Eric: Welcome to the GeriPal podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, who do we have online with us today?
Alex: We’re fortunate to be joined today by Cynthia Pan. Dr. Cynthia Pan is Division Chief for Geriatrics and Palliative Care at NewYork-Presbyterian Queens and DIO. Welcome to the GeriPal podcast, Cynthia.
Cynthia: Hi, how are you?
Alex: Doing okay.
Eric: We’re hanging in there.
Alex: It’s Eric’s birthday today.
Eric: It is my birthday today.
Cynthia: Happy Birthday to you.
Alex: Maybe we should sing Happy Birthday instead?
Eric: How about we don’t?
Alex: You got to take what celebrations we can in these trying times.
Eric: I really appreciate Cynthia first you being on this call with us. We’re going to be talking about your experiences right now in New York City with COVID. What you’re seeing right now and kind of lessons learned for our audience that’s listening. But before we go into that, we always like to lighten the mood just a little bit. Do you have a song request for Alex?
Cynthia: Yes. My theme song is, You Can Do Magic, by America.
Alex: And why is this, what do you mean when you say this is your theme song?
Cynthia: Ever since the show Ally McBeal, I’ve wanted to have a theme song, so I think this was a good one because I always want to be hopeful. So having a little magic in your day is not bad.
Alex: That’s great. All right. Here’s just the chorus. We’ll do a little bit more at the end.
Eric: So we’ll get a little bit more of that later in the end. Let’s just jump straight into it, Cynthia. What’s happening right now in New York?
Cynthia: New York has become a ghost town. If you look at pictures of Times Square and other crowded places, which is very eerie, it’s dark, but it’s also good because it means that people are doing social distancing in this era of the COVID pandemic.
Eric: And are you seeing a surge in the hospital right now?
Cynthia: It is crazy in the hospital right now. We are part of the NYP, NewYork-Presbyterian system. We are a community academic hospital in Queens. We have 535 beds. It used to be about 300 medicine beds and at this point it’s almost all medicine because all elective surgeries are placed on hold and all non-medical staff have been redeployed to see medical patients.
Cynthia: And as of today, 60% of our medical admissions are COVID-related. Either confirmed cases or persons under investigation called PUIs. And whereas before people are congregating and talking, now even I was just in the stairways today and somebody was talking to me on the stairs and then somebody wanted to come down and they didn’t want to pass that person until that person got off the stairwell.
Cynthia: And everybody’s walking around in safety glasses and masks. It is very different, not business as usual at all.
Eric: What does the ICU or the ED look like?
Cynthia: The ED yesterday I was told there were 190 admitted patients. I don’t even know how that’s possible waiting for beds, which we don’t have. And one of the Nurse’s Assistant’s that was assigned to the ED was telling me that she was trying to help a patient and she literally had to walk past other patients to get to the patient she was trying to help. It is a zoo.
Cynthia: The ICUs, the Medical ICU is filled with COVID patients. The Surgical ICU, the Coronary Care Unit, and the Cardiac Cath Lab have all been converted to COVID ICUs.
Eric: The Cardiac Cath Lab too?
Cynthia: Because there is no elective procedures of any kind at this point.
Alex: Did you say the ORs had been converted to ICUs as well?
Cynthia: ORs, no, but the OR personnel like the peri-op people, the anesthesiologist, everybody have been redeployed to medical units. At first, not COVID units. We still have about 40% not COVID, but eventually I think that we’re going to be pretty much all COVID.
Cynthia: Last Friday when I left the hospital, we were about a third COVID. Over the weekend it was 49% yesterday was 57% and today’s 60% and Governor Cuomo, who is New York’s Governor, is saying that basically COVID is doubling every three days.
Eric: What does that look like for you right now seeing patients? Are you on the palliative care service right now?
Eric: What does your day look like and yeah, the rest of your team, how are you guys hanging?
