it ends as that numbing starts to kind of wear off a little bit and the reality of that person gone starts to set in that the pain really comes out. And that’s actually the hard part. Like that’s actually when I would find, I would get calls for grief counseling was around that stage. So, you know, somebody passed on, they have all this family and friends coming to provide them with support.

Heather: 19:19 Um, and their new normal hasn’t really introduced themselves yet, right? Because they’re still living in that world of that person being there. Cause everybody’s around, right. And then as people start to go back to their normal day lives and people that are the person, the bereaved person’s left and they just looking around going, Whoa, what happened? You know, where is that person? I’m, you know, I’m used to getting up every day and having a coffee and then we head off to work and then we come home and we do this. That’s not, that’s not there anymore. So then the pain starts to come in. And that’s when people would call me and they’d say, I don’t know what’s going on. Like I thought it was doing okay, what? Now I’m just like, this is awful. This really is painful. And, and, and that’s when I’d say, well, I can’t get you around it, but you know what?

Heather: 20:07 There’s a way to go through it. Right. And that’s where the remembering that, you know, the morning comes in remembering the person who’s died, right? And it’s that work. And I see it not only in grief like a post-death, but I see in palliative care, it’s really kind of that wonderful transition, you know, where you see families initially like, wow, I can’t believe this is happening. No, it can’t be in there in crisis. Right? And they’re questioning the diagnosis and the prognosis and what’s going on and they’re in this state of helplessness. Right? Um, and then as you develop this kind of, um, time to give them space, uh, to answer their questions, provide education and support and of honor the process that’s going on. It’s this beautiful movement that you see, right? As they shift from the head to the heart and acknowledging that person’s about to pass. And I love that, you know, after like a while, and you walk in the room and they’re all sitting around the bedside and they’re sitting vigil and they’re sharing stories and they’re laughing and they’re crying. You see that morning work coming in, right? And that starts there. And it’s really quite a beautiful process. And it’s not that they want their loved ones to pass, but they’re, they’re acknowledging it, right? And they’re giving honor to that person. And that’s a really wonderful thing to be doing.

Kwadwo: 21:23 Yeah. And I mean, I could speak also from the clinical side. I think you would agree with me on this being part of that, being in that privileged part of being, of watching them go navigate through these tough times. And the very reason I got into palliative care was those moments and the life where you’re sitting with the family, you’re talking about uncle Gus funny jokes at Christmas and that funny outfit he wore at Halloween and you’re laughing and you’re crying in here and you’re just, you’re being present.

Heather: 22:05 Yeah. You’re honoring the joy. The love. Yeah. Yeah, yeah. No, it’s, it’s incredible. I know. Cause people haven’t say, well, how can you work in palliative care? It’s, I’m not, it’s not about the dead, it’s about the living, right. It’s about honoring the living and uh, it’s that, it’s that it’s life, it’s life affirming. Right. And it’s really quite life affirming. Yeah.

Kwadwo: 22:26 So maybe we could speak to what to do to help our fellow employee, our fellow nurse or a fellow loved one, navigate through this process. Cause once again, come like I alluded to at the beginning, sometimes a lot of people just don’t know what to do. They want to say to, you know, send them a song. Do you, you know, I can write a Paul, what do you do? What’s the best advice that we could give people listening.

Heather: 22:58 Yeah. Well, you know, whether you’re talking to a colleague or families that are going through it is it’s important just to meet them where they’re at, right? That’s the first step. Um, because again, like grief is about, I’m going backwards before going forwards. It’s about saying hello before you ever say goodbye. And what we tend to do is in our society in general, we tend to want to move things forward, right? Sometimes that’s because it makes us feel better. But really that person, like when you’re working in healthcare, people will often notice that, uh, families will keep going back to questions and keep going back. Well, why did that happen? And did, did we do the right thing? And, and it can be frustrating sometimes cause you think, Oh my God, I’ve told them how many times. Right. But it’s because mourning there actually. And that’s where I say, okay, you know, just take a moment because they’re going backwards.

Heather: 23:51 I just had a family recently and lovely daughter’s sitting vigil by the bedside and they kept going back and I kept going back. And then finally I just sat down and I said, can I describe a little bit about grief and mourning to you? And I did. I sat down and I talked about what is grief, what is mourning and what we need to do in that process. Um, and uh, I said a lot of it is about going backwards. And I said, and that’s what you’re doing. So I’m going to honor that and I’m gonna answer your questions, but I want you to know that that’s what you’re doing right now. And they just kind of went, Oh, okay. I see. Okay. Cause otherwise they think, well, why I’m going crazy. These questions are driving me nuts, you know? Yeah.

Kwadwo: 24:30 That really is enlightening because I got to tell you, without knowing this as a clinician sometimes I’m like, I’ve answered this question three times. I’m like, what’s happening? And I always related it to being in shock because of all the things I going through, which is totally understandable. But what you’re saying makes a lot of sense. We James downer, he’s initiating an ICU study actually on bereavement and this was quite eye opening for me. Like ICU. A lot of the families have tons of questions after they leave us and you know, not being on that side, like I’ve never had a loved one in ICU and I wouldn’t know what it would be like to hear that information on, you know, your loved ones dying and trying to process all that, you know, and in that time frame. But hearing James speak to the matter, it’s like a lot of these people are, have questions after they have all these kind of, uh, concerns that, you know, there’s no real process to, to help navigate and, and my whole, I mean, the whole point of doing this podcast, the whole point of doing what we do is to help others and to help them reduce their pain.

Kwadwo: 25:55 And so, you know, it’s, I hope this is at least helpful also too, a lot of the clinicians out there hearing these things and, you know, it really comes down to being, making time, being present, not giving the bullshit answer of like, all you’ll get through it and we’ll move through this, you know, your warrior move forward. But to sit with them, you know, sit with them and hear them out and we don’t need to give a rah rah speech every time we see them. It’s just being present, acknowledging it’s hard.

Heather: 26:27 Yeah. It’s especially difficult in ICU because the unexpectedness often, right. Right. So that’s another flavor entirely around it. So, um, again, so they’re in that unexpectedness and so moving from the head to the heart, it’s not about what, you know, it’s what you feel right in grief. So when you’ve got somebody in a try, usually a tragic situation in ICU and uh, that, that kind of reality of the loss is going to take them a little bit more time. Right. It’s, you know, it’s gone from zero to a hundred and like one minute of their lives often. Right. So, yeah, that’s a whole other flavor as well. Um, and trying to, to help them through that. So yeah, they’re going to have a lot of questions cause they’re trying to kind of, their mind is trying to connect with their heart in terms of what just happened and just then trying to acknowledge that person. Right. So hadn’t how that’s transformed and transition for them. So sext or work for sure. Yeah.

Kwadwo: 27:34 You’ve experienced loss in your life. You lost your both parents relatively recently, especially your dad was just December, December, coming up and coming up here and I want to know how it’s affected you as a grief counselor or a social worker in hospital. Do you feel

Heather: 28:00 it’s changed?

Heather: 28:03 Um, well, typical social worker is going to redirect it back to you, but uh, yeah, of course it does. It, it, uh, you know, that’s when I talk about the beauty and grief and mourning, people go, wow, was she talking about, um, but when you’ve had a loss yourself, like we can all kind of relate to it, right? You know, there’s empathy and sympathy, you know, sympathy is, you know, I feel sorry for you. Empathy is, let me understand what you’re going through. And the big buzz word now is compassion is meeting somebody heart to heart. You know what? Suffering is a shared risk. We all go through it, right? We all so when you’ve gone through a loss, and if you don’t mind me saying, so quad Joe, I remember in your Facebook after your, I think your dad’s anniversary. Okay. To talk about, um, I loved what you wrote because you said, um, that it made you a better doctor.

Heather: 29:00 And it’s not like you’re going to sit with your families and patients and like whale and cry, but you know what it is to be human and you know, what loss means and how painful it can be and that we all are in that together. You know, the world’s a mystery. Do I have all the answers to everything? No. Do you know, but we, we recognize in our fellow man that that sense of pain and suffering and, you know, when I’d have like the F the patients or clients that I had in grief counseling, I think almost everyone said to me something along the lines of, you know, I never really understood it, you know, um, until I felt it myself and I feel more for other people. Yeah. I can relate to their pain more. Like one lady had said to me, uh, you know, so-and-so lost their mom recently at work and last year I would’ve probably thought, Oh, whatever, just hurry up and get back to work. Yeah. But she said, you know what, now I look at her and I, I go over and I give her a hug. And I said, wow, this is hard, isn’t it? Yeah. You know, welcome to the club kind of thing. You know, the shared human existence. And uh, that’s the beauty I’m talking about. Right. And to connect again to say, wow, you know, this is how we, this is what we go through. Right?

