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The Emergency Department (ED) is a hard place to have serious illness discussions, whether it be goals of care or code status discussions, or whether or not to consider intubation for a seriously ill patient. Emergency physicians often don’t have the time for in-depth discussions, nor have been trained on how to do so. There often is limited information about the patient, their functional status, or their prognosis. These are some of the most challenging and some of the most important conversations in medicine, as 75% of older adults visit the ED during the last 6 months of life (data thanks to this Alex Smith publication in Health Affairs!)

So how do we have these urgent conversations in a time of crisis to ensure that patients receive care that aligns with their goals? We have Naomi George, researcher and ED physician extraordinaire from the University of New Mexico, and Kai Romero from UCSF and Hospice by the Bay to help answer this question.

Naomi discuss her practical approach to crises communication that she published along with others (including previous GeriPal guest Kei Ouchi) in this Annals of Emergency Medicine publication titled “Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure.” We also talk with Kai Romero about her Academic Life In Emergency Medicine blog post on “Work Grief: A Practical Primer for Emergency Medicine Providers.

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 have Naomi George, who is an emergency medicine and critical care physician, and she also does some research at the intersection of emergency medicine and palliative care. She’s at the University of New Mexico in Albuquerque, New Mexico. Welcome to the GeriPal Podcast, Naomi.

Naomi: Hi, thank you for having me.

Alex: And returning to the GeriPal Podcast for the, I don’t know, fourth, fifth time, something like that? Kai Romero, who is an emergency medicine doctor and chief medical officer at Hospice By the Bay. Welcome back to the GeriPal Podcast, Kai.

Kai: Thanks so much for having me.

Eric: I think the last time you were on, Kai, we were deciding which was our favorite palliative care song or something like that?

Kai: Yes, that’s true.

Alex: No, I think she’s been on since. We had a COVID talk-

Eric: Oh yeah, we did have a COVID talk.

Kai: Oh, that’s right. That’s right. But I can’t remember where we landed with the best palliative care song, either.

Eric: So we’re going to be talking about crisis communication in the emergency room, talking about things like having code status conversations, or other serious illness conversations in the emergency room, how individuals manage grief in the emergency room, lots of great topics to discuss today. But before we do, we always start off with a song request. Naomi, do you have a song request for Alex?

Naomi: I think we’re going with Kai’s song request today, which I love.

Eric: Ooh. Kai, what’s the song request?

Kai: So my song request is a family favorite of mine, I’m Still Standing by Elton John.

Alex: And why that?

Kai: Mostly because it’s very adaptable to whatever … well one, at the end of a long day it’s a good reinforcement, and you can adapt it to the situation. So for my kids, it turns into I’m still naked after a bath, I’m still hungry when dinner’s over. So you can kind of really trade it out with a lot of options.

Eric: And we are recording this on November 4, so it’s the day after the election when everything is still very much in turmoil. Nobody knows what’s going to happen, so Alex? You want to give us a little?

Alex: Here’s a little bit.

Alex: (singing)

Eric: Okay, Kai, who sang it better? Alex, or your kid around bath time? [laughter]

Kai: Definitely Alex. It’s more of a screech around bath time, so that was really great. Thank you Alex.

Eric: I’m going to start us off. Naomi, we’re going to be talking about crisis communication. I’m really here to learn. Actually, just last week, one of our fellows was asking, “How do we have these code status discussions with individuals in the emergency room? Is it even worth it because it’s so rushed?” But before we answer that question, how did you get interested in this as a topic?

Naomi: Yeah, Eric, I think probably asking that same question that your fellow asked. So I remember, and maybe Kai has a similar recollection even starting from intern year in the emergency department, maybe particularly because I did my residency in Rhode Island, which is like a small city state. It’s like Athens or Sparta. So everyone in the state, if they have a serious illness, they’re coming to your hospital. You’re the tertiary care provider, you’re the safety net provider in this state, and it was probably not long into intern year when I realized, I’m seeing the same seriously ill older adults, probably CHF or COPD most commonly but also advanced cancers, and I’m seeing them over and over again. And I’m seeing them for acute respiratory failure, over and over again, and probably seeing them more than their primary care physician, because they’re kind of stuck in this ER/in-patient rehab cycle. And wondering probably after I got over the kind of giddy high of being a halfway decent resuscitationist, or at least knowing what my attendings were doing for resuscitation, oh my gosh, maybe this isn’t what the patient wants. How would I know, how would I approach it? I have no clue.