Cynthia: Yeah, so we have already, one of our physicians is out sick because he tested positive for COVID. Another physician got pulled to cover the hospitalist service, so she’s attending right now with two interns on a non-COVID unit. So I’m the only attending left on the palliative care service. We have three NPS. One of them is out sick being tested for COVID. With the COVID units, what they’re trying to do is not allow extra extraneous people to go into the COVID units. So they’re just limiting all the frontline people to be stationed there and not have to change or waste PPE going from room to room. So even if we get called for a COVID patient for palliative care, we’re trying to do that by FaceTime or phone or something like that.
Eric: How does that actually operationalize? How are you getting that video feed from inside the COVID patients’ rooms?
Cynthia: So we review the charts, get whatever we can from the chart, and then we get one of the frontline PAs or nurses or a doctor or somebody to go into the room and FaceTime us so we can see. A lot of times, with palliative care patients, they don’t have mental capacity to make their own decisions.
Eric: Mm-hmm (affirmative).
Cynthia: So we would be speaking with family members anyway and right now it’s very hard because there’s zero visitor policy at this point. Zero tolerance, zero visitors. And for palliative care and geriatrics, we usually want family members to come in, right?
Cynthia: We want family members to come in and help orient the patients and prevent delirium and all of that. Right now there is nothing and family members are freaking out because they can’t come in. And if the patients die, they don’t have a chance to say good-bye. They’re not there. And if the patient goes to the morgue, there’s no funeral arrangements, it’s direct burial or cremation. So there’s zero chance for closure. It’s very bad.
Alex: Oh, it sounds so hard, Cynthia. My heart goes out to you. Wow. How are you coping?
Cynthia: You know, I like to be positive. So at first, it’s only been three weeks, but so much has changed in the three weeks. At first, I was trying to be positive and encourage people and use jokes and a sense of humor, sending out inspirational messages. And then I was talking to one of my intensive care physicians and afterwards he emailed me and he said, I felt the best that I felt in the last two weeks. And I said, What happened? He goes, after I spoke with you, I just cried and I let it out and I felt better. So yesterday, when I was speaking with Eric, I was just downloading all that’s going on to him and then I started crying. And so I think laughing and crying pretty much.
Alex: Yeah. This is so hard. How, how is your team doing and how are you supporting each other?
Cynthia: Yeah, so there’s no mass congregations. So we don’t do our team meetings face to face anymore. We have maybe three to four people in a room and we WebEx, phone call, our team meetings. So it’s much shorter and because there’s no FaceTime, I think we all feel like it’s not the usual support that we can give to each other. But we try. So we had a nurse, very respected senior nurse on our team that retired recently. So today I arranged for her to call in and join the team meeting and surprise all our team members. So just having little things like that and trying to support each other through the Mobile Heartbeat, which is how we communicate with each other with HIPAA compliant texts.
Alex: Mm-hmm (affirmative). It just strikes me that this pandemic, COVID, has caused such disruption to our norm. Some of the aspects of palliative care that we take such pride in and that are such key components of our skillset. Being with patients, being present with them, physically touching them. Supporting them, supporting family members, working with family members and patients to see their loved ones, see what kind of condition they’re in. Such an important part of getting on the same page about what’s happening clinically. These are just such immense challenges. I wonder if you have any pointers or strategies for others who may be facing the same sort of situation down the road in a week, two weeks, three weeks from now about how to manage under such difficult circumstances?
Cynthia: Yeah, I think that one of the things that really struck me is that four weeks ago we were just hearing about how it’s in China and then how it’s in Italy and then all of a sudden it’s here and we live in such a global community, which is good and bad, right? The bad thing is that things can get transmitted very easily and the good thing is that we can learn from global lessons. So maybe it’s not in another state right now. New York is the epicenter right now, but I think eventually it’s going to go to many other states. One of my friends just told me that a bunch of people are going down to Florida for Passover and congregating. Well anybody in New York are going to any other state is not safe at this point. So there are a lot of lessons that I feel like I learned like making sure you have enough PPE, personal protective equipment, which we ran out of very quickly.
