Palliative care during the pandemic [PODCAST]

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“We are health care workers. We are doctors, advanced care practitioners, nurses, pharmacists, social workers, and so much more. We are on the frontlines. We are our parents’ children, and we are parents to our young children. For the first time, we are at an extremely high risk of being quarantined by the same beast we are trying to conquer. We are experiencing moral distress, guilt, and frustration, knowing our colleagues and patients need us when we can’t be there. And now, for the first time, we feel like you need to know what we are truly feeling.

For the first time, there is no you or I. No famous or average. There is no difference in race, sex, religion, or culture. We are one and the same, and for the first time, we all know what it feels like to be in each other’s shoes. You are me, and I am you. We are you and I. For the first time, we are all equal in the eyes of this virus as it challenges us all physically, emotionally, socially, and spiritually.”

Simran Malhotra is a palliative care physician and can be reached on Instagram @drsimran.malhotra and on Twitter @simranm15.

She shares her story and discusses her KevinMD article, “The many firsts of coronavirus.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Simran Malhotra. She’s a palliative care physician, and she wrote the KevinMD article “The many firsts of coronavirus.” Simran, welcome to the show.

Simran Malhotra: Thanks so much for having me.

Kevin Pho: So we’ll get into the article in a bit, but first off, tell us your story and your journey to where you are today.

Simran Malhotra: Yeah, so I was born and raised outside Toronto, Canada. After med school, I moved to Maryland to pursue my internal medicine residency. During residency, I met my now husband. We got married, and after that, I went to Hopkins to do a one-year fellowship in hospice and palliative care. I finished that in 2016, and then over the last four years, we had two kids, and I’ve been working as an inpatient palliative care consultant. So I’ve basically been part of an interdisciplinary team that sees patients with serious illness. So every day, I help patients make difficult medical decisions, help them with difficult symptoms, and just kind of address their overall goals of care and priorities in life.

But one of the things is, over the last few years, as I was caring for these seriously ill patients, I started to feel that despite our aggressive approach with pharmaceuticals and interventions, patients still continue to suffer with suboptimal quality of life. And so because of that, my own personal strong family history of cancer, and my own genetic predisposition to cancer as a BRCA1 carrier, I became really interested in lifestyle medicine, and kind of how, using approaches such as food, exercise, and stress management, we can use those approaches to treat, or reverse, treat, and prevent chronic illness.

So my interests have kind of shifted a little bit, and it’s kind of interesting, because I mostly deal with end-of-life care. But right now, I’m working on completing my certification in culinary medicine, culinary coaching, specifically to empower patients to cook at home. And then I’ll be taking my lifestyle medicine boards in November. So eventually, I hope to merge my passion for palliative care, culinary medicine, and lifestyle medicine to truly provide more of a comprehensive approach to patients with serious illness, to improve their quality of life and maybe even provide some longevity.

Kevin Pho: Wonderful. And how has the pandemic affected you and your practice?

Simran Malhotra: Interestingly, and this is kind of what I wrote about in my article, which we’ll get to in a bit, it’s been interesting how most of my job, the heart of my job, was always sitting face to face with patients and families: empathizing, listening, helping them make incredibly difficult decisions. So much of it was face to face. And now, with most hospitals having a zero-visitor policy, mine included, I transitioned more to a telehealth model, and having end-of-life care discussions via video has been probably one of the most humbling experiences of my life. I don’t even know if I have words to describe what I’ve seen over the last four months. But, you know, what I wrote about in my article, about patients dying alone in ICUs, is exactly what I saw: the existential distress in families, as someone sitting across a screen to provide comfort. It’s just so difficult, but it’s very humbling.

And so I think the other thing I saw in my practice is that, you know, our colleagues would always call on us for these difficult decisions, but just like there was a shortage of ICU beds and ventilators, there was a shortage of palliative care clinicians. And so watching some of these residents and seasoned physicians struggling with these incredibly difficult conversations, it was really hard.

Kevin Pho: Now, what have you learned over the last few months? Because clinicians across the country are going through similar stories, like what you’re describing, in terms of zero-visitor policies and having difficult conversations remotely. Can you share any advice and tips with these other doctors?

Simran Malhotra: I think the biggest thing is just to remember to be human and to remember to empathize. You know, we all know what it feels like to have family and to be away from them when they’re sick. We can only imagine what that feels like. So I think my biggest tip would probably be just to be human, to listen, and to let them speak. Let them speak their fear, let them speak their anxiety, and sometimes just that in itself can empower them and give them comfort.

Kevin Pho: Now, let’s get to your KevinMD article, “The many firsts of coronavirus.” So you talked about this briefly earlier, but can you walk my audience through that article and the reasons why you decided to write it?