Naomi: And so I used the time I had with electives, and explored VitalTalks and other palliative care resources to figure out how to talk with patients, which is amazing, and I’m so thankful for all of that learning from you guys. But that also there’s this limit that you bump up to. How do I actually adapt it for the ER? How do I deal with the heightened degrees of uncertainty, the time crunch, all these sort of constraints that force us to kind of change our heuristic a little bit around goals of care conversations in the ER for these kind of hyper-acute or crisis moments. And so I’d been thinking about that for a really long time and trying to kind of work my way around this question. And fortunately for this recent publication I was able to convince, probably through COVID being such a motivator, convince folks from the palliative side to kind of take a deeper dive on this with us, folks at Brigham, and at UNM where I trained previously, to take a look at where can we take serious illness conversation and adapt it for the ER? And I think ER docs are probably hungry for these kind of tools. That’s my hope at least.

Eric: Yeah, and we’ll have a link to the article. It’s from Annals of Emergency Medicine, and you wrote it with Kei Ouchi, right? Who we’ve done a podcast with before. Folks like Rachelle Bernacki. You were a senior author, right?

Naomi: Probably by mistaken roll of the dice, but yes. [laughter]

Eric: And taking a big step back, why is this so important? Even in the intro, just want to highlight the thing that stood out to me was three out of four older adults visit the ED in the last six months of life. That seems like an overriding issue. When you think about this, what’s the imperative?

Naomi: Yeah. I think what you just mentioned, and probably that experience I had as an intern, and realistically all the way through emergency training, and as I mentioned now I work in the ICU and I see that carry through, which is that older adults are visiting the ED in droves. And it’s not typically for low-acuity complaints, right? It’s for these serious kind of crisis moments that change your illness trajectory. And Kei and I have worked together, Ouchi who you just mentioned, worked together on some prognostic papers, kind of asking ourself, sure, their SOFA scores and APACHE scores, kind of putting on my ICU hat, that talk about prognosis. But in the ER, when someone’s struggling for breath, you don’t know those things. What you might know, though is their age, a rough cut of their comorbidities, and what they may be facing if you move forward with intubation. And the fact is that probably increasing by decile, meaning 65 to 75 year olds don’t fare quite as poorly as those that are 90 and over, not surprisingly, but that a third of adults are going to pass away in the hospital, or die in the hospital after emergency department intubation. Older adults, that is.

Naomi: And maybe even more worrisome, and kind of what we see on that cycle through the ED from rehab, is that a lot of older adults are going to face significant functional decline if they survive, and that that survival probably isn’t very long. Their yearlong mortality is quite curtailed. So having an opportunity to talk about that, if you could figure out a way in the five to 30 minutes before the decision of an ER intubation is upon you, that would be such an opportunity to make sure that the treatment is aligned with their values.

Kai: One of the things I really loved about your paper, Naomi, was the fact that I think something that can … you think about palliative care as being a specialty of translation, right? You’re translating all of these complex medical decisions to a person who may or may not fully understand what they mean. And I actually think when it comes to talking about palliative care, you need that translation for ER doctors. If you speak about palliative care in the way that it’s traditionally approached, they’re like, “Get out of here. I don’t have time for this, this is ridiculous.” And I think they very quickly move into that space of being like, “Okay, you want me to have a 90 minute family meeting with someone playing the bongos. I’m out.” If that’s what you’re-

Alex: Bongos are key. How could you not include the bongos? [laughter]

Kai: … Right, they’re just like, “This doesn’t even begin to approach my reality,” and so hard pass. And what I loved about your paper was that it acknowledged … one of the things I noticed very quickly, was the very first step was not build rapport. There’s no time to build rapport. The person’s about to get intubated. Start from, the way that you build rapport is by knowing a little bit about their past medical history, and by showing up and saying, “We don’t have a lot of time, but I want to give you all the information that I can,” that’s your rapport, beginning and end. And I think what’s definitely become clear to me is you need a person that really, subtly understands the time pressures, the cognitive pressures, the weight of the decision making, to really kind of offer them tools to get through it. And I thought your paper did a really good job of just acknowledging that you can’t show up with the same expectations of an inpatient palliative care service, or an outpatient palliative care visit, and keep ER doctors kind of buying into the idea.

