Aortic Stenosis, TAVRs, and Code Status: A Podcast with Gwen Bernacki and Ashok Krishnaswami

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today we are delighted to welcome Gwen Bernacki, who is assistant professor at the University of Washington and the VA Puget Sound and is a noninvasive cardiologist. Welcome to the GeriPal Podcast, Gwen.

Gwen: Thank you.

Eric: Wait, we had a Bernacki on before.

Gwen: Yes, Rachelle.

Eric: Yeah. How are you related to Rachelle?

Gwen: I am her little sister. She has always called me her little sister, and so I don’t think I’ll ever be the younger sister or other sister.

Alex: We’re also delighted to welcome up Ashok Krishnaswami, who is a clinician researcher at Kaiser Permanente and a geriatric cardiologist. Welcome to the GeriPal Podcast, Ashok.

Ashok: Thank you both. It’s wonderful to be here.

Eric: Okay, Gwen, I think you have a song request for Alex. So before we get into the topic of TAVRs and para procedural code status, you got a great paper in jugs that we’re going to review, you got a song request for Alex.

Gwen: We do. The song that we’ve chosen is Cold Heart by Elton John and Dua Lipa. We didn’t actually choose the song because Elton John is 75 and some might say he’s geriatric, touring the world with these new lyrics. We actually chose the song because the lyrics are a blend of four classic traditional Elton John songs and the lyrics together bring new meaning. And you can hear that. You can hear that new things can happen when people collaborate.

Alex: Well, something new is going to happen when I sing this song. Let’s see what happens. Okay, here we go. (Singing)

Eric: I love songs that push Alex.

Alex: That pushed me a little too far. [laughter]

Eric: So you mentioned the importance of collaboration and that’s part of why you picked this song. What does this have to do with TAVRs?

Gwen: Well, for starters, I loved your interpretation of the song, Alex. Absolutely loved it. I think the first two lyrics of the song, and I’m not sure if you started there, was, “It’s a human sign when things go wrong,” and I think that a discussion of TAVR is very well suited to those lyrics, certainly from the perspective of the valvular disease and then of course from the perspective of what can go wrong in the cath lab and thereafter.

Ashok: And you’ve got famous people having TAVRs done.

Gwen: That’s right. That’s right. Mick Jagger had a TAVR done not too long ago, a few years ago when he was 75. And aortic stenosis is really common, one in 10 over the age of 80. So the idea of Cold Heart, we really can’t have cold hearts when it comes to this.

Eric: Oh yeah. Ashok, I got a question for you. This one has been bugging me since I’ve, I’ve heard about TAVRs. Is it TAVR or TAVI? Because I have seen it a lot of different ways. Do we use TAVI more now?

Ashok: Yeah. So first I have to say it, I think they’re both used. I think it depends on who is doing it. I’ve also had that in my mind, who actually taught about TAVI versus TAVR? And so your point on in that, but I’ve been using TAVR I think in a regular discussions, it’s usually TAVR, rarely TAVI.

Eric: Yeah, it sounds better. And what is a TAVR?

Ashok: Sure. I mean it’s basically the actual, if you expand, it’s called transcatheter aortic valve replacement. And it really just means that. Where we used to sit and do stuff by surgery, you’d have to go through surgery, open you up, and then do all this implant stuff surgically, here you’re doing everything with a small hole either in the groin, sometimes transapically and rarely kind of transscroted and through a whole catheter system. And I think that’s the wonderfulness in terms of, I think cardiology, we’ve kind of made things easily accessible in terms of not going through the rigor of a full blown surgery.

Eric: And the percent of people getting TAVRs over surgery has been really skyrocketing over the last decade, is that right?

Ashok: Oh, absolutely. I mean, think by the time in the next decade you’re going to see a lot more individuals having aortic stenosis and then being referred to for percutaneous or transcatheter approaches to this problem, which is severe aortic stenosis where the last door, the aortic valve, not opening well, usually resulting due to basically atherosclerosis calcification. And you need to fix it mechanically and this mechanical fix is either surgery or now pretty much more transcatheter.