Cynthia: And how do you conserve that? And also having daily communication updates, which our health system does and our medical group does and also our group does. Having like good leadership to send out. Like what are the numbers? I think that helps people. What’s the evolution? And then just in terms of taking care of patients, it’s just very difficult. We try to facilitate FaceTime or Skype family meetings whenever we can. And then when I ask other providers in the ICU on regular units, they’re not doing that. They’re just too busy to do that. They don’t do that to begin with and they’re certainly not going to do that now.
Eric: So there seems to be, this very big role for palliative care services to be also an intermediary between the primary team and the family members, is that right?
Cynthia: Yes, yes. I think that’s a very big role because that’s our strength and we can really help our patient experience that for patient advocates service to try to coordinate things like that.
Eric: Yeah. One group that is being hit the hardest are older adults, especially those with comorbidities.
Eric: What are you seeing in the frontline with that population right now?
Cynthia: In speaking with my ICU colleagues and when I just review cases, patients that are on a COVID unit, it really doesn’t matter your age. Young people are getting hit and we have residents who are distraught because they are taking care of 30, 40 year olds who are decompensating and going into respiratory failure right in front of them. And when I talk to my ICU colleagues, they’ve intubated, 20, 30 people and I said, How many people are coming off? And they tell me one or two have come off.
Cynthia: So as a palliative care person, I’m being asked, Well, when are we going to start triaging and allocating resources because we just don’t have enough ICU beds or ventilators? All this is coming and what do we do about it? And as far as geriatrics, I think definitely older people don’t have the ability to bounce back as much. So those are the patients who are going to have the highest mortality.
Eric: Yeah. Are you running also, you’re both geriatrics and palliative care. Are you running a geriatric service too at this time or is it a manpower issue?
Cynthia: Yeah, we’re pretty much combined. So our team can respond to palliative care consults as well as geriatric consults. We get vast majority palliative care consults and very few geriatrics. I guess that’s different each hospital, so that’s just how it is here.
Eric: Yeah. And do you have a formal triage policy in place? Are you working on that? Where are you right now with that?
Cynthia: Yeah, so I think that New York state has been very progressive and prepared. New York state actually has from 2015, a ventilator allocation guideline that was put in place to respond to the flu pandemic, which of course you can apply to the COVID pandemic and it has a very clear set of action plans in terms of criteria of which patients should get a trial and which patients should be excluded and rapid reassessments at day two and day five to see if they’re benefiting. And then they talk about having a hospital triage committee that’s composed of intensivists, ethics committee members, pastoral care, patient services, so that these decisions can be made by the Triage Committee and not by the individual physician because that’s too much. And everybody feels like there’s a death panel, which, what can I say?
Eric: It’s a tragic choice. It’s every other day when we practice medicine, it’s about patient-centered care. And this is about population-based decisions.
Cynthia: That’s right.
Eric: And when I think about it, and for those who are interested, we have a podcast with Doug White with links on our show notes on our GeriPal website to the New York state a framework to Doug White’s framework too that’s used in over a hundred articles that you can actually download the PDF or the Word document.
Alex: Over a hundred hospitals.
Eric: Yeah. Mm-hmm (affirmative). And then also to the VA guidelines, there are multiple guidelines that you could use. In the end, there’s no perfect system here. It’s about triage. It’s about a tragic choice and it’s about trying to make the best possible decision given what we’re facing with. And I mean it sounds like you guys are getting close to that supply/demand balance where it may be triggered.
Cynthia: Yeah. Well, Governor Cuomo’s mind doesn’t seem to be on that. He’s focusing on getting enough ventilators. I think he asked for 10,000 and he got 400 so that’s what he’s focused on. And I know that our NYP health system has a legal group that’s talking with the state about this triage committee system. But right now we don’t have legal immunity. So if we invoke it…
Eric: Yeah and I guess the other question is, is it about the ventilators? Is it about the staff that can actually manage ventilators? There’s a lot of talk about ventilators, but not a lot of talk about, Okay, do we have the respiratory therapists? Do we have the nurses? Do we have the physicians who actually know how to use these machines?
Eric: And with people calling out sick people getting quarantined, it’s not just about the machines.
