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In this week’s GeriPal podcast we talk with May Hua, an anesthesiologist, critical care physician, and researcher from Columbia (in NY, not the country). We’ve had a number of podcasts and blog posts about palliative care in the ICU:

May Hua’s study addresses the still unanswered question – do specialized palliative care consults in the ICU do anything? She looked a number of outcomes comparing ICU patients in hospitals with and without palliative care consults. While most outcomes were similar, rates of hospice use were higher in hospitals with palliative care teams.

One issue Eric raises toward the end deserves highlighting. We know of no trial demonstrating the effect of cardiology, endocrinology, or gastroenterology consults in the ICU. Why do we feel compelled to study and prove the effect of palliative care in the ICU?

I think the answer is that we are still nowhere near as established as those fields, where the benefits are assumed and unquestioned. It’s a sad state of affairs, really, but there you are. As Ken Covinsky is fond of saying, we live in the world as it is, not as it should be!

We briefly also discussed May’s article examining the impact of the 30-day mortality reporting measure in surgery – here’s the link.

-Alex Smith @AlexSmithMD

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

Eric: Alex, who is our guest today?

Alex: Today we have a guest from the other side of the country. We have May Hua who’s an Anesthesiologist, Intensivist and Palliative care researcher at Columbia. Welcome to the GeriPal Podcast May.

May: Thanks for having me, guys.

Eric: All the way from New York City.

Alex: New York City, and for those of you who don’t, May is a great singer and we have this, she’s one of the Beeson crowds, so these are like geriatric aging researchers, and we have this sing-along. We usually go until like 12 or 2 in the morning sometimes at the Beeson meetings and May is always one of the last people standing.

Eric: Well, given that, do you have a song for Alex to try to sing? Make it a hard one just to …

May: I do. Life Is A Highway by Tom Cochran.

Eric: Is that hard, Alex?

Alex: It’s very hard. I can play the guitar part or I can sing it, but I have a lot of trouble playing the guitar part and singing it, so we’ll see what happens.

Eric: I also want you to pat your head at the same time.

Alex: Right, right. Just a very tiny snippet.

Eric: Echo.

Alex: [Singing]. Oh boy.

Eric: I can listen to that one all night long.

Alex: All night long.

Eric: All night. Just keep it coming.

Alex: Sometimes the disasters are better than … I kind of get it.

Eric: May, is there another reason besides it’s a difficult song to sing that you chose Life Is A Highway?

May: I actually chose it because I thought it wasn’t that hard.

Alex: Great. It probably isn’t that hard. It probably really isn’t that hard. I just can’t get it coordinated.

May: But I don’t actually play guitar, so I wouldn’t really know.

Eric: But you’re a singer.

May: It doesn’t really seem that hard to sing, but doing both is probably tough.

Eric: Do not ask Alex to multitask.

Alex: There’s some skepticism about how tough that actually is. Yeah, well, oh well.

Eric: That would have been good for our last podcast about firearms, the stay in my line, Life Is A Highway.

Alex: Oh yeah, yeah, yeah, stay in your lane.

Eric: So, no longer speaking of our last podcast but this podcast, congratulations. We’re going to be talking about the article you just got published on the association between the availability of hospital-based palliative care and the treatment intensity for critically ill patients published in ATS Journal, right?

May: Yeah, Annals of the ATS.

Eric: Annals of the ATS. So maybe before we go into this article, how did you get interested in this as a subject?

May: During my fellowship I was learning how to use a lot of technology to keep people alive, and I did my fellowship at Columbia and we’re very aggressive. I think that I felt like I was pretty good at the high tech stuff but not so good at the low tech stuff of just talking to people when the high tech stuff failed. That’s kind of how I got interested.

Alex: Tell us about what your clinical practice is primarily.

May: So my clinical practice, I attend in our cardiothoracic ICU and I also do a little bit of operating room anesthesia about one day a week.

Alex: Are there palliative care consults in the ICU?

May: Yeah.

Alex: Yeah.

May: We do have them fairly commonly. Part of that is because we have a big vet population and then they have just been a lot of work to get buy in for palliative care in that unit where we actually have a palliative care trigger there now, so that’s pretty exciting.