Eric: And who generally gets on? And I’m guessing that as the prevalence for aortic disease increases, severe valular disease increases with age because the largest proportion of people are older adults. That said, also my wife’s grandmother, she was I think 98 years old, when she got her own TAVR because she was symptomatic with heart failure and had valular disease.

Gwen: Oh sure. Well, it’s interesting. The way this procedure started about a decade ago, just over a decade ago with the larger clinical trials, was that this procedure was done only on inoperable patients. And so there’s really no medical treatment for this disease. And so the inoperable patients had an opportunity for treatment for the first time and then the procedure was so widely successful that it was expanded to patients who were high risk. And then the procedure was so successful. So now this procedure is actually available to anyone with severe aortic stenosis who has three leaflets to their valve, not a bicuspid leaflet. There’s a subset of people who are born with only two leaflets and that’s really the only group that we’re not routinely offering TAVR.

Alex: And how bothersome is severe aortic stenosis? I mean, what are the major symptoms that people are living with severe aortic stenosis?

Gwen: Originally, the original outcome metrics was just to help people live longer. And so people could have a Singapore event and die following their arrhythmia with having had no prior symptoms. So this is Bronwod’s classic tryout of symptoms. So either an arrhythmia or heart failure or angina. And so the heart failure symptoms, the dyspnea and the angina are more often what can drive patients to seek treatment. And as this procedure has gotten a lot more popular, we’re seeing more requests for it.

Ashok: And I think also syncope, I think also in that mix., it used to be let running for the bus issue. Did you have a problem running for a bus and you passed out? That used to be the general, one of the big symptoms in terms of when you’re asking for more perfusion in the brain, you’re not getting it allowed because the doors don’t work and then you’re made to do more. So syncope is also something that’s in terms of a symptom, high on the list.

Alex: And so we’re talking about disease aortic stenosis that has a serious impact on quality of life for older adults. Is that a fair statement? We’re talking about chest pain and we’re talking about shortness of breath, we’re talking about limited function and potentially even fainting.

Ashok: Oh, absolutely. I mean think those classic symptoms are something that can basically end up really decreasing quality of life. And I had a patient many years ago who actually came to me saying that she was overweight and not doing much, “I just feel like I’m not doing much.” And I think some people in the spectrum also kind of adapt to their disease. So they know when they kind of get pushed to the roof, they’re going to have some event, syncope or heart failure or something. So they stay below the roof and don’t ever do much and then their overall physical activity kind of decreases.

Gwen: That’s a great way to put it. That’s a great way to put it, Ashok. Function is limited by the disease and also symptoms. And sometimes those are co-mingled in that we see people just doing less so that they don’t have symptoms from the disease.

Eric: So I’m hearing TAVR can help both with symptoms, mortality, some big trials like the partner trial. And when we’re thinking about the use of TAVR, because I’d like to get complications, I got one more questions before we do that. Is it just for a symptomatic folks? What about asymptomatic folks with severe AS?

Gwen: Funny you mention that Eric. I hope my clinic is comprised primarily of older adults with either multiple chronic conditions or very advanced age. And I do have patients in clinic. There is now a more recent study that shows that very severe aortic stenosis, there is good evidence to suggest that we should do TAVRS for those patients, even in the absence of symptoms. Traditionally in the past, we always waited for symptoms. But the interventionalists have gotten very good at this procedure and it may be a little bit riskier to wait until someone is sicker than to proceed in the setting where patients have very severe stenosis.