Eric: We’re not going to share our favorite poems before we go into patient rooms?

Alex: We all held hands in a circle first. No? That’s-

Kai: A brief circle.

Alex: Drum circle.

Kai: It’s, yeah. I mean that’s the thing, is that … and palliative care providers also are pulled into these higher acuity situations. But that’s not where the focus of the training is. The focus of the training is on incremental building of relationships and trust. And there’s nothing incremental about these conversations in the ED. It’s just shock and awe.

Naomi: Totally, Kai, and I think that’s one reason we try to kind of structure this conversation as, you’re dealing with some incredibly high rates of uncertainty, right? You might not even have a medical record number for the patient yet at the time you’re making the decisions. Oh, and by the way, you may have three other patients at the same time who also need attention for their acute respiratory failure. So, the whole first phase of the conversation is just trying to identify those patients for whom intubation is not in line with their goals of care. Hard stop, little uncertainty. They may or may not survive, you won’t know that yet. They may or may not have a lot of disability afterwards. You won’t know that yet, because you don’t know their date of birth.

Kai: Right.

Naomi: But, if this is a person for whom whether or not there exists advance directives, and there almost never do, unfortunately … I was listening to a little bit of the podcast you guys had with Sean Morrison, and the polemic that he wrote recently, and I just want to say I love advance care planning. I love it, fully, but there’s also a lot of things about what he said that have a lot of face validity for an ER provider. Folks are not coming to the ER with advance directives, overwhelmingly, and if they do they’re not durable most of the time, or you can’t find them. And so all you want to find, whether or not an advance directive exists, which it doesn’t, is who really doesn’t want this path? And once you find that level for which there’s very little uncertainty, you just hope you did it without ruining alignment, and without corrupting any potential for alignment and for kind of a time limited trial, or a greater exploration the next 24 to 72 to whatever hours.

Naomi: And that’s the ICU physician in me talking, which is that [inaudible 00:13:09] you guys have created enough alignment, and set up an arena where uncertainty is understood, and prognosis not being wonderful, has kind of been put on the table and then we can keep talking. And if the ER provider can lay that groundwork as sort of a step one and a step two, that’s huge in my perspective. I don’t know how you guys feel.

Alex: Yeah, I wanted to go, I used to do some research in this area. Thank you for citing both two of my papers here, the 75% of people who are seeing the ED in the last six months of life, and the other one, which is titled Am I Doing the Right Thing?, where we interviewed emergency medicine providers about palliative care, and they wanted to do the right thing, but they had no training. And it wasn’t part of the culture to do any of this palliative sort of stuff. So the drum circle thing is in jest, but there’s something there too about the culture of emergency medicine being different from the culture of palliative medicine. And it’s not just that it’s time pressured, and this and that and the other, it’s also the people go into it, they say, “We went into emergency medicine to do, to act, to save people. ABCs, ABCs, ABCs.” Right? And so this idea of pausing, taking time out, communicating, we’re going to get into this later, talking about our grief. That is in some ways antithetical to the culture and the reason that people went into emergency medicine in the first place. But I’m sensing from you that there’s a push for culture change here? And that maybe the younger generation, that’s you by the way-

Naomi: Yeah, and I think honestly it comes from within ER docs too. Because I think you only have to do it for so long before you start having those doubts and misgivings, and you want an avenue to address it but you may not have the language. You may not, you have the mindset that you want to be doing the right thing, but what Kai was saying, right, or sorry, Kai, there is an interpretation issue. And so we kind of set it up like, what do emergency docs love, and clinicians love, is procedures. So we try to say, this is a procedure which comes from the palliative care world, I know, but I think ER doctors may really take to it. You need to choose your phrase about values the same way you would choose which blade you use, which laryngoscope you use based on the thyromental distance of the patient. You need to have and hone expertise around this like you do for a critical or resuscitative procedure, and we’re hoping that will have some traction and some sort of interpreter value there.

Eric: And I love in the end how you talk about like ACLS, your goal for this is not to produce specialty level cardiologists who understand everything about the heart, it’s about giving people the tools to have these discussions in these really urgent situations.