Kwadwo: 30:20 Yeah. I, I gotta tell you the, after going through it, the way I see people that are now going through a loss is, I want to say it’s a completely different, but I am, I’m there, I understand more where they’re coming from until the empathy and the compassion. It’s inevitable. And one thing that I did totally appreciate is you take it almost tell by how someone hugs you if they’ve experienced lost themselves recently or not. Like the like meaningful bear hug would usually come from people that like, I know what’s going down, I know how you feel around. Um, but yeah, it’s amazing. Like I that did give me personally a lot of solace knowing that you can make good out of the bad situation. I mean, it sounds cheesy, but I truly believe I’m a more compassionate, compassionate, dark. Now. I think I’m more present when someone’s telling me about loss and now I give less of a damn too. I’m like, I don’t think I’d be doing this show if it wasn’t for experiencing loss and knowing how, you know, like can just be done. And so let’s live now

Heather: 31:45 for [inaudible]. You did the, you, you took the time to do the morning work. Right? And that, that’s where sometimes people get stuck because they don’t know what it is. They understand they’re feeling this awfulness but they don’t know how to move it. Right. And what you did learn about that and you shared, you had a social response to it, right? You share to everybody what it was like for you and you worked with your family and you started to move in that process. And it’s not that it wasn’t painful, but in, in some respects you were able to move, right? You moved from that physical presence of your dad to want a memory. Cause I mean, death ends a life. It doesn’t end a relationship.

Kwadwo: 32:24 Interesting.

Heather: 32:25 And yeah, that’s, that’s really powerful. And because it does it, you will forever have a relationship with that person. It’s integrating into that your new normal and your new identity that they’re not there in your life anymore physically. But they’re still really powerfully there all the time. I mean, I know with your dad and even with my mom, as I get older, I can look back at my mom and go, Oh wow. Yeah, she’s just, we’re all just human beings trying to do the best we can. Right. You know, and as you evolve and you go through your own life transitions, you go back to that relationship, right. And you see it differently. It evolves just like as you evolve.

Kwadwo: 33:05 Yeah, no, it’s, it’s true. This is why I want to do on the show. I like, I’m a bio to care doc. I’m an ICU doc. I see death all the time. And after experiencing it at a, with my father, it was, I didn’t know all this stuff. I didn’t expect all this physical, spiritual, mental difficulties that were to, uh, that I experience. And so I really think it’s important to share this with people, to be able to be open, to be there for their fellow man or woman and be less of a denying culture. And I really think we will go a lot further if we approach this with open arms.

Heather: 33:58 Yeah, absolutely. And by not only the, you know, the public, but especially as healthcare workers, we need to kind of honor that. What that happens to each other and to be, do we all have to be grief counselors? No, but do we all have a responsibility and maybe, uh, to be more aware so that when we see our fellow colleagues who would go, Hey, yeah, okay, I get it. I get it. Okay. They’re not just being lazy or they’re just, they’re just self-pitying. There’s actually something going on in there. Like, even like people just sitting vigil, like when they’re sitting with their loved ones dying, I will say to them, you know, I talk a lot about self care to them because even though you’re just sitting there, you’re running a mini marathon inside, right? Because so much is going on and processing and there.

Heather: 34:45 So I remind them, I said, you know, you’re mint, your body’s physically running a mini marathon. Make sure you drink, make sure you get some rest. You gotta be good to yourself. Um, and it’s the same thing when we’re grieving, right? There’s a lot like it’s, so if I, if you had a broken leg, I wouldn’t be expecting you to be running around the hospital. Just, you can’t see it. You can’t see when somebody’s grieving. Right? So, but I, it’s what dr Wolfelt says, he actually gives out pins. I love it. It says, uh, if you’re in grief, you put a pin called under construction. Yeah. And it just gets your mankind to say, Hey, you know, I’m slower right now. Be patient with me. There’s a lot going on in here and you can’t see it. But it’s there. Right.

Kwadwo: 35:26 So you, you even brought up a point too when we were talking earlier about the house, just some cultures, like, you know, they’re grieving based on attire. So it’s like part of the culture to

Heather: 35:38 be able to whether visual or, um, take time with the loved ones. But that’s part of, yeah. Well that’s a fascinating part is that we’ve, we’ve moved away from that, right? People used to die in the home, you know, grandma and grandpa lived with us or extended family and uh, they didn’t tend to die in the hospitals. Like what 70% of people die in the hospitals now it’s often removed. So it’s often away from us. So, um, you know, before people would die, the was a national part of life, right? And now it’s kind of removed from us. Um, and before like, like maybe what, 80, a hundred years ago, uh, if you’re a widow, do, you’d be wearing black and you’d be walking around. But what’s wonderful about that is you’d be walking around in your black attire and you would start to do the morning work. Cause people would stop you and say, Hey, you know who passed away?

Heather: 36:34 Was it George, your husband? Yeah, I did. And he started talking about George, right? And then you’re that shared response to loss. It starts to evolve and you get to talk about that person. And so it’s a wonderful thing, right? But we’ve moved away from, we’re not supposed to talk about it, so I’m comfortable. Um, and that’s healing. It’s incredibly healing. That’s incredibly healing. And you know, people often have, you know, just a little tidbit, like people are afraid to say, Oh, I saw so and so when I don’t want to say anything. Uh, I know they just lost their mom, but, uh, I don’t want to remind them of the death. Well, I’ll tell you what, they know that person’s died, but when you say something to them, what you’re doing is you’re reminding them that person lived and that’s the part that really needs to be done.

Heather: 37:21 I remember recently actually a shout out to cam on a five and medicine. Um, yeah, as I said, my dad passed away in December. And is this a, this is part of what I’m talking about is she did this, and I don’t even think she knows, maybe she does now. Um, but I was sitting at the five nursing station just charting and uh, she came over to me and I forgot that she taken care of, both of my parents were in their hospital and then she started talking to me about travel or something and then she started to say, Oh yeah, your dad’s from Scotland and you told me about this. And he said this. And he, she started sharing stories and I was like, wow, that’s my dad. He was like, wow, he is in the room for a moment. It’s like, I got a piece of my dad.

Heather: 38:03 And I was like, wow. She just did some amazing morning work and she didn’t even realize it. That’s, uh, that’s the funny part is when I talked to nurses or other healthcare providers about grief and mourning, it’s just sometimes as simple as like going into the room of somebody who’s, you know, terminally ill and picking up the photo frame and saying to the husband, Oh, I love this photo. What’s going on here? And then you see that kind of often stiff and often I’ve, I don’t think I’ve ever remembered anybody not wanting to share. Right. And then they start talking about that person and um, they’re, they’re moving, they’re, you know, they’re trans and that’s what we, it’s so important. So vital.

Kwadwo: 38:41 Wow. I think, I hope it serves a little bit as a inspiration to a lot of people seeing patients out there like take that time. It doesn’t, it’s a little like, you think I’m learning about doing, we shows and so far it’s like they really is a little things like literally looking up that picture and saying, wow, look at that. Look are from a few years back.

Heather: 39:08 Yeah. Oh yeah. Do you see the smile on their faces when you do that? Yeah. Well, it’s kind of like, you know, people don’t really want to know what you have to say unless they know you care. And like more like for physicians that’s really important, right? Cause you’re sitting down giving really bad news and you’re making recommendations and if you’re doing it from a, you know, intellectual kind of, this is what it is and people aren’t going to respond as well. But if you sit down and say, Hey, you know, this is tough, tell me a little bit about whoever it is in the bed and then start to work from there and say, okay, well this is what’s going on. And they feel like that person’s in the room, that they’re not just a number and just another person to take up a bed. But they’re real, that they mean a lot to them. Right.

Kwadwo: 39:53 Wow. Some good shit. Yo, I hope you all are buying in. Um, last couple of things, uh, while I have you have there. Okay. So just to give some context, Heather’s got like, I don’t know how many guardian angel things on our, on our, uh, [inaudible] lanyard on your land planning yard when you’re, yeah, she got about seven guardian angels on her lanyard, which is like weighing her down actually. She actually walks with a limp. It’s crazy. Um, so just to give you a sense of how giving and how much love she gets at the Ottawa hospital, but can you share a story where, you know, you’ve been appreciated because we, you know, we appreciate you all every day, but like,

Heather: 40:47 yeah. Um, yeah, I’m so bad at names, but I never forget a story. Like I almost remember stories when people tell me them, well, I guess recent, like I always, if somebody passed at the hospital, I always make a point of giving them a followup call because it’s not part of my protocol, but I think it’s essential because all of a sudden you’ve got all this support at the hospital, people are coming in and talking to you, and then your loved one dies and then boom, you totally disconnected. Right. And they may have questions and worries. So I always generally give them a call after. So,

Heather: 41:24 and I love to hear about how they’re doing. But I think recently I had a family. Um, if father husband was dying, two older sons and a lovely family, just, just beautiful the salt of the earth. And you can see how much they loved this man and you could see it walking in the room. And that, that journey I talked about where it was like, Oh my God, what’s going on? Can’t we do this? Can’t we do that? You know, that like that helpless. I think one of my favorite quotes in grief is, uh, by C S Lewis, he wrote Narnia. I used to have it in my grief office. Um, no one ever told me that grief felt so much like fear. Wow. Cause it is, it’s, it’s absolute like, it’s, uh, an insult to your identity. It’s an insult to your safety and security. And it’s an insult.

Heather: 42:13 Well, men, since [inaudible] insults a strong word but affects your sense of meaning, right? So much unknown. People are terrified and you see that and there’s no where in this world where you feel more helpless when you’re not able to stop what’s happening and you’re watching this deterioration. So I S I witnessed this family, um, in that state and then as we evolved and we talked and we shared and they have some education and understanding of our own what’s happening, that really cool family just kind of sat in this tight two bedroom in the hospital. But I would open up the curtain and I would just go, wow, this is so much sacredness right here. Wow. You guys haven’t nailed. Like even though it was in a tight, awful kind of setting, they made it beautiful, you know, just that honor. And you could hear the stories and the children were coming and um, we actually, I got the kids to do a hug blanket, which is something I love doing with the kids.