Alex: Oh, wait. Tell us more about the palliative care trigger. This is like people who meet a certain set of criteria automatically get a palliative care consult in the ICU?

May: Yeah. I think that what it is, so what we’ve identified is that there’s a really high risk population of patients who require mechanical circulatory support for post-cardiotomy shock, and those patients, we are having at least early conversations with the surgeons to involve palliative care. So it’s an automatic, not quite an automatic referral, but an automatic discussion for the discussion that happens between all the three teams, meaning the surgical team, the ICU team and the palliative care team about the need for palliative care.

Alex: I think that in my experience talking with pulmonary critical care docs in particular, or people who work in critical care settings, be the anesthesiologists or pulmon-ICU, they come to palliative care with different sets of biases. Some of them are of the mindset that we do this, we do this well ourselves. We don’t need palliative care. This is part of what we do. This is part of our training.

Then others feel like palliative care is terrific in terms of the skillset they bring to augment and help manage as a supportive service to what we do in the ICU. What is your perspective and what sort of did you bring to this research?

May: I think, well, perhaps it’s obvious that I think that palliative care is a very valuable resource in the ICU. I think that figuring out how to use palliative care in the ICU is something that we still don’t understand very well partly because it is a scarce resource and you often are … Then there’s a lot of other patients who also may benefit from palliative care. You know, there’s a lot of data now coming out about the benefits of palliative care for other patient populations with serious illness, so I just don’t think we know exactly how to best use it. I know how I like to use it, but I’m not sure that we have any data to support what I do.

Eric: I can also imagine working in a cardiothoracic ICU that there also may, like, that must have been a very large culture change to get palliative care at least somewhat integrated into some of these patients because there’s a lot of forces, including quality forces like 30 day mortality rules, things like that that may act against some of the goals of palliative care, which is like talk to patients about their goals, what they want.

Alex: After the surgery.

Eric: After the surgery or after the TAVR or after the …

Alex: Not just before, but after.

Eric: Yeah. If things don’t go the way we hope, what do we want to do? Did you guys, was that part of that culture change? Are you still experiencing that?

May: It’s definitely been a process over time. I think that a lot of the culture changes happened for two main reasons. One is that it’s mandated. We have a very large vet population and those surgeons do also operate on other patients, non-vet patients, and so I think there’s been some bleed over effect because it’s mandated to have palliative care involved in those implantation of L-VATs.

Then the other is that we just have a really fantastic palliative care team that has worked incredibly hard over the past two to three years to really gain the trust of the surgeons and the trust of the ICU different intensivists working there, so that I think has really changed things. I think this idea that people have seen the success or what success looks like with palliative care has been really powerful.

Eric: Yeah, we actually had a podcast with Vicki Jackson a ways ago and we were talking about her stem cell transplant paper in the New England Journal. New England Journal? New England Journal I think or JAMA. One of those two.

Alex: One of them, somewhere.

Eric: She talked about how like building this, it’s all about relationship building, building these services. It’s not just about like delivering a very specific type of care, but it’s about building that relationship with these different service lines.

Alex: Eric, what is our relationship with our cardiothoracic surgeons here?

Eric: It is we are building our relationship. We all …

Alex: There’s a lot of building to be done.

Eric: We all want the very best for our patients. I do think that. That’s the hard part. At the heart of it we all want what’s best. We all want what they want. I think there’s really hard forces at work. I think the 30 day mortality rules are, it’s one of the downsides of quality measures.

Alex: Yeah, unintended consequence.

May: Well, it’s [inaudible] that you mention that because we actually did a paper on that and didn’t really see a difference in differences or timing of death in states that had 30-day mortality rules.

Alex: Wait, say more. What did you look at?

Eric: Here we are. Wait a second.

Alex: Different paper, but also very interesting. What’s the headliner?

May: The different paper is that … So one of the things, and I think that this is our misconception, so I want to say that I also had the same, and I think intensivists also feel the same way, that surgeons do not want to talk about these things because of their quality metrics that they’re concerned about. While there is some data to suggest that that may play a role, I think when we looked at it empirically there’s actually very few states that use a strict 30 day mortality metric.

