A deep passion for palliative medicine [PODCAST]

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“COVID has brought us new challenges and a genuine opportunity to be part of the critical response to optimize the care we deliver not just to our patients but also to their families and caregivers. I am lucky, blessed to do this work every day and carry such a deep passion.

We are making a difference and impacting care in positive ways. We support not only patients, families, and caregivers but also each other, our colleagues, and other members of the health care teams.

We are all in this together — a shared commitment for assuring humanity in medicine. And each day, we hope that our eyes will see the best in people, our hearts forgive the worst, our minds forget the bad, and our souls remain ever steadfast in our faith, commitment, and love for this sacred medical work we are so lucky to do.”

Patricia M. Fogelman is a nurse practitioner.

She shares her story and discusses her KevinMD article, “A soul that never loses faith.”

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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. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show we have Patricia Fogelman. She is a nurse practitioner, she has a doctorate in nursing practice, and she wrote the KevinMD article “A soul that never loses faith.” Patricia, welcome to the show.

Patricia M. Fogelman: Thank you. Glad to be here today.

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

Patricia M. Fogelman: Sure. I always tell people I’ve had a ridiculously blessed process through a career in medicine. I was a staff nurse in an ICU. I was then hired as a nurse practitioner into the pulmonary practice of our ICU physicians, the pulmonary ICU physicians in that unit. And then from there, because of our work with so many of our advanced lung patients and our partnership with the thoracic surgery group, I was recruited by our local thoracic surgeon to come to Columbia University, where I was the clinical chief of the lung transplant program. I helped grow that and got it CMS-aligned and a Blue Cross Blue Shield Center of Excellence, all those things. We got our market share up in transplant volumes.

And then I met my husband, who’s from central PA, and made a move to Pennsylvania, which was, again, another fortunate opportunity, where I sent a letter to the recruiter at the regional medical center and got this opportunity to start working there. I was then recruited into palliative medicine and kind of grew my career there under the mentorship of Dr. Neil Ellison, who is a chairman emeritus now of palliative medicine.

And from there, I was actually recruited here to my current position at Guthrie, which is a rural integrated health system in the northern tier of Pennsylvania and the southern tier of New York. I’m now the system medical director of palliative medicine for Guthrie as the health care system, and I manage palliative medicine delivery across three hospitals, one of them kind of a critical access site, as well as our outpatient clinics.

Kevin Pho: So walk us through a typical day, and maybe tell us some of the challenging cases that you see on a daily basis.

Patricia M. Fogelman: So palliative medicine is this fascinating entity, right? You’ve got to be comfortable kind of being in a gray space with patients. And I think what brings a lot of satisfaction to our work here is that we are able to kind of walk our patients through this chapter, whether it’s managing their symptoms as they move through cancer therapy, so that their nausea and pain are controlled and they can complete their therapy and come out on the other side. Sometimes it might be the critically ill patient in the ICU that you’re having critical illness conversations about, establishing the goals of care, or perhaps meeting with their families to kind of talk about compassionate extubation.

I think these last two and a half years with COVID have really evolved the practice of the integration of palliative medicine here with the critical care services, and our presence in the ICU has really evolved over the last two years as a result of that. That’s both in part because we’ve had very supportive leadership in the ICU that welcomed a partnership with us, but also because I think the need for integration and the engagement and collaboration with palliative medicine just really started showing a clear efficacy, a clear benefit.

Having us kind of embedded and engaged in the COVID ICU, for example, gave the ICU team more bandwidth to deal with the acute issues that they needed to deal with, and then we kind of took on the majority of the responsibilities for the communications, the goals of care, and family discussions and family meetings. And then, all too often, if those patients went towards a palliative extubation, then we would handle that as well and kind of continue that support. So it was a really good collaborative practice that we’ve managed to evolve here.

Kevin Pho: So you talk about that evolution between palliative care and critical care medicine. Now, what was it like before that evolution, just so I can give my listeners a sense of a before-and-after picture?

Patricia M. Fogelman: So I was recruited here to build the palliative medicine program, and prior to my arrival, there really wasn’t a structure or a process. There was a half-time nurse practitioner who was also split with oncology. We were part of the cancer service line, so a lot of our work is engaged with both critical care and oncology. And there wasn’t this kind of process, like: How do you direct patients? How do you identify them? What should be the trigger criteria for referring patients to palliative medicine? And should there be a process, really, for earlier involvement and engagement in the ICU?

So coming here, there were a lot of things on that to-do list, but within the first six months, one of the things I’m often really the proudest of is that our engagement with providers and provider satisfaction improved close to 90 percent with the surveys we did. And we also kind of established a very visible presence through the system, and part of that is really engagement and embedment. So that’s being in the ICU, present consistently for team rounds several days a week, and meeting with our hospitalist team once or twice a week for huddles, particularly in our high-volume med-surg floors.