Simran Malhotra: Actually, funny enough, the article came to life purely as a journaling exercise because of my own COVID-related fear and anxiety around the uncertainties of the disease and the future. So I wrote it at the beginning of March, as the pandemic was starting to emerge here. And so I wrote it from my very different views. Some of the things I wrote about, I actually experienced over the last four months, and some of the things I didn’t, thank goodness, like the lack of PPE. I didn’t have to experience that, so we were grateful for that.

But, you know, personally, my husband’s a critical care physician, so I knew that he was going to be in the trenches when it came to COVID. And the crazier part of all of this is we spent much of January and February planning for and being anxious about my preventative surgeries that I mentioned earlier. I’m a BRCA1 carrier, so I had a preventative mastectomy and hysterectomy planned for June. And so all of a sudden, that fell through, and so that’s where this article, I just started writing.

And so we have, like I mentioned, two kids under three and a half. All our families are in Canada. We all of a sudden started planning for the worst-case scenario, you know, got our estate planning and our guardianship papers in order, and just kind of, to be honest, for the first time as doctors, feared for our own lives going to work. So that’s kind of where the article came from. It was just purely me writing out what I was worried about.

Kevin Pho: Sure. And you wrote this article back at the end of March, and we are now speaking in the last week of July. So you mentioned that the PPE situation is a little bit better now, but what else has changed now compared to when you wrote that article back at the end of March?

Simran Malhotra: To be honest, from a general, just worldwide perspective, outside of medicine, I think it’s just amazing how this pandemic has forced us all, in medicine and outside of medicine, to just put our lives on hold, to be more mindful of the little things in life. You know, I’ve seen people spend more time with their families, time outside, cooking at home. And then for the first time ever, we’ve seen the earth healing, which to me is just incredible. You know, people in India are saying they see the Himalayas from places they’ve never seen them before. Air pollution in China is getting better, you know, just things like that.

And I think with all the other events that have taken place over the last four months, it’s shifted, just on a human population level, our thinking. People want to be better. They want to do better. They’re vocalizing their feelings. And so I just think we’re moving toward a better future, for us, for our children. So I, you know, we’ll see what happens.

Kevin Pho: Now, is there anything that you know now that you wish you knew back before the pandemic started?

Simran Malhotra: I mean, I wish I knew my surgeries were going to be canceled, right? Because then I wouldn’t have spent two months stressing out and being anxious. So I guess the biggest thing COVID has taught me is, you know, you control what you can. And this is what I tell my patients. My signature line is, you know, “We hope for the best, and we plan for the worst, and in between that, you just got to live life,” right? And so COVID has shown us that you don’t know how your life is going to change tomorrow. So we just got to live for today.

Kevin Pho: We’re talking to Simran Malhotra. She’s a palliative care physician, and she wrote the KevinMD article “The many firsts of coronavirus.” No, I’m a primary care internal medicine physician. Can you share some tips with other primary care doctors in terms of how to approach palliative care, end-of-life issues, and advance directives in a primary care setting?

Simran Malhotra: I think I wouldn’t be a palliative care doctor if I didn’t bring up advance care planning and advance directives. So I think COVID has just brought to light the dire need for advance directives, and I think currently only about a third of Americans have them. So I think whether you’re young, you’re healthy, you’re chronically ill, and now even if you’re a health care worker, I think you should have an advance directive. And from my personal experience, discussing end-of-life wishes when someone’s acutely ill in the hospital is extremely difficult. There’s just so much emotion and anxiety that clouds your ability to think clearly and make an informed decision. So the best place to do it is at home, with your primary care doctor, when you’re able to have a conversation about it and think about it. So I think talking about advance directives is probably one big thing.

And then I think, just like I said earlier, we all got to just remember to be human. We’re all going through an incredibly difficult time. Everyone has something or other that makes their situation unique. So I think we just need to listen, be compassionate, empathize, and just get through this together.

Kevin Pho: And my final question: Can you share a take-home message that you want to share with the KevinMD audience?

Simran Malhotra: I mean, I think, a little bit outside of palliative care, and just kind of health care in general, I think, you know, the pandemic will eventually end, but I think there are some much larger epidemics in this country that have been preexisting and are now emerging and need major attention. The two things that came to light from this pandemic, in my mind: Number one, and I’ve seen this personally with COVID over the last four months, is that African Americans and other minorities have clearly been disproportionately affected. And then number two, people with chronic illness, obesity, diabetes, and heart disease have been more likely to get severe COVID-related morbidity and mortality, and a lot of these people are African Americans and minorities.

And so I think we need to work toward kind of correcting these health disparities, these inequities, and again, use the power of lifestyle medicine as part of the solution in the prevention, reversal, and treatment of these epidemics of chronic illness. So if we ever face a pandemic in the future, maybe this country won’t see such devastating morbidity and mortality like we have. So I think that would be the biggest thing.

Kevin Pho: Simran, thank you so much for sharing your insight and time, and thank you for being on the show.

Simran Malhotra: Thanks so much.

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