Zoom Clinical Call Provides Help to Physicians About Palliative Care

The COVID-19 outbreak has radically transformed healthcare, practically overnight. While American patients are accustomed to going to their doctor’s office or the ED when they feel sick, the pandemic accelerated the adoption of new models of care delivery. For example, as more and more patients were told not to leave their homes unless absolutely necessary, often at the urging of the healthcare community, the use of telemedicine quickly became more widespread.

The current challenge is making sure primary care physicians, and other medical specialists who may have been called into action during this crisis, are prepared for the ongoing wave of COVID-19 patients, many of who may be in dire health, and patients who may have put off health concerns during stay at home orders.

This is where physician associations can play a key role. Physician Performance LLC (PPLLC) is a federation of many different types of provider groups, including a large faculty practice, community health centers, solo and small group independent practices, and IPAs. While hospitals in our area were focused on COVID-19 testing, securing equipment, and managing the surge of cases over the past month, PPLLC has been working with its physicians and physician groups to help prepare for the wave of patients that is expected to continue in the months to come.  

In the early days of the pandemic, a weekly Zoom meeting clinical call was created to communicate together, and to provide helpful guidance for all health care professionals. The first Zoom clinical call centered on triaging patients, the latest resources available for COVID-19 testing, and new patient flows for those needing ED and urgent care services. In a later session, guest presenters tackled another essential topic: palliative care. At PPLLC, we understand that many physicians prefer to leave that care to palliative care specialists; however, we also realize that over the course of the crisis, many of our doctors will continue to be faced with the heart-wrenching reality of delivering telemedicine to patients who must confront end-of-life decisions.

Now is the time for physicians to be working to better understand how to address these difficult conversations so that patients get the care they deserve, in the most dignified way possible. Dr. Mary Buss, Chief of the Section of Palliative Care in the Division of General Medicine at BIDMC says, “COVID is truly a wake-up call for physicians to do advance care planning with patients.  As physicians, we know this is important work, but often we struggle to find or make the time to have these conversations with our patients, as we juggle all their medical problems. The COVID crisis has placed an urgency to have conversations about what matters most to patients, and to help them plan.  We need to have an open dialog with our patients now and into the future.”

During a recent Zoom clinical call, Buss gave a presentation which highlighted these three foundational steps to help patients with the initial steps of palliative care:

• Identify a PROXY. If a proxy is not identified in your patient’s chart, ask “Who do you want to be your voice if you become unable to speak for yourself?” If a proxy is identified, confirm that the contact is correct and that the patient and proxy have discussed the patient’s thoughts and wishes. Update the chart accordingly. 

• Elicit PREFERENCES. It’s important to explore your patient’s definition of “quality of life” and their attitudes toward declining health. Broach this conversation with open-ended questions such as, “If you undergo interventions/treatment, what are you hoping they accomplish?” and “If doctors were unsure if a medical procedure would help you, would you consider trying it?” Many doctors report that when asked, their patients want to spend their final hours in the familiar surroundings of their own home.

• Recommend a PLAN. Patients want and expect guidance from their physicians. Be honest about uncertainty and give recommendations that take into account the patient’s preferences, as well as their prognosis. Some patients will be very clear about their wishes. Your response to them might be, “You seem clear in your desire to avoid being put on a machine. If you are certain, then we should complete some paperwork to document that.” Others may want interventions early, but not if their prognosis worsens. Consider dialogue such as: “I understand you want comfort at the end of your life. To honor that, we should continue as we are currently; however, in the event you become critically ill, we will focus less on interventions and more on quality of life and time with your family.” If your patient is ambivalent, offer a telehealth visit with a specialist like those with the BIDMC Outpatient Palliative Care Team, who can help patients work through their options in more detail.

ED and inpatient physicians are on the front lines of the pandemic, but there are many scenarios that are being (and will continue to be) managed at home as well. By reviewing palliative care procedures, PPLLC physicians will be well positioned to provide compassionate care even after the COVID-19 crisis subsides.

Alexa B. Kimball, M.D., M.P.H., is the president of Physician Performance LLC (PLLC), the CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center in Boston and a professor of dermatology at Harvard Medical School.