Heather: 43:11 So, you know, if the kids can’t be there all the time or they need to feel part of it, you know, you’re old enough to love your old enough degree. Right. That’s very important. So I’ve got the kids do a hug blanket where they kind of draw their arms on it and write all over the blanket and then they put it over the grandfather. So they had done that. And so you walk in there and you’d see this beautiful blanket and all the kids riding on it and everybody just loving this man, you know? So when I called afterwards and I spoke to the family, uh, they had sat Shivah and they had brought out the hug blanket. So when people would come over and, you know, people come over and pay their respects and all that, they would bring out the blanket and they’d share about it.

Heather: 43:50 I was so touched. I was like, wow, that’s beautiful. Like that was really, uh, that just, yeah, that was really beautiful. Wow. Eh, before ending, I know there was another, speaking of about some pretty cool initiatives at a conference you went to recently. Yeah. The normal, if you want to mention that. Yeah. Well, grief and mourning in general is really misunderstood and it’s, um, in a lot of myths and misconceptions about it. And oftentimes when you just really trying to sit and tell people about it, they really feel more understanding about what’s happening. Um, and it’s been kind of one of my, um, ones I want to bring more forward to the healthcare community cause we’re supposed to be at, man, we’re supposed to be the mentors. We’re supposed to know what this is all about. This is what we deal with every day. But yet there is a loss in that.

Heather: 44:45 There’s, there’s not a lot of understanding around it for, um, you know, especially for each other. Right. And we really need to bring that forward, um, to support each other as we go through these really difficult times. Right. Um, and not to feel that what’s wrong with us and I’m going to lose my job and you know, we need to be supported and no matter where we are, what other, what agency or what company we work for, we all need to feel that way. Um, but when I went to recently the Canadian hospice palliative care, or did I have to say that Canadian hospice palliative care association, they had a conference recently here in Ottawa and, uh, because it’s been one of my babies about, and, and I think it’s partly because people like you and other doctors and nurses and managers have come to me because they are like, what is going on with me?

Heather: 45:31 I don’t understand this. Like, wow, like something I just assume everybody knows go. No, it’s really not understood. And then we start to beat ourselves up. You know, what’s wrong with me that I’m not moving on. And, um, so I wanted to bring this more to our workplace. Right. How can we help other, each other cause, and so part of this conference there was, I went to one of the workshops and I was really excited. Uh, it was a lady, uh, just spoke to her, Karen Brownrigg. Actually, I did ask her if it’s okay to say her name on this. She said, yeah. So under the Canadian hospice palliative care association, they have something called Canadian compassionate companies. So they recognize that this grief and taking, you know, the stress of caring for somebody who’s terminally ill, it’s a chronic condition. So the policies and procedures that are in most institutions in places of work are behind the times because they’re not aligned with how things are now in society.

Heather: 46:28 Um, you know, modern technology, advancement of science. I mean, you see it all the time, how we people are living longer and often living longer though with chronic illnesses and often debilitating States, right? So not only are you, uh, trying to, uh, attend to your family member, your loved one, um, but this can be an ongoing issue, right? And our policies aren’t in place to help support that. Um, and if you show you support your employers during those times, you’re gonna have more retention of them. Uh, you’re going to have, um, attract more people with, uh, good qualifications to want to be working there. When you maintain that good, healthy work life balance, people are happier. And when you happier employee employees, you’re gonna have better care. Right? So it’s, it’s actually so the Canadian compassionate companies, I’m just learning about it, but um, they can actually come to the HR and start to educate and bring in policies to workers who are going through this. So when you have, when you have a policies and procedures around it, the culture starts to change, right? Because then it’s normalized and validated that, yeah, this is hard. You know, I care about your psychological safety cause if you’re safe, everybody else here is safe. Right. And that’s important not just for our colleagues but for our patients and families. Right. So I was really excited about it and like that. Yeah.

Kwadwo: 47:52 I think it’s definitely worth mentioning because it’s, I want to say innovative. It’s, it’s, I wouldn’t say this is common practice in areas amongst companies and amongst healthcare providers. So anything that’s going to help people get through these tough times and provide better, ultimately provide better care we should embrace.

Heather: 48:14 Absolutely. Absolutely. Yeah. So yes.

Kwadwo: 48:21 Been a dream. I really, I can’t express the work that you do and how meaningful it is that we see it day to day. I’m going to speak for, you know, like my ICU colleagues, my palliative care colleagues, my medicine colleagues, the work that you guys do, it’s underappreciated, undervalued, and it goes in. It’s one of the most important things we provide. And I just want to say that you do amazing work and whatever we could do to get the word out to how important these things are, including grieving, we need to do it. And I hope this is just a hopeless, I hope this helps.

Heather: 49:08 I hope so. I hope it moves things forward. Yeah, that would be great. And I’m there to help it out as much as I can and vice versa. It’s been so great working with you, Kwadwo over the years. Yeah. Yeah. Right. Thanks so much. .

Improving the Patient Experience, with Dr. Duane Hickling. #Freshness

The Power of Connection, with Dr. Tamina Eapen

The Impact of Inappropriate Care with Dr. Gianni D’Egidio, Part 2

0:00

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09/27/2019

Episode Notes

Association Between Immigrant Status and End-of-Life Care in Ontario, Canada: https://jamanetwork.com/journals/jama/fullarticle/2656223

Brain death case: https://blg.com/en/News-And-Publications/Publication_5338

Resource Optimization Network website: https://www.resourceoptimizationnetwork.com/

Please send your comments/feedback to kwadcast99@gmail.com

Episode transcript:

Kwadwo: 00:01 Welcome to solving healthcare. I’m Kwadwo Kyeremanteng. I’m an ICU and palliative care physician here in Ottawa and the founder of resource optimization network. We are on a mission to transform healthcare in Canada. I’m going to talk with physicians, nurses, administrators, patients and their families because inefficiencies, overwork and overcrowding affects us all. I believe it’s time for a better healthcare system, best more cost effective, dignified and just for everyone involved.

Kwadwo: 00:37 Thanks everybody for joining us on solving healthcare. It’s your host Kwadwo Kyeremanteng. Before joining our second part of the conversation I had with Dr. Gianni D’Egidio, I just wanted to talk about a couple of things. Number one, I have been extremely overwhelmed and grateful for the feedback I’ve received about part one. It’s been mostly from nurses within critical care and, and what they’ve fed back to us is how meaningful it’s been that somebody has been advocating for their concerns. And I gotta tell ya, you know, it really does come from the heart when you see how hard these these guys work to try and improve Karen and get their patients better and functional. And I had this moment a couple days ago. Uh, working in the ICU is like three in the morning and brought down a fairly sick patient and watching everybody moved together and working together to get that patient comfortable, to get that patient set up, to provide speedy, efficient and honestly love and care it, it is truly was magical and sometimes you take for granted what people do.

Kwadwo: 02:17 And I, I just wanna I wanted to mention again, these guys are my mini heroes, how hard they work, how excellent they are at their job and it can’t be, can’t be overstated. Um, so I just wanted to mention that real quick. The other thing, uh, was going to mention in terms of any feedback, you could send an email@quadcastninenineatgmail.com and you could follow us @Kwadcast on Twitter. Okay. So part two of our conversation with Gianni D’Egidio it’s a good one. I won’t lie to you. We talk about how culture can impact the level of care that is requested. We talk about Gianni’s ability to discharge patients efficiently. We talk about the dangers of dr Google. We all know dr Google seems to know everything, but does he or she, we talk about the perception the media gives on medical care and the villainized nation of physicians. And then we talk about these recent brain death cases. So, so just to clarify, these are cases where patients are declared dead cause they’re brain dead and the family has questioned that diagnosis and and have appealed to the courts for judgment. So without further ado, dr Gianni D’Egidio

Gianni: 03:59 I’ll answer it again. The drive to address these issues to confront families I the dry, where’s it coming from? It is an absolute, I’m absolutely infuriated with the, I guess absurdity of these cases when if you, a rational objective individual would look at this and say this does not make sense. And this brings us into the topic of what is driving this from the substitute decision maker side of things. And these are my comments and some of it supported by evidence. Some of it supported by just my anecdote. The of these 12 individuals in my study, only one was born in Canada. The vast majority of individuals, 11 out of the 12 were not born in Canada. And there was always a religious argument to their, um, request for therapy. And this is similar, not exactly the same, but to a Dr. Fowler study from Toronto looking at individuals who are recent immigrants to Canada.