I also implemented what I call the palliative medicine acuity score. It’s a daily report that I run that looks at several different elements of a patient’s medical issues and gives me a score of up to nine, and that kind of triggers a palliative medicine consultation. And so I look at those who are scoring five or higher, and I review those charts, and then, if they’re highly appropriate, we’ll often reach out to the team to say, “This patient is scoring very high on our inpatient acuity report. If you agree, would you please consider ordering a palliative medicine consult?”

And what we’ve seen in almost the last three years is that the total percent of patients with a score over five who have an existing palliative medicine consult has steadily been increasing. So I think that’s evidence of outreach, education, and just that steady presence, kind of demonstrating performance and accomplishments that show that the culture, the awareness, and the understanding of how palliative medicine can engage and assist have really come forward here. So that’s been some real progress for us.

Kevin Pho: So what are some things that go into that score that you’re talking about?

Patricia M. Fogelman: So we look at a couple of things. We look at elements of frailty, fall risks and things like that. We look at their nutritional status. We also look at, for example, how many organ systems have an advanced illness or are in a state of failure. And so we may have, for example, a patient with multiple hospital admissions in the last three months, plus or minus falls, plus or minus two or more advanced illnesses, such as advanced heart failure or COPD or diabetes or renal failure or vascular disease. And then we look at those other factors as well, so the nutritional status and their frailty score we throw in there. And so we’re really just looking to see what the combined score is.

We did have it initially set at four, which I thought was particularly vicious at the beginning, and what I was capturing, honestly, was just too high a volume for a team of two providers to support. Some of that, honestly, was almost a little bit on the low-hanging side, so they didn’t really measure. It wasn’t capturing the true measure of inpatient acuity need. And so we bumped it up to, let’s say, a five or higher, and that’s when we really started capturing these high-need patients.

And so those scores are allowing us now, from a setting of ICU, med-surg, and oncology, to see these patients sooner, to start these dialogues sooner, and to really be part of an intercollegiate team for these patients, so that they have a true sense of what a multidisciplinary approach to their care is.

And I always try to reinforce, to our residents, our nursing students, and our provider teams, that we’re taking care of a whole person when we’re doing this. But that whole person is an entity that includes families and caregivers, right? So it can’t just be that we go see this patient, do this care, write a note, and leave. It’s also that we engage with these families and these caregivers and provide these updates and have these ongoing conversations: What are your concerns? What are your additional questions? What do you feel we haven’t attended to?

And frankly, sometimes it’s just coming out and asking, “Are there other things that maybe we could be more respectful or mindful of for you, or for your loved one? And are we missing something? Are we not doing something right to your liking?” And so it’s a real opportunity to kind of get us involved earlier, and I think you see overall satisfaction scores start to trend up as well.

Kevin Pho: All right, let’s transition and talk about that KevinMD article that you wrote back in February. It’s titled “A soul that never loses faith.” Now, for those of you who get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Patricia M. Fogelman: So we have had two heavy COVID surges, and this most recent one, this past fall to winter, was particularly intense. Part of that response here really required me to take a critical look at our team. Again, it’s a team of two providers, and how do you leverage your resources in an equitable way? We’re part of the cancer service line. Our clinic is in the cancer clinic. We’re in and out of these settings with immunosuppressed patients. We also have a very heavy presence on the inpatient oncology unit.

So when I kind of sat down and said, “How do we kind of do this in a way that makes sense?” one approach was to really say, “OK, we’re going to kind of split us into teams, right?” And so one of us would cover the COVID ICU and the COVID floors and then the main ICU and ED, and then the other person could be, like, the non-COVID cases, so the oncology cases in particular, as well as outpatient clinic and then regular med-surg. And we varied the timing. Do you do a one-month rotation? That proved to be a little too intense for some of us. And then we tried three, and then two weeks kind of hit on the right balance. So it’s two weeks at a time of COVID, and that gets you kind of through most of these initial conversations, establishing a rapport with families and kind of getting some goals delineated and identified.

And so this particular case that I wrote about was a case I had been following for several weeks. It turned out, for me at that time, to be about a five-week rotation covering all of our COVID units, just due to some staffing issues and things. And this case was very, very poignant. We had a very young man who had recently completed cancer therapy successfully and had come out with a clearance of his cancer. He had a young family, and he chose to kind of go out and celebrate New Year’s with a few friends, very safe, fully vaccinated, kind of in a safe setting. And then, unfortunately, he contracted COVID.

