Hi everyone, good to see you. We'll start in just about another 60 seconds or so. We'll get started. Let a couple of more folks come in. Good to see you all. Okay, well, let's get started. It's a small crowd today, but looking forward to having a good conversation with you all who are here. Thanks so much for joining us for the August Coffee Chat for HMDCB. I'm Bruce Hammond, Executive Director of HMDCB. Excited you're with us today. Thanks so much for taking the time to do this and to be engaged with one another for today. So before I turn it over to today's session moderator, Dr. Jen Burke from Mainline Home Care and Hospice I wanted to share with everyone just a couple of things related to the meeting today. We do want it to be as interactive as possible. So please jump off of mute, have a conversation, share things with one another. This is meant for you to help one another and to help yourself. And so please make sure to speak up and share, though if you're not speaking, please keep yourself on mute if you would to avoid any background noise if you could. So a couple of updates before I turn it over to Jen. First, in September, HMDCB is gonna be partnering with the American Academy of Hospice and Palliative Medicine on a webinar on September 12th, titled Caring for Patients Nearing Life's End, The Final Weeks, Days, Weeks, Days and Hours of Living. It will include one CME credit for you for that meeting. So we encourage you to reach out to Gina at gparisi at hmdcb.org to access the discount code, which will give you a member price. There is a small price for that webinar for everyone, but you can get the AHPM member price even if you're not an AHPM member by being an HMDCB certificate for that webinar. So reach out to Gina to get that information if you would. HMDCB Coffee Chat on October 19th. The next one of these, we're looking forward to another one of these in a couple of months on October 19th at noon central time. So that was gonna be led by Andy Arwari, who is a panelist in that AHPM and HMDCB webinar happening in September. So he'll answer some additional questions that come up from that, as well as kind of facilitate the conversation at the next Coffee Chat in October. Weatherby Resources is providing the next Hospice Physician Documentation Clinic in early November. So those three dates that are on the screen there, again, you can receive a 10% discount by being an HMDCB certificate for those sessions by reaching out to Gina, and she can provide that information to you. And the last thing is, if you are up for renewal in 2024, the continuing certification, excuse me, in 2023, the continuing certification program application window essentially is open right now through November 1st. So visit the website on the screen there, hmdcb.org slash CCP to get more information on that and to apply to renew in 2023 if you're up this year. So without further ado, I'd like to turn it over to Dr. Jen Burke, who is gonna serve today as our moderator. And Dr. Jen, please take it away. Great, hi, everybody. Thanks, Bruce. And thanks everybody for joining the chat today. Just a reminder, this is a really informal discussion. So any questions that you have, please unmute and ask the questions. And then basically this is about sort of informal, share any stories that you might have, ask any questions that you might have, and we're here to support you. So if you need anything, let us know, and we can certainly support you. So anybody have a question about, that they wanna talk about something that's been bothering them or any burning questions they have about hospice that we can start with? All right, so I got some questions, and there's actually two questions that are sort of related from before. So the first one is, can a hospice organization also provide palliative care, a palliative care program? And the second one is, do you have palliative care MPs embedded in your hospice or are they on the home care side? And it doesn't look like either person that asked this question is here, but I thought it was interesting to talk about. My hospice actually does have MPs. They're not on the hospice side, however. We do have a palliative care program. It's a home-based palliative care program. So we have both home care. So the nurse that goes out, it's a hospice nurse under what we call a palliative program. So they don't have the full support of hospice. So if something happens, they have to go back to the hospital. They don't have that hospice medical director 24-7. However, they can go to hospice rather easily from the palliative side. We also have a palliative MP program. So the palliative nurse practitioners actually follow the patients in their home every four to six weeks, sooner if needed, later if needed. So they will see the patients. But again, it's a separate entity as under our hospice umbrella. Anybody else have any palliative care programs that are attached to under, or any MPs embedded in the hospice that anyone can tell us about? Hi, this is Ron Van Buskirk. I'm in Sherman, Texas. We have