Gianni: 05:06 We’ll re, we’ll demand, well not demand, but will undergo sociology. Yeah. It’s associated with more aggressive care towards end of life. Right? So there’s a religious cultural factor to it and I’m not being demeaning about that or whatever else, but this brings us into a bigger societal issue of the inability of, of religion to appropriately deal with death. I find, um, if we’re going to, uh, say that physicians are not properly educated and cannot deal with death, I would have to make the exact same argument for religion. Um, there is this consistent argument that life at all costs and despite every single religion saying, Hey, when you die, you’re actually going to go to whatever it may be, let’s say heaven and better place, whatever else. Um, and there’s this consistent argument, which again, if you speak to religious leaders from every associated faith, there’ll be a disagreement about how aggressive to be towards end of life. And I’ve had that because we’re fortunate that at our institution has spiritual care services and some very well respected members of the religious community of all different types of faith who will, who I’ve had the opportunity to discuss this with. And they agree that yes, we don’t need to be this aggressive towards end of life. So that brings up a whole other, like you could do a whole other podcast on, on that. And I’m not gonna get into the sides that

Kwadwo: 06:28 that is a, a monster topic. Um, so one thing we haven’t touched on is like how exactly are we going to fix these issues? So we’ve identified that, you know, culturally we, it’s hard to accept death. Uh, we, we see that we could be better communicators, better, better at dealing with advanced care planning, goals of care discussions and so forth. We talked about how conflict manage, like we’re not taught how to manage conflict in medical school and in residency. And fellowship or as even staff really. So where do, where’s the biggest bang for your buck? Where should we, how do we fix this business?

Gianni: 07:17 Um, I guess I’ll, I’ll go back to the points I made earlier about, um, lack of education and then the fear component. Uh, tying it back to those two things in terms of education, we need to be educated on how to confidently propose a treatment plan. And you can’t teach confidence, but you have to be able to reassure individuals. And I try to tell my med students and residents this, that yes, getting sued or getting a complaint absolutely sucks. If you follow the ethical, legal and medical framework of proposing an appropriate treatment plan, you will be absolutely fine. Yes, it’s gonna suck. You’ll get a college complaint, you might get sued, that’s gonna take years of potentially of your life. But there are methods to deal with that. And the vast majority of the time, I think, at least from what I know, you’re going to be absolutely fine in the end, but you have to deal with that.

Gianni: 08:12 Um, and I’m not trying to minimize these issues, but you, you’re going to have to deal with that. And that gets into a system or of a system type of, of issue is why is it as physicians, when we try to do the right thing in these certain cases that we are absolutely going to get punished for it. There has got to be some either new legislation and new policy that will allow us to constrain the treatment options available to an individual and at the same time guarantee that this not, this does not get dragged through the courts or result in complaints or whatever else it may be. Now these are for the extreme cases. Um, but there has to be some sort of change in legislation. And this brings us back to the study that the, about the ethical failings of, of the CPS policy and the health care consent act, those, those two things need to change and they need to be more supportive of other ethical principles. And I’ll be Frank, need to be more supportive of the healthcare teams that are involved because with changing technology and changing, um, demands from the public, this is only gonna get worse unless those two pieces of policy and legislation change.

Kwadwo: 09:18 Yeah. I mean like you look at it, you’re going to have more, less engagement by a care teams and less people are gonna want to do this for a living. The longevity of our nurses, allied health decreasing, you’re seeing more physician burnout, you’re seeing more and more physician issues in terms of mental health, wellness and so forth. And then, I don’t want to keep harboring this, but like the financial impact, when you look at the decreasing labor force, when you look at providing care, like it really is defensive medicine. You’re providing care because you’re afraid of the consequences of, of the complaint of you ha or you’re afraid of the consequences of, of being sued. Like it’s a lot, you know, and like, and then in our current environment we end up cutting services that are often most beneficial like social work, physio-therapy spiritual care, like all that stuff is being cut.

Kwadwo: 10:17 Meanwhile, we’re just flogging people with care that they don’t even want. It’s insane what you, when we were talking offline a couple of days ago, you were talking about the backlog of, of the system because of all these issues and not being able to provide, for example, care at home, you know, especially near end of life because of the lack of resources I wanted to do to talk about your experience. Like you had, um, your mother-in-law, she passed away at home and maybe you could speak to that experience in and counteract that with what we see most often. Yep. So the,

Gianni: 11:05 I’ll, I’ll speak on my personal experience with, with my mother-in-law and then I’ll speak on the, I guess my professional experience with occasionally delivering end of life care at people’s homes. Um, so for instance, with my, well not only my mother in law, but my, my grandmother in law as well, both, uh, end of life care, both received end of life care at home, um, surrounded by family members in a quiet, peaceful environment, um, with access to physicians, nurses, caregivers. Now the bias in that or the caveat to explain to that as I am a physician obviously and I know what I’m doing when it comes to end of life care and patient care and there are family members of mine who are involved in health care as well, who know how to deal with these things and we’re young and able bodied and able to supplement or give some of the care ourselves as well.

Gianni: 12:04 So not everybody’s going to be able to do that. And that’s completely understandable. However, the experience at home, you can argue, and you and I have, I’ve gone through the literature on this. The vast majority of Canadians want to be at home when it comes to end of life. So the biggest barriers to that are physicians and qualified health care, other qualified healthcare professionals deliver end of life care at home. The equipment that can be set up, the medications can be delivered, all of that can be taken care of. But the access to a physician, the access to that healthcare team that has to provide that end of life care is going to be limited. Right. Especially if you look at other individuals who are not capable of delivering that care of themselves, whether it be from a lack of knowledge or lack of the able bodies to do that.

Gianni: 12:46 Um, those two experiences at home I felt went very well. Um, and the, from a professional aspect, occasionally I’ve been involved with delivering end of life care at people’s homes at their request. Um, and I’ve, I’ve delivered and I feel that I am capable in delivering palliative care in the hospital setting and in these situations, um, patients and or their loved ones asked me to be involved at home because there was no physician available. Um, actually during the summer, most of the time was during summertime months. When are extremely overworked and wonderful community palliative care physicians are on vacation, not available. Um, so I agreed to do end of life care at home in those individuals home. And it went, I think, again, based on the feedback I received from family members and my own sort of interpretation of it went very, very well. Um, compared to a hospital setting where, let’s be honest, the hospital setting is loud, incredibly loud, incredibly disturbing.

Gianni: 13:47 Um, you’ve got overhead announcements almost constantly. The fire alarm goes off, what would you say? Every day, every two days there’s a fire alarm going off almost every day. There’s some sort of of alarm going off and it’s cold. It is unfamiliar and unfortunately, because of how backlog the system in is, you are sharing a room with other individuals who are potentially screaming, agitated, noisy because of no fault of their own, again, because of their medical condition, in my opinion. That’s just my opinion. That is a very, very poor way to spend your last few days of life. Um, and the, because of our hospital system, the, there’s complete lack of private rooms now, ideally when we build our new hospital that that will not be an issue. But the dying in, in a ward room with three other patients beside you, I, especially when they’re, when they’re profoundly agitated is I think just terrible. So that’s my sort of professional and personal use of, of end of life care at home.

Kwadwo: 14:53 Yeah. And, um, I mean obviously as a palliative care doc, I, I’ve seen all sides. I couldn’t agree more like that experience at home surrounded by loved ones in their own environment compared to that potentially dis disruptive environment in hospital. Like it’s still good but it just could be better. Once again, kind of switching gears a little bit, I don’t like to give you too many compliments for obvious reasons, but we both know I look incredibly sexy. Do not know you guys. Gotta listen to this. He is wearing everything tight. Okay. And the reason I’m not drinking or eating anything is because I don’t want you all to hear me vomit on air. Okay. Um, I’m very uncomfortable in this car. Terrible by the way. Terrible. Thank you so much. Um, so getting back to the real deal, you are talented. Maybe that’s the wrong word.

Kwadwo: 15:59 You seem to have an ability, you have an ability to see, to discharge patients probably quicker or more efficiently than some of your colleagues. And I want you to speak to like what are you doing that others aren’t? Because I think this is another thing that could be scaled in terms of like improving the backlog of patients in emerge. Like when I got off a couple of days ago at the hospital I was at, I think there was about 20 inpatients in occupying a merge bets. You know what I’m saying? So like what is the, what’s the ticket? What are you doing that so that people aren’t doing

Gianni: 16:41 [inaudible] three things. One is, um, I think my colleagues or our healthcare teams don’t understand that the vast majority of tests and care can be delivered as an outpatient would be the first point. The second point would be that, again, a lot of people don’t understand that long term care facilities can actually deliver very good and um, can deliver antibiotics and oxygen. So that will prevent an admission or ongoing admission for, um, residents of longterm care facilities. And third, and I’ll get into this, I give out my cell phone number, which sounds crazy and we’ll talk about that in a sec. It is crazy. First getting back to, um, triage of tests. I can’t tell you how many times I’ve had patients that I’ll take over a team and my residents or someone will be like, they’re waiting for a CT scan for their chest before they can be discharged home.

Gianni: 17:39 Yet patient is walking around eating, talking perfectly fine, but are waiting three or four days on hospital for a test when they can get that test in five or six days as an outpatient or a week or two from now and won’t change the ultimate outcome. So I think an example like that is less. Same thing with ultrasonography, a blood work, whatever it may be. It can be managed as an outpatient. And more importantly, especially if set individual has a family physician communication with that family physician and ensuring the appropriate followup tests can be done. But it takes a tremendous amount of work to do it as far easier to keep someone in hospital and just do it yourself than it is to coordinate all the care as an outpatient, which again gets us, gets into a system. Issue number two, the long term care facility, uh, issue or, um, lack of knowledge of what they can provide.