Cynthia: Right, exactly. It’s about the manpower and I think that’s something that we’ve seen evolve too. At first, at the beginning, about two and a half weeks ago, anybody who was exposed to COVID, is supposed to quarantine themselves for 14 days with or without symptoms. And we quickly found out that we’re going to lose all our workforce in a matter of weeks because everybody is exposed at this point whether you know it or not. So now the policy is, consider yourself exposed. If you don’t have symptoms, come to work, wear a mask, wear all the gear for your setting and come to work. If you have symptoms, stay home. And not everybody is allowed to get tested. So that’s the other thing, is testing availability. We’re not where we should be.
Alex: I wanted to ask about what sort of consults you’re seeing. What are the major reasons for consults? Is it primarily goals of care discussions? Is that something that’s happening early on in the Emergency Department or is it on the floor and are you seeing consults for symptom management and are you as a team managing patients who are exclusively comfort measures? Have you sort of taken over those patients? Are you in a co-management role?
Cynthia: We’re consultative. We’re not getting a lot of consults in the ED, which is baseline for us. We tend to get more consults in the ICUs and we have a trigger project in the ICU. But now we can’t go in because they are completely COVID. In order to go into the ICUs, you have to get completely, like there’s a donning room and then there’s a doffing room and then if you want to hand in something, like a most checklist or something like that, there’s a runner that runs between regular people and the COVID unit so to minimize the exposure and to conserve PPE. So the consults that we’re getting vast majority has been for goals of care and it still is. And we try to facilitate family meetings via phone, but not directly with the patient if it’s a COVID patient.
Alex: So if you get a goals of care discussion from a patient who’s in the COVID ICU, you can’t go see them personally. You could potentially arrange, you could call family members?
Alex: Who are outside the hospital because they can’t visit.
Alex: If the patient has capacity, then you might be able to arrange for a FaceTime conversation with the patient themselves in the ICU, then they probably don’t.
Cynthia: Right. Chances are they don’t. So we might get the ICU clinician to help us FaceTime with the patient if we have a need for that.
Alex: Right. But for the most part it’s talking with family members?
Cynthia: Yes. And for some reason, recently there’s been a big string of OPWDD patients, so patients who are persons with developmental disabilities, which are a vulnerable population and there’s New York state extra layer of oversight. When end of life decisions need to be made, there’s a whole big process. So we’re in the midst of trying to deal with that.
Eric: Are you seeing many unbefriended older adults or adults in general where they don’t have anybody able to make decisions for them?
Cynthia: Yeah, here and there, but I think that’s the minority, thank God. So usually they’re family members that you can talk to. But we’ve also had situations of the elderly patients who cannot make decisions and the son or daughter were making decisions and now they themselves are hospitalized in another unit with COVID.
Alex: And some of these goals of care discussions I’d imagine our patients who aren’t doing well despite being on ventilators for a couple of days or something like that. Is that accurate?
Cynthia: Yeah, or patients who, the medical teams are foreseeing that they might get into that situation and they’re trying to prevent them from getting intubated.
Eric: When you’re having these discussions, are there useful tips for when we get into similar situations that you’re seeing that works? We just did another great podcast with Darryl Owens who really gave us some, how he’s talking to ED patients about goals of care. Any kind of lessons learned from this from your perspective?
Cynthia: Yeah, I feel like I’m using, I wish a lot. When family members want me to get them special permission to come and visit and I say, I wish I could normally I would be the first advocate for that and now there’s a zero visitor policy because of COVID. Just watch the news and I’m also trying to use things from Tony Bach… Just did a whole vital talk kind of communication guide for COVID-19. So I’m disseminating that to different clinicians to try to maybe use that.
Eric: Great. We’ll have a link to Tony’s Vital Talk messaging too around COVID. Sorry for the interruption. You were going to say one more thing?
Cynthia: Yeah and I think really conveying the message that even though there’s no visitation, we are still there for them and be the eyes and ears to communicate with them.