Naomi: And I think this notion that Alex brings up of kind of sitting with discomfort and sitting with unknown, I agree. Not high on the list of things that would propel you towards emergency medicine, right? And yet, they’re really foundational parts of being a physician and being a physician to people who are dying. And I think with a little time and attention, people are willing to identify, what is my own personal discomfort with watching and identifying a dying person, and what is clinical urgency? And piecing those apart is a big component of providing the best possible care to people who are dying.

Alex: Yes. Well put. We should, in the interest of time, because we do want to get to the grief piece as well, we should have Naomi walk us through, what are the key steps in crisis communication in the emergency department? You have a patient coming in with COVID, in respiratory distress, no advance directive. You call the surrogate on the phone, or maybe the surrogate is able to be there in your emergency department, or maybe the patient is able to talk to you through gasps. I mean this is high pressure, this is time intensive, you have other patients who you need to attend to. What do you say?

Eric: Should we go straight to, should we intubate him, and should we do things like CPR?

Alex: Should we do everything?

Eric: Should we do everything?

Naomi: Yeah, I think that’s exactly the way to go, and that’s why those overnight intern code status conversation documents are so durable. No, seriously, I think that a lot of your listeners are going to recognize this as very closely adapted from serious illness communication and VitalTalks conversations. All we really tried to do was parse down to really the most essential things to talk about, with a focus on alignment, and with a focus on really trying to push ER docs a little to try to get that sort of baseline function or underlying function that drives their prognostic estimate in their heads, and push them a little to ascertain some values questions. And so we start with a real simple phrase in this talking map, if you will, “I wish we’d met under different circumstances. Your loved one’s really sick. We need to decide quickly about his or her care.” And we use some of those adjectives, like quickly, to try to almost lure ER docs into wanting to read this, “Okay, they understand this needs to be quick. Okay, I’ll read it. Maybe I’ll think about using it.”

Naomi: And then you share the bad news, you break the bad news, focusing on simple statements that really leave aside a lot of the extraneous medical details, which frankly might not be known at this time. Your father is sick with breathing difficulty, or pneumonia if you happen to know that’s the case. A lot of times we don’t know that until day two or day three. We need to work together quickly to make a decision for them, so align with it again, and then a quick detour from the eyes of an emergency physician might be, “In order to decide on what treatments might be best, could you share a little bit about what type of activities your loved one was doing beforehand?” And here I think is where a lot of us may get a little alert, EMS is coming in with a patient with a respiratory distress, you have 15 seconds to do a chart biopsy, and you hear they’re coming from home, or coming from a nursing home. They have COPD or they don’t. But when you find out that COPD patient hasn’t left the bedroom or the first floor of the house in three months, that’s a lot different than the COPD patient who is taking their chihuahua for a walk with two liters of oxygen trailing behind. Those patients have a different prognosis, and you might want to know that before you give a recommendation.

Naomi: And after you ascertain the functional status, you may want to ask some pointed questions about values. I tend to be fairly blunt depending on the person that I’m speaking with and how I can best ascertain how they’ll receive it. But I might ask a question as straightforward as, “How would your loved one feel if treatments today led to their inability to do their favorite activities? Or meant that they wouldn’t be able to leave the nursing home even when they’re as recovered as they’re going to be?” And sort of, even though it’s a stark picture, I might paint a fairly stark picture for an older adult with serious illness, with respiratory distress coming in right away so that they can tell me right off the bat, “No, they would never want that.” Or, “They may be willing to see how it goes.”

Naomi: Then I summarize what I’ve heard, “Your father’s here sick with breathing difficulty, I heard that he feels that walking the dog around the block every day is really what’s most important to him, or being able to read a novel or whatever it is, and that treatments that result in inability to return home to his dog really wouldn’t be acceptable. Is that right?” And I reflect back what they’ve heard, and then I make a recommendation either for intubation or not, for CPR or not, and for ICU care or not. And the intubation, CPR, a lot of patients are going to elect to remain full code, or to move forward, and that’s fine. Shaking your agenda probably is the most important and most critical and difficult part of this, and saying, “That’s fine, I think this outcome’s going to be poor but they want to move forward.” But laying the groundwork for a time-limited trial is a key opportunity here, which if you’ve aligned with the patient, I think maybe possible at this early juncture.