a similar arrangement to what you have. We have a Pathways Palliative Care Program. Nurse practitioner and nurses, social worker, chaplain, primarily see people in home. The one problem in Texas when people started doing palliative care, Texas requires that to do palliative care, you have to have a home health license. Fortunately, our hospice had that license. So we're able to operate our palliative care program because we see people at home. And there is a nurse practitioner element to that, you said, I'm sorry? Yes, yes, we have a nurse practitioner who essentially is that program, even though I'm the medical director of that program, as well as hospice. I am as well. Anybody else have a similar program or different program that you could learn from? I'm Sandra Frelson. I'm in Austin, Texas. We have a separate palliative care program. It's affiliated with our hospice and only sees patients. It doesn't see patients separately, but we have, so I'm the hospice medical director. We have a palliative care medical director who has four APRNs who do not do any hospice work. And then there's a nurse and a social worker, part-time social worker and very part-time chaplain who's a hospice chaplain, who don't see patients in the home. They really only provide support from the office. But the APRNs and our palliative care medical director all go out and make visits. Great. And you make visits yourself or you're on the hospice side? I'm on the hospice side. Our hospice docs and our palliative care medical director all take palliative care call as well as hospice call. So we have a combined call, but they do have 24 seven support even for the palliative care patients. Nice. Okay. All right. Anybody else have any experiences that may be similar or different? Okay. And then another question that came in was just GIP use. Cleet, I see that you're on. Do you have any, do you wanna expand on that question a little bit, please? Yeah, I guess, as we've kind of looked at it from a regulatory standpoint, we've had kind of some interesting things. Our GIP and respite unit is actually in a hospital and we use Epic. And so that's created two kind of unique situations. So trying to use GIP with Epic in a hospital is very hard because if you switch between levels of care, you have to create new accounts. So like, and you have to start over with charting because they use like Epic-based charting for like an inpatient-like hospital. So like if you switch an account for six hours later, then you're completely restarting nursing, charting and all that stuff. So we haven't been able to actually figure out a way to use it now, just because where we're looking at it from a regulatory standpoint, we haven't been able to figure out how to use that GIP level of care while using Epic charting in a hospital-based setting. So it's just been something we haven't been able to use. So we've been using respiratory routine care primarily, but I don't know if anybody else has a similar experience with trying to use Epic in a hospital and trying to meet the demands of documentation for GIP level of care, but we haven't yet figured out how to do that effectively without an enormous amount of nursing documentation in order to make that happen. We have Epic as well. I'm sorry, go ahead, Kamal. I don't fully understand the question. So the hospital is using the Epic system and then you have your hospice system and you're saying that if the hospice changes the level of care, then it messes with the hospital's documentation? Yeah, so basically, you know, so now we're using, we went on to doing hospice documentation through Epic remote client last May. We've been doing that for over a year. The issue becomes is the way that the hospital is set up, like the beds that we use are swing beds in the hospital. So they're not dedicated to hospice, but so then what happens is, is that if a patient comes in and if we were to use GIP level of care, they would create an encounter for that from a billing standpoint. But if we switch them from GIP to routine, that's a new hospital encounter. And so like all this like nursing charting that you have to do for Epic and for billing, they have to do it all over again. And if we were to switch back to a different level of care again, they have to do it again because we're using it in the swing bed situation. If we didn't, if the beds were dedicated, we wouldn't probably have to do that. But it's been a unique situation that actually our whole health system, it's not just me and my region. I work for UnityPoint in Iowa and they're in Illinois and Wisconsin. And we have like six different regions and we're all kind of trying to figure out the same thing. It's how to use Epic in a hospital setting to provide GIP level of care without having to do so much documentation that makes it almost impossible to be able to do it. In addition to the fact that the GIP use and scrutiny with that has changed quite a bit too. So, you know, there's kind of really two factors going on with that right now. It has to do with the FIN. Like