Ashok: And I think specifically in older adults this issue, a symptom sometimes is hard to kind of ascertain. Because in the past, I remember when I joined 15, 20 years ago, we put some of these people on a treadmill to see how they do, what did their blood pressure do, even though that is a no-no in terms of the general audience of not putting anybody on a treadmill. In some people we want to see their hemodynamic response. Now we’ve kind of evolved to try to get kind of corollary information. We often will look at kind of valve calcium. If the valve calcium score is high, it’s kind of an indirect saying, “Well, even though he or she may not be symptomatic, the calcification of the valve, the look of the valve on echo, the calcification on CT are all reasons to say, “Let’s do it a little earlier than later.”” And I think that’s a general trend because to take an 80 year old or 85 year old past hip surgery, all this minimal frailty, I mean in terms of minimal significant gate issues, they’re hard to get actually symptoms sometimes.

Eric: Yeah. So then the question becomes, what are the risks of doing this procedure? What are the complications?

Ashok: So I can tell you, I think one of the big things of TAVR and I’ve thought this a lot, it’s really a remarkable procedure. I mean, I think although now we’ve kind of gone into the frame of, I would say, like the Shania Twain reference, so basically it doesn’t impress me much that we basically do this, but it’s a remarkable kind of a procedure that’s evolved from first man implants, what Gwen talked about in terms of the partner trials. And then now there’s been a big issue of more TAVR valves on the market, there are more programs. We used to start this, but basically hybrid ORs. It’d have to do a TE, foley, intubation, everything. Now basically, it’s not an outpatient procedure yet, but it’s really kind of strung. So I think the initial issues of mortality and all are still there, but now it’s trying to focus on reducing complications, reducing length of stay. And I think those are the big things that are really the focus, I think, in terms of the TAVR world.

Gwen: When this procedure started, it was not uncommon for patients to leave with the pacemaker as well. But that’s become much less frequent, although I wouldn’t say infrequent at this point.

Ashok: And I think SAVR, in terms of length of stay, has always been around eight to 14 days, somewhere between one and two weeks. TAVR length of stay in the hospitalization was as much as seven days. And it’s now starting to get into that three to four range or so, and then occasionally less than three days. But I think some of the complications is what you are alluding to Eric, I mean, you can think about it as when you do the procedure you have to find a place femoral or carotid or ethicon, and so vascular complications and then peacemakers, what we said and some other things.

Gwen: We used to worry a bit about dialysis and patients who have chronic kidney disease, but the occurrence of that is very exceedingly uncommon now.

Eric: I remember from the early partner studies, stroke was a complication with TAVRs. Is that still a common complication or is that getting better as well?

Ashok: Well, SAVRs are basically between zero and 5% for SAVR, meaning standard aortic valve replacement are about 5%. In TAVRs, they can be as much as minimal to much as 6%. We’re not interventional cardiologists. There has been a progress even in that in terms of reducing stroke rates by distal embolization protection and all those things. And depending on the site and in terms of whether you do it femoral, ethicon or carotid wise, which is really kind of a remarkable thing, doing the whole procedure from the carotid artery. So yes, they have, I think, reduced it quite significantly. But there’s still work to be done.

Gwen: I think that’s a great question because as this procedure has become more popular, we actually at the VA have done TAVR procedures in patients who are on dialysis. And so I would say that the risk of a stroke… We’re doing procedures on patients that previously might not have been referred to us. And so I think that needs to be taken into account as well.

Eric: And that kind of leads into this idea of, what should we be doing both not just after, but even before these TAVRs, and how should we be thinking about having these discussions. And for a lot of older adults, survival is important, but it’s not often the only thing that’s important, quality of life, feeling better. And if they do have a major complication, not something that they want, and thinking about what would they be willing to endure and go through? I want to jump into Gwen’s paper and in jugs, because I think it touches some of these issues. And then maybe we can talk about afterwards, what does or what should the para procedural kind of care look like? And in particular, thinking about collaborations too. Gwen, so you did a paper on the para procedural code status and TAVR, what made you want to do this paper?