Naomi: And that’s it. Asking if they’ve heard your recommendation, what they think, if they agree, or have questions, and moving from there. So we trial this a bunch with actors, and feel like we can get it in within five minutes or so.

Alex: Wow.

Naomi: And the pitch to ER doctors is that this is the time if you work in a staffed ED. In a rural ED, this may not be possible. But if you worked in a staffed ED, that’s the time it takes your respiratory therapist to come down and set up her vent or his vent, to unpackage the intubation equipment, to get ready. So you’re having this higher level conversation while everyone else is working in conjunction with you for the patient’s goals.

Eric: And have you taught this yet to emergency providers?

Naomi: We have. We’ve done it here at UNM for the emergency docs, and we’ve done it at Brigham as well.

Eric: And can I ask, is there a particular step that you get the most pushback around?

Naomi: Baseline function. Baseline function.

Eric: Yeah? Why is that?

Naomi: I think people struggle to see how it might be connected to the prognostic estimate, and I think frankly people are uncomfortable with prognosis. I think we all, every specialty, prognostic uncertainty is ugh, it’s like the barb. I wish I just knew. [laughter].

Alex: But we’re still good at predicting things like polling- laughter]

Eric: Elections. [laughter]

Naomi: Don’t mention it, this is my diversion today from the election. [laughter]

Alex: That’s right. 100% certain all of the time.

Naomi: Right. But it’s so uncomfortable, and knowing that the whole purpose of that step is to help you form a prognostic estimate is like, “Whoa, this is in my hands. This is really uncomfortable.” But I think it’s okay.

Eric: What about the recommendations? Is that another … because I feel like you see a lot of giving people just a bunch of options, rather than based on everything that you’re telling me, this is what I recommend. Is there some pushback around that, or are emergency room physicians completely comfortable with that?

Naomi: I think that actually drives at one of the most interesting things that we kind of discovered here at UNM is that we developed this on paper and we worked with our colleagues at Brigham and Women’s, and it’s a very different patient population. And one of the first things that kind of became obvious about this, is that the strength of the recommendation or the kind of dose of the recommendation really needed to take into account some of the mistrust or historical relationships or inequities that our patient population, which at UNM is largely either Native American or Hispanic community, with the ER doctors who for the most part are largely white, but at the end of the day they’re also doctors. And so we realize that the strength of that recommendation really needed to be tailored and sort of dialed down based on how much you felt that the person you’re talking with could share and feel equal with you in the discussion.

Naomi: So if you’re having a conversation with a family member who’s not saying much, or who isn’t sharing much, there may be a misalignment there. There may be a discomfort with them disagreeing with a recommendation, and the last thing we want is to give ER docs a tool that’s too paternalistic or overbearing in terms of the recommendation for families who may not feel as comfortable sharing or negotiating the space with the doctors. And so that’s one thing that we kind of change from this publication early on in our teaching at UNM, and I’m not sure how the docs at Brigham are approaching this.

Kai: I was just going to mention the fact that one of the things that happens with hospice medicine is that anyone who’s enrolled in hospice and has a family member pass away, there’s this bereavement benefit afterwards, right? And so when patients end up, these are hospice patients so obviously, pre-screened into a group who was not desiring an intervention go to the ER, and are aggressively resuscitated because of a family member changing code status or whatever, we hear about the fallout of that in a way that I think is actually data that’s harder to collect on most people experiencing these interventions. And I’ll tell you that the vast majority of patients who go through these interventions, and again, it’s a select group who theoretically was not desirous of this initially, have a lot of really complicated grief, or their family members, I should say, have a lot of really complicated grief.

Kai: And I think what it brings to mind is the importance of appropriately framing failure, or appropriately framing a bad outcome for ED providers who are kind of brought up in a system that defines the failure or the bad outcome as death. But making sure that they keep in mind that if death is happening, all of the steps before it can actually, including ICU and resuscitation can actually make that even harder than the death on its own. I don’t think that was something I appreciated as a trainee. It was kind of a choice between life and death, which is really not what’s actually happening.

Naomi: So you’re saying that all that care that your hospice patients may be experiencing in between when the crisis happens and when death finally ensues, the family experience is burdensome or kind of drives some of their grief?