Gianni: 18:30 Oxygen can be provided at longterm care facilities more times than not. The classic example is I get, uh, an elderly individual from a longterm care facility who presents with a pneumonia. They’re on two, three liters of oxygen. You take off the oxygen, they de saturate to 85% or 80% or whatever it may be. And the team overnight has admitted this patient because they require oxygen. While the team overnight doesn’t realize that that long term care facility they came from can actually provide oxygen. They can actually provide intravenous antibiotics through coordination if it’s even required. And the vast majority of time, intravenous antibiotics are actually not required. So you can get away with an oral antibiotic. You can get away again with an, seems a little bit cruel, but an intramuscular antibiotic if an intravenous route is truly needed. And this brings me into the whole point of what we were talking about earlier, is the whole goals of care conversation as well.

Gianni: 19:17 Um, so an individual advanced age with multiple comorbidities who comes from a longterm care facility. The first thing I will do is have a discussion with the substitute decision makers about where are we headed with this care and what are their expectations and what are the treatment goals in this situation and I can’t tell you how many times that the substitute decision maker when I approached them with a treatment plan of palliative care or no further transfer to hospital basically tells me thank you for having that conversation with us. We’ve been thinking that the whole time, but we just haven’t had that opportunity to discuss this and thank you. And then I established that we’re going to send them back to their long term care facility with a different type of treatment plan. Fair enough. So that, that’s point number two. Point number three again, in terms of coordination of followup tests and whatever else, I give my phone number to individuals to call me when their tests are done or to ensure that their tests have been scheduled and whatever else. And you’re kind of looking at me like I’m [inaudible].

Kwadwo: 20:13 I do think you’re crazy. There was zero chance I would give a patient or family member, my Sally, you know what I mean? Just like I get even from friends alone, I get text message or their kids P to see what would this a asking me to figure out what’s going on with this. And I can’t imagine giving my cell phone to all the patients that we see. And the, the amount of over use I guess in terms of this is nothing not supported by any evidence

Gianni: 20:48 except my own anecdote and my own experience in that 10 years or so, 10 or so years that I’ve been doing this, I’ve only had to tell one individual to stop calling me a because the calls were, were inappropriate. Uh, video was me. So, um, I will, I will say that the, even when I give the instruction, I will tell them face to face. I’ll write down the instruction and their discharge plan to call me on Tuesday or Wednesday or whatever day it may be to follow up on how they’re doing. I will say a good 75% do not follow those instructions. So the vast majority people don’t even call me. Um, those 25% who do call me great. I followup on their blood work and I would say about five to 10% of the time we actually catch something or require that they be readmitted to hospital or something needed to be done.

Gianni: 21:38 Um, so that has helped, uh, tremendously, uh, in coordinating their care. Whether it prevents hospital admissions, I’m not entirely certain. I think it does. Um, what I would say is it probably prevents emergency room visits, especially in the individual who doesn’t have a family doctor. Um, cause they can call me with followup tests and whatever else. I mean, where you’re throwing down make sense like you’ve ever thought about doing your office number or you problem with office number is completely inefficient. Right. So, um, they’ll call my office, my admin assistant may not be there or they may give the, they’ll leave a voicemail and the phone number or the name is hard to decipher, um, or they’re going to be calling after hours. Right. Um, something may be going on at seven or eight o’clock at night and yes, I’ll have my cell phone on there.

Gianni: 22:26 Yes. Uh, with me, uh, yes, I will answer it the vast majority of the time, but it cuts down on all that. Um, I guess phone tag, which I find can be very infuriating sometimes. Um, so from an office perspective, again, everybody’s practice is a little bit different. I would prefer they just call me directly, um, because spelling of names, phone numbers that they leave, whatever it may be and that my admin assistance, there’s no way they know of all the patients that I’m dealing with. That’s not how my practice is set up so. Well, Gianni,

Gianni: 22:59 anything else you wanted to add or comment on in terms of whether that’s solutions or problems that you’re, that you’ve been exposed to? [inaudible] I’ll make these comments and sort of a, a analogy, a passenger on an airplane would never tell a pilot how to do his job. Even if they had all the information available. Let’s say you were in the cockpit, the door was open and whatever else and you could look into the cockpit and you have all this information from you and you had direct access to a pilot. You would never tell the pilot, I want you to fly this way cause I want to get there faster or I want you to land over here or whatever it may be. Okay.

Speaker 5: 22:59

Gianni: 23:39 you can argue that medicine and not to put down pilots, but medicine is far more um, challenging and requires far more training than a pilot. Okay. Yet every single day that I am in the intensive care unit or on my internal medicine wards, I have a family member telling me what to do.

Kwadwo: 23:58 Where is this coming from? I mean obviously I’m experiencing the same thing and it is draining because yes, I don’t mind being questioned. I don’t mind asking people asking me for further explanation in terms of why my treatment plan is the way it is. But the amount of time spent to explain why what you’re suggesting is not beneficial

Gianni: 24:25 or even nonsensical is like getting worse with time. Like it’s like half my day. You have to, again, this, this, we’ll start going on rants here, but this is the problem. They are receiving their medical education from television, movies and Google. So if you type into Google, um, or let’s, let’s use the example of CPR. I can’t tell you how many times I’ve been screaming at the television watching Grey’s anatomy or Chicago hope or ER or whatever. Toby, lot of Grey’s anatomy watch tons of it. Yeah. So the or any movie for instance that someone is getting operated on. I saw a guy in one show, I can’t remember which show, who has a ruptured aortic aneurysm, who’s being operated on from a surgeon who’s not even a vascular surgeon. And that individual is not even intubated. They don’t even have a breathing tube in.

Gianni: 25:19 So I’ve got news for you people, if you’re going to have major abdominal or vascular surgery, you would require a breathing tube inserted in your mouth. This is a subtle thing that a physician would pick up on, but it’s completely, completely unrealistic. That patient would be dead. That would never happen. Right? That. So people are getting their information from, like I said, from television, that is completely unrealistic. And Google has now allowed you to access a wealth of information. However, the ability to tease down that wealth of information to what is credible and what is not credible. That’s where your training comes in. I had a patient asked me the other day, I want STEM cells for my loved one to repair his brain. I read it on the internet. I read it on Google. I’m not kidding. This is not made up. I want STEM cells to cure his massive stroke. I Googled it. It exists. I want it. That was literally the conversation.

Kwadwo: 26:17 Yeah. And it’s, and it’s not going anywhere. It’s gonna get worse. And this is the thing that I’m, I don’t know how to deal with this in any other way except for constant education, constant conversations, explaining why. And to be honest with you, even sometimes that doesn’t work. No. They’ll still insist on you ordering that pet or whatever tests is not indicated. And it comes down to like we’re, for lack of a better word, that coward or cowardliness of of of physicians, we will, lot of us will order the tests and it comes down to being defensive because we don’t want to be named in that complaint. We don’t want to, if we point 0.006% chance that they might be right, you know you’re, you’re too fearful.

Gianni: 27:12 No they will. They won’t be. I’ll, I’ll challenge you on that. They’re not going to be right. These are situations where we all know we can do another CT scan, we can do another MRI. It is not going to change a single thing. All it is done is allowed you as that as that treatment physician that the, or excuse me, attending physician to avoid that difficult conversation which would take half an hour to an hour to do, let’s be honest, it take half an hour to an hour of your time. It’s going to be emotionally exhausting in order to explain why I’m not doing an MRI. It is far easier and takes five seconds to do on my computer right now to order an MRI for that patient. It is way easier to do that than to have that conversation to say, no, I am not doing the MRI. I’ve explained it to you time and time again, I’m not explaining it again and I know this sounds cold and it sounds callous, but I have spent hours and hours with substitute decision makers explaining why we will not do something and the information will not sink in and you cannot tell me that I’m not communicating clearly because there are other members of the healthcare team there.

Gianni: 28:12 There are social workers, there are nurses, there are residents, there are med students who have all had this conversation and like I said, I’ve had this conversation

Kwadwo: 28:21 five or six times previously

Gianni: 28:23 and eventually we just have to say no and it might result in a complaint. It might result in whatever it may be, but we just have to live with it. The right thing to do for everyone’s sake, other patients, society, that patient, that substitute decision maker is to say no. In those situations.

Kwadwo: 28:38 I mean, just think about the potential consequences. Even like think about the MRI example in our world, they might need to be sedated for it. They might need to be having a endotracheal tube put in place to have the procedure done. You might have a false positive, you might get a result which is, which looks like it’s something, but it’s essentially not that you then have to chase down. Meanwhile that is, that’s cost. The system will say one to $2,000 literally for nothing because, uh, because of, uh, dr Google because of curiosity, because of anxiety, it has all these downstream effects and it’s, it’s got to stop. And I actually think we’ve talked about this on offline a bit in medical school. Think about how valuable it would be to have, whether it’s conflict, uh, what’s the term? Conflict management, uh, conflict resolution, resolution training to have like expert advice in terms of how to deal with these circumstances.

Kwadwo: 29:43 This would go such a long way and it’s like that little nudge that would have so many downstream implications and an improvement. Like you said, you’re getting this advice from usually your, your colleagues and who knows how good they are at managing this. So yeah, man, like it’s, and it’s, I don’t think it’s that hard. You know what I mean? I, I know we get offered conflict resolution training through a R like Canadian medical association, but really if we’re talking about creating some legit change, you know, investing that that little bit of investment could have such incredible downstream improvement.