Gwen: I have to laugh because Jim Kirkpatrick, who’s the last author on this paper, approached me that there was interest by the college, our professional society in this question, what happens when patients come with severe aortic stenosis who have a ‘do not resuscitate’ code status? And so the question was not mine, but I was very fortunate to work with a wonderful group of people, interventionalists, anesthesiologists, qualitative methods, researchers, methodologists, structural heart team, nurse practitioners, and just a very, very broad group of people to examine this question. So I’m not sure if that answers your question about how it came about. I think there was just a lot of enthusiasm and interest in this question. [inaudible 00:21:01].

Eric: What do you think brought on that enthusiasm? Did you get a pulse of what people were thinking?

Gwen: I think at that point we expected this to be fairly straightforward and we thought that potentially we might be excluding a certain segment of the population or not. And so that’s when it got a little bit more interesting. We originally thought that this could be a survey where we could just reach out to programs and ask, “Hey, what are you doing for patients that come to your program like this?” Turned out that wasn’t the case, we really needed to have a talk about it.

Eric: Yeah. And you mentioned your clinic, right? I’m guessing a lot of frailty, older adults, people with varying preferences around life sustain treatments and code status. Is that right?

Gwen: Absolutely. Absolutely. And potentially even somewhat more fluid than maybe we’ve traditionally considered them to be. So-

Eric: Yeah. Ashok, I got a question for you. Before reading Gwen’s paper, if you were to think about the results of this paper looking at policies and management around para procedural DNRs, what would you think it would’ve shown?

Ashok: Wow. So I actually felt that initially before undertaking this project, that if you were a DNR, that you probably would not be offered TAVR. That was my general gist. I think this paper just kind of opened it up a little bit showing that there’s significant heterogeneity in this complex topic. I think that… Yeah. I mean, I would not have expected it.

Eric: I want to reiterate. Yeah, I want to remind [inaudible 00:23:24]. I’m referring to Gwen’s paper, but this is Ashok’s paper too, as you were an author too.

Gwen: Absolutely. Absolutely.

Eric: I want to clarify. Okay, what did you do in this paper, Gwen?

Gwen: So we first thought to contact TAVR coordinators in Washington and California states. So it was as simple as making a phone call and asking program coordinators what the informal practices and what the formal program policies and organizational policies were surrounding TAVR, in patients who have DNR code status preference. So that was the first step. And would you like to know what we found?

Eric: I’d love to know.

Gwen: I’ll cut to the chase.

Eric: Yeah. We’re much more about results then methods on this podcast.

Gwen: Okay. Well it turns out only one program among 50, some programs we contacted excluded patients from consideration and-

Alex: Excluded patients who were DNR from consideration

Gwen: Correct, correct. So, it was, “Call back if you change your mind.” And then we had approximately half dozen programs that maintain DNR code status in the cath lab.

Eric: So they kept the DNR status in the lab.

Gwen: Correct.

Eric: So that if they’re arrested, they wouldn’t do CPR on them.

Gwen: That’s correct. So some of these programs were not speaking from the hypothetical perspective, but were speaking from what their intended practice was as well as their historical practice. Wow. And Then… Yeah.

Eric: That’s the part that surprised me, that there are some places that actually don’t revert to full code for these procedures, which is somewhat actually good to hear.

Gwen: Right. And what was great about having a semi-structured interview was the opportunity to explore these topics some more. And so for some of these interviews, it was really an opportunity to be that Monday morning quarterback person and say, “Well, how has your practice changed as a result of maintaining code status in the cath lab? Has it changed?” And so obviously we had to be sensitive about patient specific information, but the coordinators were able to talk globally about their experience over the years and how their programs have evolved and how they’ve gotten to the practices that they have over time.

Eric: Was there a general theme about how they evolved?

Gwen: No.

Eric: A lot of heterogenetic.

Gwen: There was a lot of variability. And I would say talking with one program coordinator, there’s that saying, “If you’ve been to one academic medical center, you’ve been to one academic medical center,” and I think that same dictum applies here. If you’ve talked to one TAVR coordinator about one program, you’ve talked to one TAVR coordinator about one program.