they have to change the financial number so that they bill hospice and not the hospital. So we do it as well. And it is rather cumbersome in that you have to do a discharge summary, you have to do another HMP and you have to do then the final discharge summary when the patient dies and or goes home. So there is, but I don't think our nurses have to do quite the full Epic sign-on that they have to do when they come on because it's a hospice encounter. So you may wanna talk to Epic and see if there's anything that they can kind of pull out of that. Well, that's a whole nother thing. Yeah, that's coming up is optimization in Epic for hospice. I mean, I guess I feel like that maybe other people have had experience with this too. The way that Epic built their hospice build, I think did it to try to like meet every regulatory requirement possible. But the problem is, it's probably way too- And more that aren't. And more that aren't. So we're trying to work with them as a health system right now to see if there's a way we can optimize that so we don't have our case managers doing as much documentation. I mean, you could get lost in that for hours with stuff. So we're trying to streamline it so we don't have to do as much redundancy or stuff that we just don't need to do. Yeah, a lot of our attendings, just the discharge and the re-agent pay is enough to kind of turn them off from having to do that. But the benefits are, it is a Medicare benefit that people are eligible for and mortality. So they kind of weigh those two kind of standards with it. But yeah, thanks for clarifying. Anybody else have any experience doing that? Any tips or tricks for Clete? I can share my experience during a fellowship where I was doing hospice and palliative and the hospice rotation. Inside the hospital, we used Epic and we had to do charting with the hospice agency and charting for the hospital. So irrespective with Epic, we have to put the discharge summary and the daily progress note so that we comply with the hospital policy. However, our billing and everything else we do is through the hospice agency by dictating through their system, which is completely different from Epic. I don't know if that might help out. So Clete, my question is, what happens if you were to GIP patient in the hospital and then look back later and say, I'm gonna downgrade this level of billing? So, I mean, the way we'd have to do it is we would have to go through the hospice agency and then we'd have to do it from a financial standpoint is then we have to change the level of care. And then it comes up to that, it's a different financial number that we have to switch them to. So we have to create a new encounter, essentially, for that hospital stay. If we were- And nobody can help in the background? I don't think so. They've looked at it from the health system standpoint and haven't been able to yet figure out how to do that. If it's in a different facility. So in my region, we use our hospital for this with swing beds. In a different region, we have a hospice house because then it's using remote client Epic Hospice and you don't have to create these different accounts like we do in the hospital setting. That's where the issue has come up. It's because it's not dedicated beds. It's swing beds in the hospital. It can be used for anything, but because we're using it like that and the way that Epic interacts with it with billing, it creates this kind of unique situation. And we're starting to see more of this. I'm not sure, because I know I've read this about across other areas, but like in Iowa, at least, hospice houses are struggling and or closing too. So we're having to work on this issue even more now because there's some of our regions that use that hospice houses that just haven't been able to continue to operate. So now that we're having to use our hospitals more to do that and that's made it more complicated while at the same time using Epic. It just doesn't make any sense to me. I'm trying to wrap my head around it from a regulatory perspective in which that's exactly why you're asking because a lot of this stuff could be solved in the background, which of course I'm speaking from not experience with Epic in this particular situation. But like, for example, you have to have the ability to change the level of care later on if you met that or found out that you didn't meet that level of care. And so there has to be a way to administratively change the level of care without changing the episode. It has to be that way. So like, how can you push back on that to be like, how much of this is you making me work within the construct of the hospital that I don't actually have to work within because this is a contract of bed regardless of how it's licensed, it's contracted to you. And so it should be there bylaws that you could work with them on. Does that make sense? Yeah, I mean, I'll have to probably provide feedback at some point. I mean, from our health system standpoint, like at a higher up level and from our legal financial, it's not