Whether it’s from going out on New Year’s versus just being out in the community in general, I think that’s really hard to pinpoint. I’m not convinced it was just the New Year’s. He also worked full time. He also was active in a variety of things with his children. So I think there are a lot of potential places where exposures could have happened. But despite every effort we made, he just could not get better. At one point we thought, “OK, maybe we should try to get him to a higher level of care, maybe ECMO.” But then, with a very recent cancer, he was not a candidate for those types of things, and he was not a candidate for lung transplant. And then he just really became too sick at that point to kind of send anywhere.

So we were having these very intense conversations with the family on an every-other-day to everyday basis, where we were conversing about the changes we were seeing, what we thought this might be indicating to us, and what direction this might be going in. We were working with this family to kind of say, “Where are your boundaries, and where are your thoughts going?” And it was a really lovely family, very, very, very honest in their perception of the situation, kind of like, “We hope for the best, but we’re also preparing for the worst.”

And then one day, the worst news really came. He was in multi-organ failure, with high-pressure ventilator settings. Nothing was improving. He was clearly, clearly accelerating to death, and we had a very hard meeting.

And I think when you are embedded in these situations, in these environments with families, and you have these long trajectories of contact over weeks and weeks, especially because your team is the same team, your nurses, your critical care providers, our resident teams, we all have this very vested interest in this family and in this patient. And part of compassion and caring, I think, is that we invest in our care of our patients. It’s just all around an exceptionally difficult experience.

But what stuck out the most for me is that even though we did this work that was so terribly painful and so difficult and just unrelenting, it’s like this battering ram of sadness sometimes, we really kind of, as a team, had this sense of, “We’re going to keep doing this work. This is important work. We’re going to care for each other as well as we’re caring for our patients.”

And that’s what kind of led to that title. You always want to pray that you have eyes that see the best in people, a heart that forgives the worst, and a mind that forgets the bad. And then, as a result of all those things, it’s a soul that never loses faith, right? And so that’s the culmination of that hope. And so that experience was very, very, it was very vital, I guess, just very intense.

And just in kind of bringing it forward: Of all the things that COVID has taken from us, how about we talk a little bit about what it hasn’t taken? What I’m seeing here with our teams and with our nurses, our critical care docs, our residents, my team, my providers, is that it has not taken our compassion. It has not taken away our love for humanity and our ceaseless curiosity in the human condition. It has not taken from us this desire to continue to do good work and to care for these patients.

And rural health especially has this appeal: You are often caring for patients in your community. So it is not at all uncommon that you could take care of a patient or a family in the ICU and, weeks or months later, see them at the grocery store, because this community is a smaller-knit community. And so it’s not at all uncommon that you’re going to have these ripples of connections to others through the community. Or you’re taking care of someone, and you find out they’re related to someone in the hospital, or that person contacts you and says, “You’re seeing my uncle,” or, “You’re seeing my granddad. Can I be part of that meeting? Can I be part of that discussion?”

So I think it just kind of became important to bring some attention to the things that COVID didn’t take from us, right? I think that it’s been hard to watch the attrition in health care personnel, particularly in nursing. It’s been hard to watch the burnout and the fatigue, feeling that public pressure of that tide turning, from being kind of pro-support of health care providers to now kind of being like, “Well, you’re perpetuating the problem because you guys are pushing an agenda,” or, “Vaccines are not the answer,” and things like that.

But at the end of the day, all those things, to me, kind of fall away at the bedside of the patient. We’re here to care for the person in the bed, and your choices up to that point, or your decisions or whatever, aren’t what I’m here to judge, right? I’m here to help you as best I can, and we’re going to do our level best to make things better. But know that sometimes, despite our very best efforts and our very best technology, we can’t.

And I think people also mistake this. They think, “Oh, rural health, you don’t have a lot of tech.” But this is a really top-notch, high-end medical center. We have a shock trauma program, and we have a very, very lovely ICU with all of the top technology. We have a super involved, engaged cardiovascular service line with a breadth of service. So we offer some pretty sophisticated care for such a rural area. And I think that’s a really phenomenal stroke of fortune, to be able to do that kind of work and to be able to serve a community this rural, because I don’t think that happens in every rural community.

But this is the same care everyone deserves, right? And so I think it’s also the flip. It’s the care everyone deserves, but as the care providers, as a team, this is also the care and acknowledgment we deserve, to kind of remember that despite the very tough things happening in these tough moments. There was a recent quote by Brené Brown that kind of said, “These are the tough edges of love.” When you’re in these conversations, palliative care really engages in those tough edges of love. And I think that’s really what we’ve all kind of stepped back as a team and said: “Yeah, this work we do, a lot of times, this right here, these are the tough edges of love.”