Eric: There’s groups that just say, “We change everybody…” They need to be full code for this procedure. One of the qualitative comments I loved was, “We do not perform TAVRs on patients who are no code status. It’s not a walk in the park, it’s an expense. Why would you have a TAVR if you didn’t want to survive?” Was that-

Ashok: I actually found that incredibly remarkable in terms of… I mean I think I have to kind of back up here. I mean, I think the amount of work that Gwen actually did in terms of interviewing all of these programs and getting this in depth understanding is really just, I think, it’s incredible. And so getting these kind of granular data was actually so remarkable. But you’re right, the whole problem is when I talk to the interventionalists, it’s generally they feel that and how do you balance what they’re feeling with a little bit more global perspective?

Eric: And in some ways it sounded like that was kind of the norm, is that for the procedure, there was a temper rescinding a dnr. What, 78%? There was that belief. Not necessarily policy, right?

Gwen: Right. Practice, informal practice. So the vast majority of programs did not provide policies. And those programs that did provide organization level policies, their practices more often did not match with those policies.

Eric: And it also sounded like, so you had the vast majority, nearly 80%, you had the temporary rescind if you’re going to get the TAVR. And the question then is how long, what is temporary rescinding? And it sounded like the timeframes about 40% was less than 48 hours post TAVR, about 44%, 48 to discharge, and then about 20% was greater than 30 days post discharge. How do people come up with these numbers?

Gwen: Well, that’s a great question, Eric. And I didn’t ask specifically how did you get to where you are unless that flowed organically in these semistructured interviews. It wasn’t one of set interview questions. And we actually had three cardiologists code the interviews and what the practices were. We excluded a select number of programs. I think we had four programs where we really could not determine a consistent code status practice having reviewed the interview transcripts. And so I think for as much as there was variability in practice, I suspect that there was variability as to how programs came toward having that particular practice.

Eric: But there’s also something potentially special about 30 days?

Gwen: Right, right. And that was very explicit on the part of program coordinators.

Eric: What’s special about 30 days?

Gwen: And that was unexpected. So this actually vents nicely into the second part of the study. So, 30 days was mentioned because all TAVR programs are required to report their outcomes to a national TAVR registry. And programs are evaluated, their performance and the interventionalists who perform these procedures, there are metrics, mortality and outcomes. And so those programs that mentioned that they maintain code status for 30 days, some of them were very explicit, their reasoning, which was that their metrics, their outcomes could potentially be affected if patients reverted their code status prior to that 30 day mark.

Eric: Did that surprise you, Ashok?

Ashok: Well, even though I’m not an interventionalist, I think I’ve been attuned to a lot of the proceduralists. And I think that is a big issue in terms of policy. How do you judge a proceduralist? And they want to help in terms of people who have got significant morbidity, significant other things. But when their hands are tied in terms of, I think it becomes, especially in the day of public reporting, New York and California, I think those are things that I have learned from my interventional colleagues, are important for them. But I think papers like this are the first step to really kind of address, are those policies really helping people? And how did they help? I’m blanking on the exact… The hospital readmission program had a lot of issues in terms of CMS, in terms of not actually delivering on what it was actually meant to do. So I think public policies is something that can handcuff interventionalists when they’re really trying to do the best that they can.

Gwen: And I think that speaks a bit to organizational incentives. And so like you’re saying Ashok, that when we incentivize practices like get with the guidelines and that type of thing, it’s really with good intentions. And so I think there’s always consequences when we incentivize certain behaviors. It was very helpful, I think, on the part of the coordinators to be so forthcoming about what the limitations are of some of the current practices that we have and that there may be some disincentives that we’re not recognizing.

Alex: Yeah, seems like there’s a great opportunity here for a follow up study where you interview older adults who are candidates for TAVR, who are DNR at the time that they’re candidates, and see, well, what is it like to be told by those programs that don’t take patients who are DNR? To be told you can’t have this? What is it like when they tell you that you have to be full code for a period of time? And what did you think when they told you it was 30 days or some longer time period? And get their understanding of what does it mean to be full code versus DNR in an intervention room where they have incredible amount of control over what happens to you? So the likelihood that you’ll actually get to the point where you have complete cardiopulmonary arrest and a code needs to be called, it’s very slim, I would think.