happening right now. So we're restricted in it. And hopefully like as we go through an optimization project with it, that there'll be a better answer. But I was just interested if people had similar issues. The other issue too is we need to optimize our community-based hospice Epic documentation too because that's right now probably too onerous. And hopefully we'll be able to do that at some point as we go forward. Yeah. Robin, you had a comment? I was just gonna agree with Lauren. It seems like they're having to jump through hoops for the hospital system requirements. And we do this, we do GIP here at Duke. We're not on Epic. Our hospice is not on Epic yet. It's moving towards Epic. If we downgrade to routine level of care, there's really, it's administrative. We don't see any difference at all. There's no extra provider work at all. So I don't think it's required. And that's what we would do in our inpatient hospice facility as well. Absolutely. Great. Let's start with ensuring that the hospital doesn't think they have to follow the swing bed rules. When they're not using the bed according to that Medicare standard, they don't have to meet that Medicare standard. Just like if you GIP a patient in the hospital, you don't have to do an HMP and discharge summary. There's no Medicare hospice requirement that says that you have to do that outside of the hospice's requirement. And so it's you meeting the hospital bylaws that they apply to their standard of hospital level Medicare. And so if it's costing your hospital mortality numbers because they're not using the GIP level of care because of this, if it's costing them quality and patient care, that's how I will get their attention to use this appropriately, maybe to work with you on this. Because there's other implications to this not- They're very aware of the mortality part of it. And so that's actually probably the pressure point that will change things eventually, but it's getting it to work across several regions and three different States and within Epic and different hospitals because they want it to be uniform across the system. Yeah. Afraid. So speaking of- Yeah, tough one. With this, how do you control agitation? And so I guess that's a question I'm going to throw out there. How do you control agitation? And I know Ronald, you asked this, do you have anything specific you want to know or just generalized? Yes, I'll be as brief as I can. About four months ago, someone at our hospital sent out a letter to everyone in the hospital that we could no longer use antipsychotics to sedate people at all, period, basing it on some Texas code, which I went and looked up yesterday, and it really doesn't say that. But they listed the medicines that we could not use to control agitation, including Halball. And then when I asked some questions, I got a letter which says I can't share any of the letter's information with anybody or I'll be sued. So I can't really disclose too much about that, except we're operated by UHS, a corporate company out of Delaware, who is supposedly sending an expert to teach us how to deal with behavioral issues. He's an MD with an MBA, so I'm not sure what qualifies him for dealing with bad behavior, except he has an MBA. So I wonder if any of the other, especially people from Texas, if you've encountered the same situation, because they're basing it, they're basing it on what they're calling chemical restraints are outlawed by the TAC code that prevents us from using chemical restraints in the state of Texas. Anybody else dealing with a law that says you can't use chemical restraints? I would have a question. What about Depakote? Do they consider that a chemical restraint? So the reason I ask that is that I do a lot of, I'm a medical director at eight nursing homes too, and actually there's been a big trend in the United States to use Depakote for behavior disturbance, because there's some data regarding verbal outbursts and things like that. And so now our state surveyors have kind of started hinting at that there's maybe some interest in treating Depakote like antipsychotics. And then at some point, where's the slippery slope on that? At some point, if you can't use any medicine to help somebody feel better, you can't do everything with nursing interventions. So I'd be interested in what they think. What about Trazodone? What about Mercosur? What do they think? Trazodone? What about Mirtazapine? How do those all play into those? Because that may fall under that same guideline too. I agree with you a hundred percent. And I just have to comment on Depakote. Two years ago, I ran it and raved against people using Depakote in nursing homes for behavior. And then I read some articles and it said, and I thought, geez, maybe it does work. And guess what? It really does work. And I use it quite a bit. But no, they only listed primarily antipsychotics. Even though in our hospital, I can put somebody on a morphine drip and kill them. I use IV dexmetomidine anytime I want. I can't give them an injection of IV Halbal. But I would think