Kai: Yeah. I think they end up thinking a lot about the suffering that happened in a way that’s different from people who are experiencing also death, and sometimes symptoms at home. And I think they have more images in their mind of what suffering at the end of life looks like, and I think yeah, it just really kind of helped reinforce to me, in my practice in the ER, that I got to be … I have to make sure that I’m framing this correctly, and that if in fact I’m worried that death is inevitable, to make sure that’s part of the conversation when we’re making decisions about these interventions.

Alex: You mentioned this being sure, this issue with uncertainty, this uncomfortable, discomfort with talking about prognosis, which is inherently uncertain. And here, I love the way that you emphasize obtaining the baseline function, and then thinking about what the likely outcomes are, projecting ahead to the hospital course, but not just the hospital course and the ICU course, but to the post-ICU course, for not just survival but functional recovery so that they can achieve the goals that make life meaningful to them, participate in those favorite activities that give life meaning and purpose. I love that. And yet, how do you estimate whether a person will recover enough function to be able to achieve those goals? What information do you rely on? Are we able to do that? Is that something that practicing emergency providers can do?

Naomi: I’d like to think it’s something we can do. I think that the literature is out there, but like all prognostic literature, it’s not randomized and controlled, it’s all observational. But we have a lot of outcome data that shows if you have mild dysfunction or mild limitations on your function, you’ll probably be facing moderate levels of limitation if you were to survive; if you have moderate, they may become more severe, and so on. And it’s in a pretty linear fashion. So fortunately that literature is out there. How well any prognostic estimate is ever able to discriminate your patient, I know for all 75 year olds there’s an 80% chance perhaps that your moderate dysfunction, or sorry, limitations on function might become severe, but I don’t know for this one right here, so I do my best. And I base a lot of it on what those baseline functional traits are. Again, the person who’s able to prepare their own meal, or sit at dinner with their loved one, or leave the house once a day, or once a week, probably has a much different outlook than someone who’s really kind of stuck in the living room.

Naomi: That being said, I think I use my knowledge now from the ICU side knowing how burdensome those treatments are and what it means to be woken up after being paralyzed for a week and a half, and being unable to uncurl your index finger, even let alone get out of the chair that you were struggling to get out of before COVID or pneumonia or whatever. That certainly colors my understanding of it in a way that may not be true of other ER docs, but I think ER doctors are able to do this, and a lot of it is just proposing to the patient that, “Yeah, this uncertainty exists, best case scenario here’s what I think we’re looking at. Would that be okay with your loved one?”

Eric: Yeah. It’s really interesting all this talk about uncertainty. When I think about uncertainty, I think the one profession in medicine that’s probably the masters of uncertainty is actually emergency medicine providers. They often, by the time they leave their emergency room, they may not know what the diagnosis is. They may have some ideas, they don’t know if their treatments are going to work. They are trying to decide whether or not somebody has MI, they’re using decision rules around MIs, and fractures, and everything else. The uncertainty of whether or not this person’s going to fly once you discharge them home. There’s so much uncertainty in emergency medicine that would destroy internal medicine providers. Why when we talk about specifically around mortality prognosis, I mean, because again, they’re prognosticating all the time around does this person have an MI, you don’t know. A lot of times you don’t know. You’re using decision rules, you’re using prognostic aids. What the heck’s up with this particular prognostic issue? Why is uncertainty so hard with this?

Kai: I will say one thing that I have noticed much more so in my work as a hospice provider is that people have a really hard time diagnosing death. So, when someone comes in, and we’re like, “Please don’t do any labs, the family member sent them in because they were short of breath, and blah, blah, blah.” Invariably the labs are sent, and we’ll get a call from the ER doc … or we’ll reach out to them, and they’ll say, “Well, the creatinine is six, and their BBG shows they’re super acidotic, their K is seven,” and they’ll go down this list and I’m like, “They’re dying.” And it’s kind of this … it’s a aperture problem, right? You can kind of figure out all the component parts, but death as a diagnosis is not something that we’re kind of accustomed to defining. We can define … in so many ways I remember trying to fill out forms for the coroner as a resident and being like, “Well I don’t know what the cause of death is, I don’t know. Maybe they got a PE from their cancer,” and the answer is, “You don’t have to know. They were dying of cancer, and that’s what you put on the death certificate.” But that framework was never clear to me in the same way in the ED.