Gwen: So that’s a great question. And I think before we get to what would patients and family members say, which I think is critically important, we actually looked at what happens to these patients. So we had the opportunity to look to the registry and see how these patients do. What happens? You made the comment that these interventionalists have so much control over what happens to these patients in the lab because of their code status, right? That if they code, they’re going to live or die on the basis of their code status. Well, in the end we stratified by code status practice. So the second part of the study, just very briefly, we examined patient characteristics, risk status and outcomes, and we stratified those by code status practice. And it was not clear what clinical differences between programs contribute to the observed variability and practice. It’s a long way of saying that there was really only a handful of patients in each category that underwent cardiac arrest or who had a hospice discharge or had an unexpected outcome like that.

Ashok: Yeah.

Alex: Very few. And there was no linkage to the policies of the program.

Gwen: Well, we stratified practice by the informal practice. And when we looked at the outcomes, and these were admittedly aggregate patient data unadjusted, these were very rare events. So I think this notion of, getting back to your question, what would patients say about this? And I don’t know. In our discussion section, we went back to the surgical literature because this has come up for patients who’ve had operations and there’s this notion of surgical buy-in. And there’s been some work that has shown that some patients actually expect to have a discussion about code status and they expect their code status to be reversed. And so I don’t know if that’s the case for this particular population with all of the comorbid conditions they have, frailty and what their outlook is on life, but I think that’s a great, great, great question in consideration. So Ashok, what do you have?

Ashok: No, no. I mean, think this study is really just the first step in terms of getting to a lot of more unanswered questions. So I think that’s how I look at it. It’s at least open the door for more work in this area.

Eric: Yeah. Also looking at the data, I mean it looks like in hospital arrests are rare, but still you’re looking at one in 50 to one in 80 patients who get a TAVR, have it in hospital arrest, looking at this data. So it was like one to 2%. About 1.5 to 2%. Is that right?

Gwen: And that’s just it. I mean this is a high risk population even among the lower risk patients, right? These patients who have aortic stenosis… Aortic stenosis and coronary artery disease are most frequently coexisting conditions. So prior literature has shown that patients who designate themselves as DNR do have higher mortality. So we thought we might see some sort of signal in that we might need to do a more extensive study with a lot of statistical adjustment. So-

Eric: Well, it’s interesting because there’s a lot of confounding going on in that statement, which is somewhat resolved if you don’t look at the patients, you look at the program policies and you’re not seeing that and you wonder how much of that is, just people who are DNR are just significantly sicker than people who are full code.

Gwen: Right. And I think that’s in part why the practices may be different than the policies because the patients are different. One program was located across from an assisted living facility, right? So that population’s probably very different than the one that’s located in an urban environment.

Eric: Well, I guess then the question is, should there be more standardization? Should there be specific guidance on how should we handle advanced care palliating, serious [inaudible 00:40:07], code status in the para procedural place? Because I also think the code in the lab is different than a code three days later in the ICU when things are crumping and the outcomes are different. What are your thoughts on more guidance in guidelines around this?

Ashok: If I may jump in here, I think part of the issue is just having a seat at the table, making sure that geriatricians and palliative care physicians are actually at the table. Because questions like these, I think, inherently will come about only by those who are experienced in doing this. So that’s one. Two, I think is generally kind of making sure that when… So standardization is first getting some standardization of what baseline characteristics are there. The comprehensive geriatric exam, I mean, I think there are a lot of programs that do portions of it, understanding what all it is, standardizing it and then using it for two things. One is to say, is this person actually fit enough for the procedure? Meaning is there a matching? And then the question is of course outcomes. This is the big thing.