The only one at the time that we did the study was Massachusetts, so we compared the timing of death in cardiac surgery patients who were still in-hospital, so the only ones that surgeons would be able to affect timing of death for at 30 days, and didn’t find any significant increases in that mortality after 30 days in comparison to a state that uses a combined metric of 30 day mortality and in-hospital mortality, so in-hospital mortality regardless of timing.

Eric: Well, this is the really hard part for me to get my head around is like these, I’m thinking of my N of 1 trials where on a practical boots on the ground perspective, it certainly feels like that is an issue. It would be really interesting to see like from a VA perspective, looking at VA data, can we see a signal in that data? Because it certainly feels like it, kind of boots on the ground. You talk to other people it feels like it, but I certainly recognize it may not be anything?

Alex: It may be a rumor. Maybe.

Eric: Maybe.

Alex: I mean, is it a quality measure within the VA? Do you know, May?

May: Off the top of my head I don’t know. Yeah, I should say that I don’t know, and then interestingly, CMS started measuring 30 day mortality after CABG surgery, coronary artery bypass graft surgery back in 2015, so it’s out there now, so that may affect things more, but I think that …

Eric: It will be interesting to see what happened between 2013 and 2017.

Alex: Right.

Eric: Whether or not anything has changed.

Alex: That you could do with a large Medicare dataset.

Eric: I can’t, like I can’t understand why it wouldn’t change. Like we put together these metrics to actually change behavior, right? Like we want it to do something. If it didn’t do anything, why even put it out there? So the fact that it doesn’t have other ramifications like encouraging people to be very aggressive for 30 days …

Alex: But I guess there’s also the question of does it happen on a big enough scale that you would pick up the signal or is it these sort of cases that we hear about …

Eric: The fringe.

Alex: … because once every few years the nurses come to us in the ICU and they say, “I really want to talk to you and consult you, but the surgeon won’t let me.” It doesn’t happen, maybe it doesn’t happen that often, but when it happens, it’s sort of profound and acute and really powerful. The patient’s being kept alive against what some folks believe is their wish or the wish of their family.

May: Yeah. I think that’s part of it. I also think that we probably, or I realized part of the relationship building I think is realizing where people really come from, and I think that Gretchen Schwarze who’s a trauma surgeon palliative care researcher out of the University of Wisconsin has done a lot of really great work at helping to sort of understand why surgeons have that, because it’s definitely true that surgeons have a hesitancy to move towards end of life care and are more kind of life prolonging, but she’s done a lot of really interesting mixed work and mixed methods work and qualitative work to really understand that.

So I think that a lot of what it is is not that we are, it’s just a misattribution potentially of their motivations to beat the metrics. Really the fact that they’re really struggling internally with what has happened to this patient.

Eric: Yeah, I think that what is common amongst these cases is that we all have moral distress around it.

Alex: Yeah. Yeah.

Eric: Shall we move on to the paper?

Alex: Sure. So this paper, what was the … So this paper in particular, tell us maybe a little bit more about what the background was. I know you’ve talked about what your personal experience, but in terms of the landscape of the literature in terms of hospital-based ICU for critically ill patients, where does this paper fit in?

May: Yeah, so I think that when I became interested in researching the use of palliative care in the ICU, you know, one of the things that I sort of saw was this signal in sort of multiple studies that you could, where I had mostly before and after designs, that you could decrease sort of this I’ll use the sort of catchall phrase of treatment intensity, but I think that conceptually that makes sense, but really talking about not having quite as aggressive care, particularly for patients who die.

So I actually started my career really as a health services researcher and so I’ve always been interested in sort of trying to see if I can measure effects across a population and so I kind of wanted to see whether or not I could do that for palliative care and critically ill patients and see whether or not … Because there are sort of issues with measuring receipt of palliative care on a population level, that’s sort of how that came about.

Alex: In terms of the sort of landscape out there, we’ve talked with some folks about integrating palliative care in the ICU. We had Doug White on a podcast talking about his NEJM study. It was really sort of a nurse-led intervention. We talked with, well, we wrote a blog post about that, what did we call it, Fast Food Palliative Care? In and Out Palliative Care? Something.

Eric: The non-palliative care ICU trial for individuals with chronic …

Alex: Right, the single visit approach.