intent is what they're going to fall upon. And if your intent is to alter someone's behavior, and it includes seclusion, you can't shut someone up in a room. Seclusion and alter their behavior are apparently outlawed by Texas law. At least that's what our corporate office in Delaware has told our hospital. I wonder, well, obviously this came from your corporate headquarters and it is hospice directed, but we have different regulations for use of opioids within chronic pain and hospice populations. It just seems that this is different. And I know Brera did a study like years ago that showed people who actually get through this delirium or the agitation, they're very distressed by the experience of confusion and agitation. And it supports the treatment for both safety as well as experience. I mean, I'm not sure that you can argue medically with this MBA who's coming down, but I think there's evidence to support treatment within our patients. I have that article copied enough times to administer to anybody who would take it and read it. But really the people who, the administrators and medical echelon at the hospital where I practice now and then, they really don't like to talk with me. They find me aggravating and confrontational. So this is Tom Browning. I'm up in Massachusetts. So this is an interesting conversation because it's an old conversation, and really going back to the 80s with over-regulations in the early 80s, Reagan era. And the nursing homes were chemically restraining patients on a regular basis. So that's its roots. And we've been struggling in nursing homes trying to manage behavior and justify use of antipsychotics to the point that now Medicare is actually going into records and verifying diagnoses of schizophrenia because medical directors and other practitioners in the nursing home would put the diagnosis of schizophrenia, therefore justifying the use of the antipsychotics. And as far as the treatment of, for us in the acute care setting, it's really delirium, right? That we're trying to treat, the agitation and delirium that occurs with paranoia, delusions, really vivid hallucinations that people remember. And that's what causes this intense dysphoria later. But what's interesting is that if you look at that, there's a couple of studies that show that using antipsychotics in somebody who comes in and is acutely delirious, causes a persistence of delirium, that in fact, they're much more likely to be delirious on day seven if you use antipsychotics. So my practice has been to not use them, to try to use, trying to find out why they're delirious, whether it's medications that have been delivered, opiates that have been given, other medications, hypotension, sepsis. So managing the medical condition as much as you can and managing the delirium to the point where they don't hurt themselves or others, they found that I've been more successful at resolving the delirium. It certainly doesn't prevent them from having those horrible memories, but delirium does not seem to be as persistent. But then the flip side of that is that our patients want us to somehow alter the behavior. And that, I can't do what I oftentimes say, that these medications are going to cause sedation to the point where the patient may not be able to sustain themselves and get families to understand that. And then it's a little bit easier to document why you're using these medications. This is tough. This is so hard to manage. I think it's the toughest part of our practice. So Tom, when you say that, do you mean you stop medications? Like you don't use antipsychotics. You stop medications, you do behavioral modifications. Like what specifically do you use to, you know, that's not an antipsychotic? Yeah. So what I use are, I'll oftentimes just use straight up sedatives. So I know people have this feeling that sedatives like benzodiazepines have a paradoxical effect oftentimes in delirium. I find it's just a dose issue. The dosing just has to be higher. And what you're really doing is sedating the patient. And the families have to understand that you don't have an ability to normalize their behavior with an antipsychotic. They just become apathetic and oftentimes hypoactive and unable to sustain themselves. They don't eat, they fall, that kind of thing. And so it's really patient expectation settings with the family of what you're really trying to do. But my problem with antipsychotics is this issue of persisting in the delirium. So delirium occurs as the patient's sick, oftentimes in the setting of an elderly brain or a diseased brain in some way. And so fixing whatever that is oftentimes is more successful. So concentrating on managing the sepsis, concentrating on the setting that the patient is in, those kinds of things and allowing time to take its place oftentimes will resolve that delirium quicker than if you're using antipsychotics, which in my experience actually caused that delirium to persist. Again, I agree with you 100%, but we're not speaking directly to delirium, but behavioral emergencies. I'm a little