Gianni: 30:28 And I mean, if I can make one last point about getting into what are some of the problems out there, and again, this is ranting, but in all the cases that I’ve been involved in that have gone to either that I’ve been named or indirectly referred to in the media, the vast, all the stories that have been written about these cases have been inaccurate. And that is another source of, I think, what the public will read and take into things. And there’s almost this recently I would say, and this again is my opinion a villainization of the healthcare teams. It’s crazy. Doctor wants to pull a plug, doctor wants to do this. Um, my loved one is a fighter they’re gonna pull through with the doctor, said they were going to die, blah, blah blah. And they’re, I think one of the things that we need to get better at as physicians and hospitals is actually commenting on these cases once it’s been brought into the public Ave.

Gianni: 31:20 not again disclosing any personal health information, but we can comment on such things as why we are doing what we are doing. Um, and I can’t tell you how many times we work in an intensive care unit. Patient critically injured in car accident. Well, no, the patient isn’t critically injured. I’m in the intensive care unit right now. I’ve got news for you. I’ve been working in the quadrant or any tertiary or excuse me, quaternary trauma unit or intensive care unit. That patient is not in the intensive care unit. In fact, that patient is, I would want to say perfectly fine, but from a relative perspective of being critically injured, they’re not, they are actually perfectly fine in the trauma unit or not even in the trauma unit. So there’s just a small example of the sensei, slight sensationalization in the media and it’s incorrect. That label is incorrect. They’re not critically injured.

Kwadwo: 32:07 Yeah. I don’t know where this Ville villainization is coming from. And I spoke to this a little bit earlier, like we got into this game to help people get better. We don’t have agendas, we don’t have, we just want to get that patient back to where they were and there is this insane amount of this doctor acts, he’s making too much money. This doctor X wants to pull the plug. Even like some of these cases, the brain death patients,

Gianni: 32:40 I dunno, I, I mean I’ll full disclosure didn’t read the articles that while I’ve read, I’ve read all of them. Should we even get into this? We don’t want have to, this is five minutes, five minutes on the [inaudible]

Kwadwo: 32:49 brain does stuff cat getting back to like the, you know, in terms of like dr Google or like an unrealistic expectations, these brain death cases, I don’t know what to say. I feel like it’s insane what’s going on.

Gianni: 33:08 And again, this is a, it falls into education where someone cannot understand that a brain is dead, but the rest of the body is working for a physician. This is very straightforward. Your heart is basically autonomous. It really, for the lack of better purpose doesn’t really depend on your brain, right? Right. Your sinus node is going to generate an electrical current that is going to make your heartbeat, doesn’t require a living circulating blood in your brain. Um, whereas the public doesn’t understand that public thinks death is K my heart is stopped. I am dead at that point. Uh, they cannot understand the concept that there is zero blood flow to the brain and that entire brain is dead based on imaging. Uh, we can prove it through, you know, of all the tests that we can do through the clinical exam that we can do.

Gianni: 33:57 And yet, um, they cannot, um, deal with that fact first of all, understand that fact. And then if they do understand that fact, they don’t want to deal with the fact, um, that, um, that patient is dead. And in all of these cases there has been the, again going back to the religious concept of it, uh, they will say that our religion dictates that this patient is not dead until their heart stops. That is a very dangerous Avenue to go down. Would the same religion deny or claim that while I don’t believe they have metastatic lung cancer, our religion dictates that. I don’t believe they have metastatic lung cancer. It’s the same diagnosis. The diagnosis is a diagnosis. It’s medically proven. How we can allow a religion to dictate death or a diagnosis is a very, very dangerous concept and something that needs to be dealt with at a legislative level, at a government level where there has to be clear legislation that this is death. This is medically proven, it is there. This will not be debated. This is required.

Kwadwo: 35:00 It’s time like the resources, the stream on the, on the healthcare team, and actually I would argue the stranger putting the family through to like, I don’t know, even if they’re saying this stuff, they’re going to go through some emotional roller coaster thinking that loved one acts is not dead. They’re just, whether it’s a care team,

Gianni: 35:21 I will have to say trust or whatever. Shame on the, on the legal system for even entertaining this. And someone will argue, while this has no public health ramifications, of course it does. The cost associated with this, and this was mentioned, the reasons for decision and then the kitty case, the associated with this is tremendous. That is a public health concern right there because there is no way in our society that we would allow our religion to dictate whether or not you have pulmonary tuberculosis. We would isolate you, quarantine you, treat you despite what your religious views may be because of the public health concern that is there. And again, people will, some people may hear this and say, well, doctor the GTO, he’s, he’s an extremist. Um, and these are, these are insane views. They’re not insane views in the eyes of, of the health care consent act.

Gianni: 36:06 A treatment is a treatment or a diagnosis is a diagnosis. It does not change. It cannot be influenced by religious beliefs, right? So that that needs to be dealt with and needs to be dealt with quickly. Uh, however it will not be. This will take I suspect, years to resolve. Yeah. And it’s, it really is too bad. Listen, I want to thank you for joining the podcast who was, uh, this was the inaugural one and, uh, I couldn’t think of a better person kinda to, to join me and, and to talk about these things and I really appreciate that. And uh, how do people get ahold of you if they want to get a hold of you? My cell phone. I’m just no way.

Speaker 6: 36:46 Yeah. One 900. Um, but yeah, no, seriously, thanks for joining us and uh, and thanks for doing this anytime. My pleasure.

Kwadwo: 36:59 Once again, thanks so much for listening to our conversation with Gianni. Did Judaeo in terms of takeaways from a system level or from an administrative level, lawmakers need to provide clinicians with that safety or the tools to be able to do the right thing, to feel safe, to say no to care. That is not beneficial from a clinician perspective. Address goals of care early. Don’t shy away from these conversations and suggest a treatment plan that you feel is appropriate. And in terms of the general public, what, what can you do? Don’t shy away from those conversations about end of life. You know, we’re all gonna die one day. And to have those conversations and to plan ahead and to know what your loved one will want will go a long way. I promise you that. All right, for those once again, don’t want to leave some comments. You could email us at kwadcast99@gmail.com that’s kwadcast99@gmail.com you can follow us on Twitter @kwadcast and a subscribe today cause it could be more goodness to come freshness all around y’all. All right, talk to you soon.

The Impact of Inappropriate Care with Dr. Gianni D’Egidio. Part 1

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09/19/2019

Episode Notes

Here’s our links to some of the studies we refer to.

Ethical failings of CPSO policy and the health care consent act: case review.

https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-019-0357-y

Outcomes and Cost of Patients With Terminal Cancer Admitted to Acute Care in the Final 2 Weeks of Life: A Retrospective Chart Review

https://journals.sagepub.com/doi/abs/10.1177/1049909119843285?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=ajhb

Resource Optimization Network website: https://www.resourceoptimizationnetwork.com/

Episode transcripts:

Kwadwo: 00:01 Welcome to solving healthcare. I’m Kwadwo Kyeremanteng. I’m an ICU and palliative care physician here in Ottawa and the founder of resource optimization network. We are on a mission to transform healthcare in Canada. I’m going to talk with physicians, nurses, administrators, patients and their families because inefficiencies, overwork and overcrowding affects us all. I believe it’s time for a better healthcare system that’s more cost effective, dignified, and just for everyone involved.

Kwadwo: 00:37 For our very first podcast, I’d like to introduce dr Gianni D’Egidio. He is first off, a very good friend of mine who does critical care and general internal medicine at the Ottawa hospital. In this episode we’ll talk about the impact of providing inappropriate care to patients and also discuss how to manage conflict in these circumstances. Gianni D’Egidio. Thanks for joining us. My pleasure. Um, first of all, I’d like to thank you for coming, considering that I completely dominated you in an arm wrestle not that long ago in front of many people in Clearwater, Florida. So I’m very grateful for you to be appearing on the show today. Thank you. Well, I see this podcast is going to be full of lies today. All right, we’re off with a bang. Okay. So as an intensivist, as a general internist, where do you see the problems in our healthcare system?

Kwadwo: 01:36 I would have to say from my perspective, the biggest problem has to do with our lack or inability to correctly have an end of life care discussion or goals of care discussion. Now these terms are going to be interchangeable. Let’s just say, uh, the term I’ll use is, is proposing an adequate treatment plan to people. Okay. And the reason that is important, uh, is because what it results in is basically what you see right now in our entire healthcare system is a tremendous backlog. Everything is full. Uh, the hospitals are full, longterm care facilities are full. And I think one of the biggest problems we have is an inability to deal with these issues, namely having inappropriate, uh, discussion with substitute decision makers or patients about their overall prognosis and their overall care.

Kwadwo: 02:25 So, okay. So that’s the problem. And where do you see this bottlenecking? Is this within family practices? Are we doing this within a tertiary care centers? Like where do you see this mostly being a problem?

Gianni: 02:38 Tickets from a continuum of starting with family practice? I think it can start there. It is rare that a family physician will have a well-informed, uh, advanced care planning session with their patients. And that then results in potentially, uh, an inappropriate admission to, and then when that admission to hospital comes, now let’s take it into the acute phase where there is also probably an either ill informed or inappropriate conversation during the admission process, either through the emergency physician or the admitting physician. And then that progresses to further potential deescalate or excuse me, worsening of the patient in hospital and then results in a intensive care unit admission. Okay. Without giving a co like a exact patients scenario, walk us through exactly like what this could look like. So for instance, let’s use one of our studies as an example. Okay. We looked at people presenting to the emergency department who subsequently died in the last, they were basically in the last two weeks of their life.