Eric: Right. Chronic Physical Illness, that’s the title I was looking for.

Alex: So how does this sort of fit in with all those other studies?

May: Yeah, so all of those are trying to look at like a specific intervention that is not, and those are I guess Doug’s is really a generalists’ intervention, a generalist’s ICU intervention, and then the Shannon Carson study is really kind of a, I guess a hybrid generalists, not quite palliative, full palliative care intervention, sort of its own thing. They’re looking perspectively and seeing if those can sort of change outcomes.

So what I was sort of interested in seeing is if we could measure a difference associated with having a palliative care program in the sort of like idea of treatment intensity and healthcare utilization. I feel like in the ICU in particular we tend to measure the impact of palliative care across several domains, which are really related to sort of these patient family outcomes, which have to do more with psychological symptomatology particularly for caregivers, as well as sort of quality communication and Doug also measured patient centeredness of care.

Then we also look at healthcare utilization with the sort of going off the idea that aggressive utilization of healthcare at the end of life has sort of been associated, particularly in cancer patients, with increased or worse quality of death and worse quality or, yeah, worse quality of death and worse quality of life and worse bereavement for caregivers. Yeah.

Eric: So you looked at when we think of the spectrum of palliative care we’ve got the primary palliative care interventions, we’ve got specialized palliative care teams that are involved in that care of the patients. You’re looking in this study at specialized palliative care teams, is that right?

May: Yeah, and so it’s an ecological exposure which is sort of one of the major limitations of the study.

Alex: What does that mean? It’s like outside and …

Eric: They’re looking at birds.

May: Yeah. It’s just that it’s a hospital level exposure, right? So I was actually able to see whether or not people were seen by the palliative care team. The question really is if you get care at a hospital, if you’re in the ICU at a hospital that has a palliative care team, does that change your outcome in comparison to patients at hospitals without those teams?

Eric: All right, so as far as the palliative, it doesn’t matter what the palliative care team is comprised of. If they were in, is it the NPCRC registry, is that how you … How did you determine if they had a palliative care team?

May: Oh yeah, that was fun.

Eric: I sense sarcasm.

May: Yeah. That was just a little bit of work because we … So actually the National Palliative Care, the NPCRC, National Palliative Care Research Center had actually put out a study validating the AHA data, the American Hospital Association’s annual survey data, for the presence of a palliative care program. So that has been validated, so we did a combination of looking at that data using National Palliative Care Registry data. So that’s a positive one, right?

If you’re in the registry then we say you have a palliative care program. Then to fill in the holes, particularly since this was really a hospital year exposure, so a hospital can have it in one year and not have it in another, we called programs to fill in the missing gaps.

Eric: Oh wow.

Alex: That’s a bit of work then, calling all these programs. So tell us what kind of outcomes you looked at?

May: So these, because it’s looking at administrative data, these are all and it’s sort of under this idea of treatment intensity, it really is looking at healthcare utilization. I should say that this is all looking at healthcare utilization within an acute hospitalization that required an ICU stay.

Alex: Is this all in New York?

May: This is all within New York State.

Alex: Within New York State, got it.

Eric: You excluded small hospitals too.

May: Yeah, we did. There were too few of them and there was already quite big differences between sort of medium and large hospitals and we just felt like there would be too much and our estimates would sort of be unstable to include them and to the analysis.

Alex: Yeah, so back to outcomes, when you’re thinking about like what can you collect from this secondary data about outcomes of having a palliative care consult in the ICU, what were you able to look at?

May: So it’s all healthcare utilization data, so we looked at length of stay, number of the days in ICU and a bunch of procedural outcomes like the use of mechanical ventilation or dialysis, tracheostomies and gastrostomy tubes, the use of enteral nutrition, use of CPR and then we also looked at discharge to hospice and then mortality just to show that there would be no signal there.

Alex: Tell us what you thought you’d find beforehand? Like if you have a hospital with a palliative care consult team, what would you expect to find in terms of these outcomes?

May: Yeah, so based on the prior studies which were sort of these before and after, largely before and after studies, I thought that we would see potentially a decrease in length of stay for patients who died, but no signal for patients who survived their hospitalization and an increase in discharge to hospice and potentially not necessarily a decrease in every single one, but maybe some sort of overall signal in decrease for the procedural burdens.