Kai: And so, it’s a really good question Eric, but I think it kind of comes down to on the spectrum, I think, on the spectrum of possibilities, death really wasn’t discussed as a thing that could be happening that you would just kind of put a label on and move on. It was something you were averting.

Alex: Right. Speaking of death in the emergency department, we do want to talk about grief and how emergency providers can deal with grief in the emergency department. And Kai, you wrote a blog post, wasn’t it, for an emergency medicine site that we’ll link to in the show notes affiliate with this podcast. Could you tell us more about why grief is an important issue for emergency department providers to attend to?

Kai: Yeah, and frankly since I wrote that blog post and I’ve talked about it, I’ve realized that I was a little bit myopic in thinking that it should apply only to ER docs. I think there’s a lot of people for whom grief is not kind of a … grief management is not a muscle they’ve developed or exercised. But I think one thing that really came to mind for me as I saw my colleagues navigating the issues around COVID, my ER colleagues navigating that alongside my hospice colleagues, who were also dealing with many, many, many COVID patients, and the vast majority of whom died, there seemed to be kind of a divergence in how people were doing emotionally, spiritually, et cetera, and I realized that the component that was different was that the hospice doctors had, as a part of kind of their professional expectations, the responsibility to manage their workplace grief. And I think sometimes when people hear that they think, “Well, I know how to grieve in my personal life,” [inaudible 00:36:20] this is a very different, I think a very different, much more contained task than the grief of someone that you really love. Because if we all grieved at work the way we grieve someone we really love, we would just be horribly sad and depressed all the time, and never really be able to function.

Kai: So, what I tried to do was kind of identify for myself, and for my colleagues, what’s really happening for a hospice provider when they’re dealing with a workplace grief? And what I came up with was A, the identification of grief, something that actually during my palliative care fellowship year was super helpful, someone describing the fact that there’s kind of discrepant experiences of identifying that grief is actually happening at work. And then there’s also the standard physician thing, where you just shame spiral about your mistakes instead of acknowledging that grief is there. And I think that many clinicians kind of go down that path and think of it as having dealt with the situation, but the reality is those two things can happen in parallel. You can have your shame feelings, but at the same time, you actually have to deal with the sadness and loss of that patient.

Kai: So identifying the grief, starting to process it, our hospice providers have many more built-in, structural ways to manage their grief, whether it’s, we have memorials a few times a year, every week we talk about people who’ve been lost, patients who’ve died and the providers who’ve cared for them, people talk one on one, they journal, we have a moment of silence. There are kind of both passive and active ways, and there’s no expectation that you do any particular one, it’s just that you do something. And, if you’re having trouble, the expectation is that you reach out to your supervisor to manage it. And then the third part is really kind of bringing it to a close, having an expectation that grief should have a container, and one of the things I identified in the article that for me one of the ways that I had to contain grief, and this was actually during emergency medicine residency, was recognizing that I had to contain my grief to what I was seeing in front of me.

Kai: So if I saw something, for example, there’s one patient in particular that I think about this a lot with, she was really young, was a bike rider, had been hit by a semi truck. And she had a ton of facial fractures, she was really tough to intubate, and when I was thinking about her, I felt like I could grieve the things I could see. The things that looked painful. The things that were hard about her experience at that moment as she was dying. But what I didn’t let myself do was spiral into who she was, who she might have been, what her parents felt like, how they were doing. I couldn’t actually allow myself to go into that space, because that was an area that I couldn’t contain, and that would kind of keep me really enveloped in that experience. So just identifying that people need to, for themselves, say, “These are the boundaries of my workplace grief, and this is where I’m really going to try and contain things, and try and bring it to a close.” And then if you have trouble at that juncture, recognizing that’s when you have to reach out for help, whether it’s from a therapist or from someone else.

Eric: Can I ask you about that last one? I haven’t heard about putting a container around it, and I think it’s really fascinating. I think sometimes the challenge is with grief, is a month later, you’ll think about it, or there’ll be another patient that comes in, maybe looks similar, similar situation, and you may start having those feelings again. How do you deal when the container kind of like a Halloween thing, just keeps on, like Chucky, keeps on popping up when you’re not expecting it?