Gianni: 03:45 Uh, these were people with advanced cancers, metastatic cancer who present to the emergency department and subsequently died within two weeks. 71% of those individuals who clearly had end stage disease, 71% of those individuals did not have any discussion regarding end of life or advanced care planning. So there’s a typical example of our system of a failure of our system. And this is not to put blame on oncologists or a family physicians or intensivists. This is to say that the vast majority of people or the vast majority of physicians are either uncomfortable with having that discussion or are improperly educated about how to have that discussion. Interesting. So obviously we do the same line of work. We see this problem all the time. And what do you think, you kind of answered the question, but what do you think is the problem? Like if we know it’s an issue with addressing goals of care, why isn’t it happening?

Gianni: 04:45 I would boil it down to two major issues. One is education amongst not only patients and substitute decision makers, but amongst physicians. And the second problem is fear. Um, or uncomfort or whatever you wanna label it as I would label it as fear and on the aspect or on the side of physicians especially that they are fearful of having these conversations, especially when the conversation is going to be fraught with emotion or conflict. So let’s get back to 2.1 if I may about education when I, this is just anecdote, when I pull the medical students and residents that are in a lecture and I give many talks on end of life care, advanced care planning or proposing a treatment plan, I pull them on. I ask how many of you have had any education whatsoever in medical school about how to deal with conflict or how to have an appropriate end of life care discussion or advanced care planning discussion.

Gianni: 05:43 The vast majority raise their hand and say, we have not had that type of education. If we had had that education, it’s only been for an hour or one lecture and that is it. So here are these medical students now residency. And then I asked the residents the same question and again the vast majority lack that education or that formal teaching on it. They say they pick it up from their attendings. Well I’ve got news for everybody. If your attending is not very good at having that conversation and they are going to be your role model or your source of education for that a topic, I’ve got news for you, your end of life care discussion or advanced care planning discussions are also going to be quite poor. So education is tremendously lacking and then that results I think in point number two which is fear.

Gianni: 06:31 We as physicians I think are, I as mentioned uneducated when it comes to having discussions that results in fear of having the discussions or avoidance of having these discussions. Let’s look at the small percentage of conversations or families or substitute decision makers that are quote unquote difficult and we know they’re going to be difficult. Physicians are fearful of having those conversations completely fearful and that we’ll use the term almost cowardly. Um, when it comes to having those conversations, especially when they substitute decision maker or family member is threatening with a lawsuit or threatening to go to the media or whatever it may be that they’re using. Um, physicians will avoid that conversation and if they’re not avoiding the conversation, the conversation will basically allow the substitute decision maker to guide the treatment at that point. Like I couldn’t agree more. And one of the things that people don’t appreciate is the downstream consequences of these lack of conversations.

Kwadwo: 07:32 So yes, the patient gets admitted to an inpatient or into the intensive care unit, they get all this treatment, which people don’t realize how, how much of a strain it is for the family member, for the patient, for the care team, for, you know, having that moral distress of giving, like providing care to someone that’s not going to benefit. So you’ve been involved in several cases where there’s been conflict with the treating team and the family or substitute decision makers. I’m wondering if you could talk about that process a little bit and, and maybe even describe what the experience has been like for the patient. The family, the care team and yourself. So the, for those that are listening that don’t know what the consent capacity board is, the consent and capacity board or the CCB is an independent quasi judicial tribunal. I’m appointed by the province to basically adjudicate what is in the best interests of a patient, especially when there is a conflict or dispute between what the treatment team feels is in the patient’s best interest compared to what the substitute decision makers feel is in the best interests of their loved one.

Gianni: 08:55 Um, Ivan and involved, uh, in six consent and capacity board cases and also been involved indirectly in multiple other cases. And I’ll talk about, uh, our study a little bit later on. So regarding the CCB, um, the CCB as mentioned as closer judicial, it’s basically a, uh, court like, um, a system or court like, um, process where me as the, uh, treating physician will file an application with a consent capacity board to basically, um, challenge whether or not the substitute decision maker is abiding by the principles of substitute decision making, which is section 21 of the health care consent act. And what that section 21 looks at is as mentioned, the principles of substitute decision making and a substitute decision maker. If I can make one clear point on this podcast today and what I do during my lectures as well, a substitute decision maker is only there to consent to the treatment plan that physicians propose and they have to do so based on number one previously expressed wishes of their loved one and if there’s no previously expressed wishes, then they have to act on best interests.

Gianni: 10:01 A which considers values and beliefs substitute decision makers are not there to demand therapy, they cannot demand therapy and they are only there to consent. Like I said to the treatment plan that we propose and this goes back to our education and our inability to appropriately propose a treatment plan. So in terms of their demand of therapy, we as physicians are not obliged to offer, propose or initiate any therapy that has not been started or that will not benefit the patient in our opinion. Okay. That’s what we forget all the time on our side. Substitute decision makers like me, like I mentioned have to act on previously expressed wishes and if not best interest and the consent capacity board will basically adjudicate, um, solely based on law and solely based on the section 21 of the health care consent act. So I filed a six applications.

Gianni: 10:59 I’ve been involved in five consent and capacity board hearings. Um, they are the consent capacity board. I guess the pearls of the consent and capacity board are that it is heard more end of life cases than any other court’s combined in Canada. It is supposed to be rapid in the sense that once I file an application you’re supposed to hear, there’s supposed to be a pre hearing within one week of filing of that application and it’s supposed to be much faster than the court system. Ideally you’re having a pre hearing within a week and then ideally you’re having the hearings within a month or two. Unfortunately that has been changing over time and I’ll get into that maybe a little bit later on. So getting back to the pro, it’s supposed to be fast. And more importantly when the hearing is done, you get your reasons for decision within 24 hours, which is unheard of compared to any other court Lake system.

Gianni: 11:49 Um, the cons of the consent capacity are that the decision is solely based on law. It does not factor in the ethics, the opportunity costs, the medical standard of care or whatever else physicians would deem important. When it comes to proposing a treatment plan or it comes to the care of a patient, it’s solely based on, like I said again this subsection 21 of the health care consent act. Um, my experience with the CCB has been mixed. I would say, um, lately the from filing of application to decision has been three to four months, which albeit is still faster than the court system. However, it is still, uh, quite arduous in terms of the amount of preparation that requires and the amount of time in spent in hearings. So the latest case that I’ve done, basically it was a seven day process, uh, not to mention the multiple pre hearings beforehand.

Gianni: 12:47 So it can be quite labor intensive. And the reason I mention all this is because the vast majority of physicians will not proceed with a consent capacity board case. Um, I have done six, I know of in Ottawa at least, there’s only been basically two other physicians who have filed a form G application, which deals with end of life care issues at the consent capacity board level. Um, so the vast majority of physicians will avoid it. And another factor is even if the reasons of decision, um, I hate to use a term but are favorable for the physician, let’s say they find that the consent capacity or the, excuse me, that the substitute decision makers have not acted in the best interest of their loved ones that can be appealed. And then the appeal process will take another five to six months. And, uh, only adding to the workload and time for said physician involved.

Gianni: 13:37 In that case, not only is there the workload or the never ending aspect of the consent capacity board cases, but it can also potentially result in litigation. So you can understand why the vast majority of physicians will not want to pursue this Avenue. Then getting into your point about the effect it has on families, a more substitute decision makers. While you can say goodbye to the therapeutic relationship that’s essentially over, once you file that form G application or start mentioning courts and lawyers and whatever else. So the therapeutic relationship completely breaks down there is going to be most likely an associated costs for the substitute decision maker because they will have to retain legal counsel. If they can afford legal counsel then great. Yes they will. They will have to basically a fork out their own money for that process. If they can’t afford it then they can get legal representation through legal aid.

Gianni: 14:29 Um, so you have not only the financial burden for substitute decision makers, you have the therapeutic relationship breaking down and there is no doubt is a stressful for substitute decision makers as well. Right. Going through court is not a fun process for anyone involved. So you got into the technical aspect which fine, but like why are you doing it? Like are you seeing that is driving you to want to go through this process? Like give us a sense of what a patient is going through at the time where you, you, you decide I’m going to go through this process again, this comes at um, you have to remember that consent capacity board cases are open to the public and the reasons for decision are available to everyone. So what I am disclosing, I’m not disclosing any personal health information or anything like that and I have written about this.

Gianni: 15:22 I have also used these experiences in the consent capacity board but that there is no doubt in my mind and no doubt, um, in the eyes of any of the healthcare team involved that the patient is absolutely suffering. And I will use extreme examples from cases, um, where basically there are profound ulcerations of the skin because of immobility and despite how good our nurses and our healthcare team is with moving patients, repositioning them, whatever else. Those are absolutely unavoidable. In these situations, you are dealing with an individual who is completely basically comatose who is now in one case was on months and months of vasopressin. I’ve got news for people. If you put someone on months of vasal pressers, you are basically, their skin has zero flow, it will have very, very poor blood flow. You combine that with pressure and the next step is profound ulceration to the point of sloughing of skin in multiple areas.