Alex: Mm-hmm and length of stay too?

May: Yeah, so a decrease in length of stay for patients who died, yeah.

Eric: What did you find?

May: So we found that there wasn’t really any measurable difference in a lot of the sort of acute care utilization, so no difference in length of stay or the use of any procedural procedures, but we did find that patients who were cared for in a hospital with a palliative care program were significantly more likely to be discharged to a hospice.

Alex: So no difference in length of stay, no difference in in-hospital mortality, no difference in use of procedures, CPR.

May: Yup.

Eric: I also see that in Table 1 you also looked at if they were never had a palliative care or they don’t have palliative care, they have a nascent program or the mature program. Is that right?

May: Yup.

Eric: Did you also look at … Wait, how were those two defined?

May: So basically, the study period ran from 2008 to 2014, and so never is pretty self-explanatory and mature was having all years and then nascent was developing during the study period.

Eric: Okay. Did you look at if it depended at all based on whether you had a, I guess we don’t really know well developed, but at least the longer standing palliative care program versus one that was just graded?

May: Yeah, we did. So we called it our dose response and with my air quotes that you can’t see, but yeah. No, there didn’t seem to be any kind of step up effect between nascent programs and mature programs.

Eric: Well, it’s really interesting too because it kind of goes to our discussion a little bit earlier about the importance of relationships too because having seen a lot of different palliative care programs and even with our program and seeing a lot of the different trials out there, a lot of whether or not we actually are seeing patients in the ICU depends a little bit on like our relationship with the ICU. Do they see value in us? In this data we actually don’t know are these palliative care teams actually integrated in any way with the ICU or seeing frequent ICU patients or never see them at all? Is that right?

May: Yeah. Absolutely.

Eric: That’s the ecological part?

May: Yeah. You don’t have unfortunately a idea of what I would call like touch, you know? Basically penetration. You don’t really know how many patients they’re really able to see, yeah.

Eric: Yeah.

May: Or are seen, or how integrated they are.

Alex: I have a question about Table 3 because it appears in the unadjusted analysis in Table 3 that there’s no difference in any outcome between hospitals that have, or patients who are seen in hospitals that have palliative care programs and patients who are seen in hospitals that do, but in the adjusted analysis it appears that there are differences. How do you reconcile that with your earlier statement that there were no differences?

May: Yeah. I think that these, so this dataset is over a million patients so it’s quite [inaudible], so I think statistical, there’s some statistical significance that has, I’m uncertain of the meaning of the like, the clinical significance of these findings. That had there been a little bit more of a consistent signal across a lot of these secondary outcomes I would have maybe been considered that more, but I think that I learned a lot from doing this analysis and a lot about how maybe to ask this question a little bit differently next time.

Alex: Right. So it’s interesting because as you say, this is a really important point. When you have like a million patients in your study, a difference in length of stay between six and 6 point you know, six days and one hour, maybe statistically significant, but may not be clinically meaningful.

May: Right.

Alex: Yeah.

Eric: So what’s the take home from this study? What should we think about it?

May: So I’ll give you my take, which is that since the results were not exactly what I was expecting to find, but they really did make sense to me after the fact, I think that the one outcome that we were able to really show a difference in, and there’s a bunch of sensitivity analysis around the discharge to hospice outcome to really show sort of, you know, to sort of combat some of the methodological limitations of the study, but I think that that is the one outcome that really is not dependent on timing, which you just don’t have.

Like so even if palliative care teams are seeing patients, right, we know that there’s several studies out there showing that the amount of treatment intensity that they can sort of save is going to be limited by how early we call them. So discharge to hospice is this outcome that’s really not dependent on the timing of when you call and which is also not dependent on something that basically I can’t measure in this data.

I think that that’s a real signal. It’s a small absolute difference, but I believe that it’s real and it as a lot of face validity to me so I think that to me, my take home is that it actually is possible to measure sort of this idea of the effectiveness of palliative care programs across multiple centers. I think it just has to be done in the right way.

Alex: How would you design the ideal study to look at the differences between hospitals or patients who are seen in hospitals with palliative care programs? Or maybe the core question, which is do palliative care consults make a difference in the ICU?