Kai: Totally. And I think for me actually one process of my grieving is actually crying. Making sure that I cry about a patient, because of that very jack-in-the-box phenomenon. If I didn’t cry for a patient and work through this process, I would cry in an Uber on the way home from a shift, terrifying the Uber driver, and making me feel like a total weirdo. And so I really think of it as a function. If you kind of … and it’s a discovery process, right? You figure out what exactly you need to do to process this, and if you find that you actually haven’t processed, then you go through that again to try and figure out, “What am I missing here?”

Kai: I was talking to one of our spiritual support counselors at Hospice By the Bay, and we were talking about what happens when you kind of defer the grief, or you haven’t entirely processed the grief, and that’s precisely it. It keeps jumping back up. Now, having a passing thought about that grief later on when you see another patient? Not a problem. But if it’s disruptive, and it kind of continues to haunt you, it’s suggesting that whatever your initial process of grief management is, might need to be tweaked, or refined, or broadened, or something like that.

Alex: Mm-hmm (affirmative). Yeah, this is really important stuff, and not just that it’s disruptive, but also that it can lead to poor outcomes for physicians, burnout, suicide, right? There was the story about that young emergency provider in the northeast who committed suicide.

Kai: Totally, and I think ER docs in our training, when we’re dealing with huge amounts of grief, and loss, and sadness, you might see a doctor who does it well, you might go out for drinks after a shift and kind of get a little weepy, but there isn’t this sense that this is something that you actually have to work through. And when, as a specialty, we were dealing with this onslaught of death, and dying, and suffering, and loss, and there was no, or very little attention paid to how do we as a group get through this? And kind of related to the first part of this conversation, it’s going to look different. There are definitely poems involved at hospice, and there may have been bongos [laughter], and there are-

Alex: I was just going to ask Naomi, how is this sitting with you? Are we too much bongo here?

Naomi: Oh, not at all, I think it was an amazing article, Kai. I loved it, and the first thing I thought, that occurred to me when I read it, because I have this sort of two-phase experience with grief at work, the first from EM training and then from critical care training, and they’re such different experiences, and I realized … even the other day, I was talking to a friend of mine who’s a cardiothoracic trainee, she’s doing her fellowship, and she remarked about a surgeon who had had this string of bad outcomes. Three deaths in a week, oh my gosh what happened, and then everything went back to normal and how he dealt with that, and the professional conversation that their group had around that. And I thought, “My gosh, three deaths in a week? I mean in the ER you could have three in a shift. You could have 10 in a week. You could go a week with none, and you could have 15, and that’s pre-COVID.”

Naomi: And a lot of the deaths my experience, they either come in dead, right? Because the probability you’re going to survive without a hospital cardiac arrest, or traumatic arrest, is close to zero, under 10%, or less commonly they die after you’ve met them a little. But that connection to the patient or the family when you witness the death isn’t there the way it is for hospice or internal medicine or for ICU. And so it’s going on like crazy for years when you’re a trainee before you realize, “Oh, I’m witnessing death.”

Kai: Yeah.

Naomi: And that’s what’s happening to me right now, and maybe you have some attendings who have a moment of silence, maybe you don’t, and maybe you have a few really intense outcomes that cause people to do a debrief, but there’s no structure around it. There’s no training. And so I read this article, I was really, really excited to see bringing attention and shining a light to this, because they think it speaks to a lot of what the professional experience is in a busy, certainly academic ER. Yeah.

Eric: I want to thank both of you for joining us. We’re going to have links to both the article in Annals of Emergency Medicine and also the Academic Life in Emergency Medicine, Kai’s blog post on grief, which I’m already starting to think about with November 4 and the elections, how I’m processing everything. So, I’m going to put a container around it, Kai.

Alex: It’s not over yet. They’re still counting as of the recording of this podcast.

Eric: And I’m going to ask for a little music therapy right now from Alex.

Alex: Good linkage.

Alex: (singing)

Naomi: Yay.

Eric: Thank you Alex. Naomi and Kai, thank you for joining us on this podcast.

Naomi: Thank you so much.

Kai: Thank you.

Eric: And to all of our listeners, thanks for supporting the GeriPal Podcast. Please send this podcast to two other of your favorite colleagues, especially those in the emergency department, and big thank you to Archstone Foundation for their continued support. Good night, everybody.

Alex: Good night.

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