And I think this is where the geriatrics and the palliative care perspective really needs to be brought out. The geriatricians and the palliation of cardiologists. What outcome? We’re fixated on basically mase outcomes in terms of reduction of any major adverse cardiovascular event. We should also be fixated on reducing SAEs in terms of serious adverse events. And then of course the biggest challenge is trying to get an understanding of patient-centered outcomes. Meaning I just want to be able to walk with my wife three days a week holding her hand. That’s an outcome that I want. I mean, right now I can do two days. So this is the kind of, I think, at least the pie in the sky dream that I think we can try to quantify it a little better and then over the next decade. And I think using different statistics can actually help to make these processes easier.

Gwen: That’s why coming on this podcast was such a privilege for both of us. We were absolutely delighted to have the opportunity to speak with geriatricians and palliative care clinicians, because this is where the weeds is really where it’s at. We need to know what outcome are we striving for and when is enough enough and when have we achieved what we set out to do? And those are all very difficult questions that existed long before this study and will exist long after this study. And to the extent that we can work with our colleagues who are much more expert in communication, I think we’re going to get closer to achieving the right outcome for the right patient at the right time.

Ashok: Yep.

Eric: My last question for both of you is that, I’m going to drill it down to I’m seeing a patient in my clinic and they’re going to get assessed for a TAVR. It’s looking like they’re going to get it. Should I talk about code status at all with them? How should I handle that issue with my patient that’s in front of me as a non-interventional cardiologist? I’m not going to be involved at all. I know a little bit maybe about their program, but not a lot.

Gwen: I love that question. So I know there’s been a lot in the literature about advanced care planning and it’s become somewhat controversial and I think that controversy is potentially going to be very fruitful in helping us make in the moment decisions. And so I think, for me at least, when I see patients in the clinic, I try to get a sense of under what circumstances would this person presumably like to be a full code, recognizing that this person has probably never been in the room or participated in a code. And so that’s where dialing back and saying ultimately what matters most to you and how does that translate into clinical practice. And translating into clinical practice isn’t just a matter of going to the lab. So for example, in these interviews, some programs actually would do partial codes and they would talk to patients about that. “Should we give you a shock or should we do medications?”

And that’s a very, very challenging discussion and I think we need a lot more research as to how best to approach that. But in short, in talking with your patients, I think for me at least when I work with geriatricians, which is fairly often now and I reach out to them a fair amount, is really trying to get a sense of what matters most to patients and what a good day looks like and what your goals are. And it shouldn’t just be, “I want to breathe better if I have this TAVR,” but, “What can I do because I breathe better?” It can just be, “Well, I want to breathe better and be out of distress,” which I think is an outcome and of itself, and that may be the outcome, but if there’s more, if it’s not that, “I’m just going to breathe better, but I have to breathe better so that I can go do this,” we want to know that there’s also that go do this. Because if we can’t get that person to ever leave the hospital and go do that, then it would be good to know that upfront.

Ashok: Yeah. And I think I’ll make it two seconds. I think part of this is really just saying, “Yes, I do discuss in terms of code status.” I also try to say it, I think expanding on what Gwen was saying in terms of what matters most, trying to make it smart. Is it specific, measurable, achievable, relevant and time limited, to say for physical functioning, cognitive functioning, and then you start building the code status discussion on what you want. That’s how I’ve done it.

Eric: And I love the idea of really thinking about, what does home look like for this person? Well, how are they functioning? How long has this been going on for? Because even will the TAVR even fix the problem as far as function if there’s something else that is causing it? And for a lot of our older adults there is. They don’t know that I’m not the man they think I am at home. Alex, that was your intro cue [laughter].

Alex: That was my cue. (Singing)

That high part was really high.

Gwen: I Love that you reached for it.

Eric: Gwen, Ashok, thank you for trying to us on this podcast. It was fabulous.

Ashok: Thank you very much for having us.

Gwen: It was a pleasure.

Eric: And as always, thank you Archstone Foundation for your continuing support and to all of our listeners.