Eric: Can I ask you, how are you talking about prognostication and then certainty around that with COVID? With your patients?
Cynthia: With COVID patients, what we’re finding, both here and also with I guess literature from Italy and China, is that about 80% will do well with mild symptoms or minimal symptoms. About 16 to 20% end up going into the ICU needing to be intubated and once you’re in the ICU, the mortality is somewhere 50, 60% or higher. And the clinical course can be very tricky. They go into hypoxic respiratory failure, ARDS. We’re actually soliciting people to go prone the patients in the ICU and they seem to like turn the corner, maybe some renal failure and then when they turn the corner, everybody’s happy, they tell the families and then they get hit with a severe cardiomyopathy and die. So it’s very demoralizing for the ICU doctors and nurses, not to mention the family members.
Eric: Wow. One other question around just how the system is dealing with this. For those whose focus is on comfort, can you discharge people to let’s say hospice? Or do you know how hospices are dealing with this in New York right now?
Cynthia: I’m not really quite sure. I think that hospices are still doing home visits. I’m not sure about COVID discharges since about 80% will do okay, we’re trying to keep them mobile so they can go home because if they get the condition and they need a nursing home, they’re not going to go anywhere.
Eric: Are nursing homes just not accepting anybody?
Cynthia: No, nursing homes, no visitations. Because nursing home patients are high risk, right? From the Seattle experience. And then hospices, I don’t know. I don’t think we’ve gotten even that far yet. What we’re doing is with any non-COVID patient, we’re trying to get them out. Before all this started, we had a [inaudible 00:24:07] policy trigger that said that any patient before getting a new feeding tube inserted, needs to have a palliative care consult and we used to have these extended goals of care conversations, especially in advanced dementia patients to try to really kind of go through the process. But now if the family seems to be pretty firm after a couple of conversations, they want a feeding tube, we’re just like, Feeding tube and out. There’s no more talking. Just get out before you get COVID.
Eric: Got to free up the beds.
Eric: And protect the patients from getting COVID.
Cynthia: Right. If you don’t have COVID, just leave.
Eric: Yeah. What are the major symptoms that you’re seeing and how are you treating them?
Cynthia: For COVID?
Eric: Mm-hmm (affirmative)
Cynthia: For COVID, it seems, well the standard symptoms that people are screening for are fever and shortness of breath and cough. But there turns out to be a variety of symptoms that people can have, like just generalized malaise, diarrhea. Some people present with renal problems, so it could be a variety. So the problem is that there’s not enough testing, so a lot of people who might have it, we’re just not going to know the denominator because we’re not testing enough.
Eric: One thing that Darryl Owens talked about in our last podcast was that he’s really trying to also think from a palliative care perspective how best to control symptoms for people who are more focused on comfort, including thinking about around the clocks, over PRN medication so really decreasing people coming in and out of that patient’s room.
Eric: Do you have any other tips that you’ve learned from a palliative care perspective how to manage symptoms?
Cynthia: In addition, opioids have always been a big mainstay for pain and shortness of breath so we definitely depend on that and people, I think clinicians feel more open about doing it because there’s no choice. But at the same time we also have a shortage of IV morphine and IV hydromorphone right now. So we’re trying to reserve that for the ICU patients and for any other patients who we anticipate going home, we start them on Fentanyl patches and then do oral PRN so we can get them out of here and get discharge ready.
Eric: Oh, so an opioid naive patient, you might even start on a Fentanyl patch?
Eric: We wouldn’t ordinarily do that because it’s not great for dose finding, but in this situation you’re doing it because it’s a faster way to get something long acting on board that is available, that they could potentially go home with.
Cynthia: Right. And at low doses, I think that is safe because we’ve had to do that in our nursing home consultations. When we used to go to a nursing home, we no longer go, but in a nursing home that we go to, they weren’t really proactive about controlling patients’ symptoms and we have a joke that says that if we order something PRN, it actually means patient receives none. So we started doing just Fentanyl patches low dose because those do stay on.