Gianni: 16:25 And in one instance basically a complete degloving of a scalp from simple, um, bedside combing of the hair, um, that has happened, that has been documented. Um, and the same process will happen with any indwelling tube, uh, and breakdown. So for instance, rectal tubes, rectal tubes will result in the complete destruction of the rectum if it is unbelievable to see what will happen to these individuals. Um, so first and foremost it comes down to the suffering of a patient. And second, it comes down to just the injustice and uh, ethical dilemma that it presents to physicians. And that results in me basically bottom line, full disclosure being absolutely angry about the entire process. I could feel the anger in the room right now. But yeah, I gotta say I’ve seen you in and around a couple of cases and this is not easy getting back to like the reasons to do this. So I couldn’t agree more that the cases that we see in the ICU have these prolonged uh, treatments where the patients aren’t benefiting and it’s been driven by the families, the amount of sufferings, insane. And one thing that goes under appreciated is the work our nurses are a allied health team members go through to to provide care. Like I’ll never, when I was a fellow,

Kwadwo: 17:50 we were rounding on one of these patients that weren’t going anywhere and the nurse was crying in the corner, like trying to hide that she was getting emotional. I’m like what’s the matter? Like what’s going on? And she’s like, every time I walk into that room I feel like I’m torturing that patient. I’m like 12 hours of torturing this poor guy. And it was actually a huge epiphany for me because like when we get involved, we’re involved for like five to 15 minutes, right? To do our assessments or whatnot and they’re at the bedside for 12 hours doing this. You know, it comes down to for me, you know, in terms of the justice point of view, like people don’t realize also about the financial burden that is being put into this. Like into cases that people aren’t benefiting in. You know, 1% of your gross domestic product goes into treating people in the ICU.

Kwadwo: 18:51 A reasonable percentage of these, those people aren’t benefiting. And we need to think about some of the opportunity costs. A colleague of ours, Michael Harwich, he was talking to us about his kid who has a, I think there’s a breakfast program at his school where they, for underprivileged kids, they provide food for, uh, to ensure that they get nourished and they had to cut the program cause they were short money. And I’m like, this is insane. We are flogging some people that would never want cake, would never want treatment and we can’t feed kids like, you know, get all that is.

Gianni: 19:30 So let’s, let’s, that’s a perfect segue into the next study that, uh, I or we are doing and will be presented at the Canadian critical care forum. Uh, in November there were 12 patients. Uh, let’s, this is a case series of 12 patients that I’ve been directly involved in. And just off the top of my head, picked 12 patients that have been these, let’s say drastic cases or extreme cases, but these 12 patients had a median age of 83 years old. They were meeting median age of all 83.5. So let’s round up to 84. Let’s just do that. Fair enough. They had an average length of stay in hospital of 263 days. Okay. That is absolutely I think incredible. And their average ICU length of state was 109 days. All 12 of these patients died. All 12 of these patients had extreme cognitive impairment, either the vast majority through dementia.

Gianni: 20:25 And three, if I remember off the top of my head, three out of the 12 cases due to a severe interest cerebral, um, incident. Um, so as mentioned, all of these folks, unfortunately, well I should say all of these patients, I shouldn’t use the term folks. All of these patients pass away the average cost of these 12 patients to our system, not including physician costs or any other, these are just indirect and direct costs. Nearly $8 million for these 12 patients. One patient spent 704 days in hospital. Now you cannot tell me that this is a wise use of our resources when we talk about opportunity costs. Now let’s talk about the things this study didn’t capture. Multiple nurses have quit and I know that directly, uh, multiple nurses have sought sick leave because of this. Um, we have had, um, there, there has been a tremendous um, decrease in the sort of wellbeing of our health care team.

Gianni: 21:26 When these cases happen or even after the fact, you could feel it. Yes, yeah. Yes. And it has scarred certain individuals, scarred individuals to the point where they have quit. They have left their position. And these are not junior nurses. These are nurses in mid career who have decided I have seen enough. This is this case in particular has pushed me over the edge. I will not, I will no longer be an intensive care unit nurse. And you know what’s insane? It’s like their whole mantra of their whole job is to like, I want to make people better. I want to help heal people. I want to help them get their function back and they get shat on to get verbally abused. They get inundated with all this. They have the moral distress and they often feel powerless. Yes. You know what I mean? And it’s like we need to do some shit about this.

Gianni: 22:20 So this is, this brings us into another part of the bigger problem, which is as physicians in a healthcare team, besides the roots of the consent capacity board, the odds are stacked against the healthcare team right now. And if I may use the analogy of, of the pendulum, the pendulum has swung far too much towards the principle of autonomy. And I will refer people to the study that we recently published as well about the ethical failings of the end of life care or CPSO end of life care policy. And the health care consent act, which are completely favoring autonomy and they completely disregard other ethical principles such as distributive judge justice, non-maleficence and beneficent, excuse me. Um, and the reason that is our policies and law are completely stacked against um, those ethical principles and completely favor autonomy. For instance, the CPSO end of life care policy, which basically just to summarize, basically says you need consent not to perform CPR.

Gianni: 23:22 This is the only treatment that I am aware of that has ever been or deemed by the college or any, uh, professional body to be uh, universally indicated in everyone. And as I point out, again, when I lecture my med students and residents, there is no treatment that is universally indicated in any one. I use the simple things like water and oxygen. Oxygen is not universally indicated and everyone, in fact, oxygen can be harmful when not indicated. Water is not universally indicated in everyone. For instance, in the hyponatremic patient, there is no way that CPR is universally indicated in every single individual. They are going to be clear cases where CPR will never benefit in an individual and should not be offered. I mean you and I both know how insane that that statement was. Like just to be clear for the listener, like you could have a patient with end stage cancer.

Kwadwo: 24:13 You have a patient that is having end stage renal function. I, he needs dialysis and the treatment, the treating team says like this patient is not a, uh, is not a candidate for further chemo. They’re not a candidate for further dialysis. They’re not tolerating it. This ruling would still say that if they die you would need consent not to do CPR. Correct. Which is insane. Now, one of the things we as physicians, and this gets back to again, the uh, topic that I’ve been focusing in on is our proposal of treatment plans is very poor. And as I mentioned earlier, we do not need to offer any treatment or propose any treatment or begin any treatment that has not already been initiated or that’s not going to be beneficial to an individual. However, that requires that the entire treatment team be on the same page.

Gianni: 25:06 And you have to remember our healthcare system or the way we operate in intensive care unit, I don’t want to call it fragmented, but we have a most responsible physician or attending physician every week. Right. And to get consensus for let’s say 20 individuals, 20 physicians who are going to be looking after this patient, there’s going to be a different level of comfort amongst those attending physicians about what they’re gonna offer and not offer for fear of reprimand because of a lawsuit, a college complaint or whatever else it may be. Even though said physician completely agrees that this treatment should not be offered, but they are fearful of the consequences of saying I am not going to offer dialysis. I am not going to offer peg tube feeding. But they are fearful of the consequences of that. I mean is because of the process. Like just to be the devil, the process.

Kwadwo: 25:52 Once you get a complaint, you get named in a lawsuit. That’s years of your life. Yes. You know what I’m saying? And, um, so there is a lot of unfortunate the deterrent to be able to stand up and do what’s right. But I think at the end of the day, all of us gotta look ourselves in the mirror, yo. And full disclosure, I have had a college of physicians and surgeons complaint, um, which took 15 months to basically resolve. I have had complaints to the chief of staff of the hospital to the CEO of the hospital, to my member of parliament as well. So these are, and I’m willing to deal with those. Uh, but again, I don’t, I can’t blame my colleagues for saying I don’t want any of that. Especially if there is something else going on in their life that has providing them stress in their personal life or their academic career, whatever it may be. Right. They’re going to completely avoid that. And part of me can’t blame them.

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Interesting perspectives!
by sharr091 from Canada
Great show! Interesting hearing about local mental health/ medical issues in the Ottawa area.
Loving it
by hdhdhxndj h from Canada
Loving this show. Kwadwo, keep up the great work
I cannot agree more.
by Lovelyren from Canada
This podcast is everything I have been saying about psychiatric treatment of patients. I am a psychiatric Nurse and the episode with Dr. Eapen was everything that I know and see in my own practice. I completely agree with what she was saying, my experiences/ opinions are very similar. I can’t say how important it is to have these conversations. A few thoughts of my own: We need to address the lack of resources in the community for psychotherapy and psychiatrist follow up, like was already stated. The wait-lists are creating an increase in ED crisis visits because people can’t wait 6-12 months to speak to a professional and people do not have the ability to pay for private care. We need to address the lack of resources for people who experience homelessness, substance use concerns and dementia as their primary concern. People with these concerns generate long stays due to lack of family and community supports. This blocks beds for patients who have severe and debilitating mental illness. Thank you to the host of this podcast who is willing to approach these hard topics, ill be recommending this to colleagues.
Freshness!
by hil mjdn from Canada
So good. Everyone needs to listen to this show. Kwadcast is refreshing and authentic.
No comparisons
by Aby30 from Canada
Best podcast on healthcare. Period. Dr. K’s delivery is a cherry on top. Totally entertaining and informative.

Solving Healthcare Podcast

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Solving Healthcare Podcast

Our Awesome Contributors

Dr. Duane Hickling

Dr. Tamina Eapen

Heather Bousada

Dr. Gianni D'Egidio

Marcel Rochette

Carly Hickey

Adrienne Matheson

Dr. Jeff Turnbull

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