Because these are patients who are critically sick. They’re often the sickest and most vulnerable people in our institution, and we’re doing everything we can to really try and help. Some days that’s making your pain better and relieving your breathlessness. Other days it might be helping you fill in an advanced directive so you have some resolution and peace that you have a plan of care in place. And other times it might be opening the door to a super difficult discussion that you haven’t been able to kind of effectively have with your family, and so we navigate that for you. So I think that we’re very lucky to have this huge range and scope of stuff we can do, and we just derive so much satisfaction from it.

Kevin Pho: Now, whenever you talk to families, of course, in the palliative care setting, a discussion with one family may be completely different from a discussion with another family. What kind of questions do you ask to get a sense of that particular family’s values that may influence their decision-making?

Patricia M. Fogelman: I always ask questions to give me several pieces of information. One is to always kind of find out how they like to receive information, right? Some folks are really high information seekers; some may be more middle of the line. What I also ask is, kind of, “Tell me what your understanding is of where things are at right now.” So are they on the same page? Do they have the same information that I have? And if they don’t, that’s a starting point: “So let me tell you what I know, and let me tell you what my updated understanding is.”

And sometimes it’s just a very simple question. I’m known in my space for being the person who asks the question, and my residents will tell you this. A lot of times I start off meetings with a very simple, “If I told you you’re pretty sick and it’s pretty serious, would you agree with me?” I kind of just put that out there as the first question. And most of the time, people really say, “Oh, no, I agree with you. I think so.” And sometimes they’re just like, “No, I don’t think so.” And that gives you a sense of where the disconnect might be and where you might need to kind of start with the information providing and bring things to bear. Those are the things I like to try and suss out at the beginning.

And then, as the meeting goes on, I usually also want to kind of know, because again, this is whole people caring for whole people, as Ira Byock says, and so it’s important to know: What are the things that are important to you as well? Like, is there something, for example, from a religious or cultural perspective that I could be more mindful of? And if there is something, how can I do that for you? Who can I call, or who can I ask for help to make that better? Or is there someone I can call for you? Sometimes it’s reaching out to their own spiritual care community, or one of their designates, to kind of say, “Can you come see this patient for this family?” And so I think that that’s the type of information you want to at least try to get.

And if you know you’re going in to deliver some bad news, so, for example, you’re going in to tell someone that their cancer has progressed, or that chemotherapy may no longer be an option because of this progression, then also go in there and be ready to kind of deliver a warning shot a little bit and try to prepare people, and just say, “This could be kind of a difficult conversation. Do you have everyone here that you would want to be part of a conversation like that, or are there other folks that we should include or call or have present? And how should that be for you?” Because I don’t want you to feel like you’re hearing a lot of information and getting overwhelmed and then feeling alone or struggling with isolation. And so those are those preemptive things, I think, that are just as important as the actual meeting itself.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Patricia M. Fogelman: Yeah, I think the take-home messages are always from the perspective that palliative medicine is certainly here to help engage in the care of the advanced illness patients. We are another division of medicine, another subspecialty. We’re all board-certified in this. We’ve had various career trajectories that got us here. One of my partners was a hospitalist who then pursued palliative medicine. My background is pulmonary critical care, and then I segued into palliative medicine from there. And another one of my providers is from primary care and moved into palliative medicine. So I think we all kind of bring something to the table that kind of shapes those experiences.

And I think the second thing is to just really remember, as health care providers, that I’ve never experienced in my life a time where taking care of ourselves has been more important and more vital than now. And it’s also, at the same time, a period of life where it’s difficult to care for ourselves maybe as well as we need to or should. But there are countless resources out there. The Center to Advance Palliative Care has an entire COVID-19 resource webpage, and it’s all free. There’s no membership required. And in that, actually, is a great section called emotional PPE, and I pull from there when needed.

And even just the experience of, where do we stand on our team? How do I bring them back and ensure their resilience? And so I meet with everyone individually, every week or every other week, and once a week we do some time together to reconnect. So it’s often a lunch, and sometimes it’s quick, or we kind of spend a little time at the end of our morning IDT doing a quick debrief. And if any one of us seems to be struggling with a case, or having trouble with a family, or just clearly starting to get to a point of some frustration, another person very quickly says, “Let me take that family meeting for you,” or, “Let me see that patient for you today. Can you see this one for me instead? Or can you see this clinic patient for me instead?” And we’re sharing that work burden.

And I think we’ve been really good about protecting ourselves from a resilience perspective, so that we can continue to do this work. And so that’s really that big takeaway: to remember to invest in ourselves and to care for ourselves, so that we can take the best care of others.

Kevin Pho: Patricia, thank you so much for sharing your stories, time, and insight, and thanks again for being on the show.

Patricia M. Fogelman: Thank you.

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