Eric: I’m wondering if we can kind of also take a step back. When we were talking to Dr. Owens, he also talked about what’s it like to even just to go home and this, how are you managing doing all of this in the hospital that all potential exposures and then going into a home setting with your family?
Cynthia: It’s… I don’t know. I’m scared and my husband is scared. He’s an ED physician. He had his breakdown a few days ago, after being bombarded in the ED with COVID-like patients and I have two sons, they’re home and at home because school shut down already. So they’re doing distance learning and when I go home I don’t feel comfortable hugging them. I try to keep my distance because I don’t want to get them sick. And it’s very hard because I’m a huggy person and I like to be with my kids but now I feel like there’s this barrier.
Cynthia: I don’t visit my mother and my brother anymore. I used to visit every few days. Now I just call them. My mother-in-law, I just call her. We don’t visit anybody.
Eric: I’m hearing people also when they get home, they wear the scrubs in the hospital. They come home. First thing they do is they shower and some time for family time, but also recognizing that it’s hard.
Cynthia: Yeah. My son was showing me the schedule that he made and it says in the morning, Do this, this, whatever class, social studies, English. And then in the evening he put family time and I was looking at that and I was like, Oh my God. It’s just crazy.
Eric: Well our thoughts are with you. Our hearts go out to you and your team and your family and this such a challenging time and really, we’re proud of all that you’re doing as a field in geriatrics and palliative care. You’re really on the frontline, so to speak, in this challenging situation.
Cynthia: Yeah. And I don’t think any of us can afford to be complacent because I think eventually a lot more places are going to be hit and I really see that having good state leadership, starting from the Governor, having good kind of health system communication and advocacy and then having people in each hospital kind of helping each other, communicating on a regular basis, having enough equipment. That’s really, really key.
Eric: And for, if you have like one thing that when we’re talking about geriatrics and palliative care teams, things that they could do right now, they may not have control over PPE and those types of things. Anything that they should start preparing for that maybe you wish you did like two weeks ago or three weeks ago aside apparently from buying toilet paper at home?
Cynthia: You know what they say? That the Asians are buying rice, the Russians are buying vodka and the Americans are buying toilet paper. So I think from a geriatrics and palliative care perspective, definitely using our strengths to help with family communications in times like these using whatever, FaceTime or video chatting capacity that we have to rev up for that because eventually there’s going to be a lot of social distancing. And also from a palliative care kind of ethics perspective, we’re going to be asked to say what’s the next step in terms of rationing and who’s going to get what. They’re going to look to us for answers.
Eric: Yeah, and really encourage all of our listeners don’t reinvent the wheel. There are some really good frameworks out there for triage. Encourage you to check out our posts with Doug White and James Frank with some excellent resources including Doug White’s framework that he’s using, the New York state framework, the VA framework. All with links on that show notes page.
Cynthia: Yeah, and I think that for palliative care, even though we can be involved in these types of decisions, we should not be front and center. We should really leverage the whole hospital and the Ethics Committee and it has to be an institution wide effort.
Eric: I would say a big proportion of our Ethics Committee are palliative care attendings. So maybe a challenge, we’ll have to think about how to restructure that.
Eric: Cynthia, I really want to thank you for joining us.
Alex: Thank you so much for taking the time.
Eric: Talking to you and talking to folks like Darrell really makes me so very proud of what people are doing in our field and the way people are stepping up to this monumental challenge and these tragic choices. So again, thank you for joining us today. Maybe we can add, I see in the back you have… what does that little yellow book say? Think of one thing that makes you happy?
Cynthia: Good vision!
Eric: Can you read that for us, Cynthia?
Cynthia: Do one thing every day that makes you happy.
Eric: All right, Alex, I know for you what makes you happy is singing…
Cynthia: Thank you Eric. Thank you Alex.
Eric: Thank you very much for everything that you’re doing – all of the palliative care teams, geriatric and everybody else that is pitching in, even if it’s just social distancing. We are doing our job in trying to control this pandemic. So thank you to everybody. As always, thank you to The Archstone Foundation. Good-bye everybody.
Cynthia: Thank you.