May: Yeah. I think you would ideally have a patient level exposure and that you would, you know which has its own issues because of the indication bias of patients being seen by palliative care versus not, and then you would also have the timing and I think that particularly I think it’s a really tricky thing to do and without those two pieces, I think it’s really hard to look within a single hospitalization at what palliative care can do.

Alex: Right, but that would be the ideal sort of study. Or if you could randomize people, similarly sick patients to receive a palliative care consult or not.

May: Yeah. I think that would be the big study that still hasn’t been done that would definitely help to answer the question.

Eric: Well, it is interesting because I know of no randomized control trial of let’s say cardiology consults or endocrinology consults or gastroenterology consults in the ICU showing improved outcomes.

May: True.

Eric: I love the bars that we set for ourselves.

Alex: Right. You have to have more proof. Yeah, the bar is higher for palliative care consults and arguably for geriatrics consults as well.

Eric: Yeah.

May: Yeah, but I think that some of that my guess is will change over time.

Alex: Mm-hmm and it may be palliative care consults become so well integrated into ICUs that it no longer seems appropriate to have a randomized control trial because it’s become standard of care.

Eric: Yeah.

Alex: Whereas now I think there’s still an opportunity to randomize patients to receive palliative care consults or not because there’s enough uncertainty in the published literature given all the studies we’ve just talked about, this present study, about the effectiveness of palliative consults in the ICU.

Eric: Yeah. I think the big challenge too that we face is what do we mean even when we’re talking about specialized palliative care, what are they actually delivering? Is it from a full specialized palliative care team that includes social work and a chaplain and a physician and a nurse and a pharmacist? How often are they following up with patients?

How many of the domains of palliative care are they addressing? There’s very few randomized control trials of palliative care that actually address a lot of domains, that encompasses the full palliative care team, that frequently follow patients longitudinally. So yeah, we’ve got a lot of work to do so I’m super happy that we’ve got researchers like you looking into it.

May: Yeah. No, it’s I think it’s a really, it’s exciting, right, trying to figure that stuff out. I kind of knew that I wanted to work in this area because I was sort of searching for a research area during my fellowship and everything else that I looked at, when I read the literature I was like, “Well, that seems really difficult,” and then I read this literature and I was like, “Wow, that seems really difficult. It seems perfect for a lifetime of work.”

Alex: That’s right, yeah. If it was easy you could solve it in five years, that’s no career.

Eric: What is next for you, May?

May: So what’s next? Yeah, I think a couple of different things. I think I’m really interested in some of the things that we just talked about, about the heterogeneity of palliative care teams and what that means. I’m also really interested in this idea that we also touched on about the relationships that are necessary to sort of integrate palliative care.

As Alex mentioned I’m a Beeson Scholar and the aims of my Beeson is doing qualitative work to try and understand why ICU doctors do decide or do not decide to call palliative care consults. That is really fascinating data. So those are kind of things that I’m interested in.

Eric: We’re going to have to have you back on once you publish that.

Alex: Yeah, we’ll have you back. When that one out let us know.

Eric: I want to hear the answers to that.

Alex: Yeah, me too. Right.

May: Yeah. No, that’s still a work in progress, but it’s pretty, it’s kind of difficult to, you know, it takes a lot of work to do that type of research but it’s worth it. The data are really interesting and now of course completely color everything that I see.

Eric: I want to thank you for having us on, or for …

Alex: Having us on your podcast.

Eric: I was flying all day yesterday. My brain’s not working, but maybe we could just end with Alex, a little bit more of Life Is A Highway.

Alex: I’ll try.

May: You can do it Alex!

Eric: You can do it!

Alex: [Singing]. All right.

May: Yea!

Eric: With that folks, we will be calling it an end to this podcast. We really appreciate you hanging in there. I thought you did a good job, Alex.

May: I thought it was great.

Eric: Again, join us next week for our next podcast. If you’re interested in any of the studies that we talked about, we’ll include them as links on our GeriPal Blog and just a reminder to our listeners, if you haven’t done so already, please take a second and review us on any of your favorite podcasting apps. May, thank you again.

Alex: Thanks May.

May: Thanks guys.

Eric: Bye everyone.

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