bit surprised that none of my emergency room physicians have cared to join me in my attempts to get some kind of reasonable policy. Our hospital has no policy against sedation. I can put you on a morphine drip and kill you, and that's okay because I'm not attempting to avoid your bad behavior. There's no terminal sedation policy, none, zero. If you're struggling to breathe in ICU, I can put you on a dexmethomidine drip and render you unconscious until you die. But I'm not allowed to give you an oral dose of allopurinol if you have agitation. And I've been told that. Yeah. So I think the people from Delaware, the legal foundation it sounds for discontinuing the use of chemical restraints. So we do have to work around that somehow. They're correct. So we have to figure out what language we can use in order to justify the use of the antipsychotics. I mean, that's the only thing. I don't think they're telling you anything that's incorrect. It's just practically pretty challenging for us to manage these patients. And the reason, I would say that the reason that law was there was because of the abuse of antipsychotics in their nursing homes. People were chemically restrained. That's why it happened. And I, interestingly, over my 35-year career, I've seen it start to swing back the other way where I'm battling every day in the hospital patients who will come in or delirious or put on antipsychotics. So the next thing you know, I'm getting consulted because they're NPO, because they can't swallow anymore. And it's really because they've been placed on antipsychotics. So, so it is a struggle. We're a little bit of victims of our use of these medications. So we're going to have to figure out how to use them in some judicious and reasonable way so that we can do it because they are legal and legislative foundation itself. Kind of brought it on ourselves years ago. I agree 100%. So I have a question. We have a, we, we use cure for documentation of our hospice diagnoses. Has anybody else noticed that they've been changing diagnoses? So for example, the other day in my hospice team, they said that the patient's end-stage medical condition was diabetes. So it turned out the patient had renal end-stage renal disease, which is what I put in my CTI. But the coder basically told me that we had to go for the coding convention said you had to put diabetes first. So has anybody else had weird diagnoses that come up in team or just trying to get to the bottom of the diagnosis? That is correct. And that's the, the regulatory standard that we should be following in hospice. We just don't do it. Historically, if you see the top 20 diagnoses, our diagnoses are so generic and, you know, but that's correct. And an auditor won't, it won't translate the way we think it is if you, so what that person probably said is that the number one should be diabetes with chronic kidney disease as the, the number one diagnosis and then ESRD below it. Is that what they were saying? Yeah. So when an auditor looks at that, they're going to grade you on your kidney disease. They're not going to review the record based off of the diabetes alone. So that's not the biggest concern, but it's just that as we, as an industry use appropriate ICD-10 coding, it looks really weird. Like for CHF, it shouldn't be CHF as the principal diagnosis. It should be something like hypertensive heart disease with CKD is the right ICD-10 code. But you're still as the physician choosing that, that this is a, if you're in Palmetto cardiopulmonary or in NGS or CGS cardiac disease, and they're, you know, NYH for refractory to whatever treatment or those types of things, all of that stuff is still in play. It's just that we, as an industry are catching up on ICD-10 coding. Okay. Anybody else have any burning questions, comments, stories? And how about use of AC at end of life, DVTs, PEs, AFib, any thoughts as far as this? That was a question that came up. Did you actually repeat the question? I'm sorry. I didn't hear you. Any thoughts about anti-coagulation at the end of life for DVTs, PEs, or AFib? They wanted to know what their thoughts were on that. Do you do it? Lots of thoughts. We probably all have lots of thoughts. Probably my thoughts too. Well, I would just say that, go ahead, sorry. Yeah, this is Tom Browning again. You know, if somebody has a DVT, I treat them. And if they have PE, I treat them. I think those are easy. I think the prophylaxis is actually so much more challenging and using the tools we have to do the risk-benefit analysis. I just, for warfarin mainly, they're on warfarin and they are unstable. They're out of the therapeutic range more than they're in it. I just tell them it's not helping anymore and stop it. The aliquots, you know, if they've had life-threatening GI bleeds, I can stop that and tell them that they're going to die from the GI bleed, but they may have a stroke. So it is just, you know, so individualized. Just do it one by one. Yeah, I so agree with that. But number one is individualized. So if we're talking about stroke risk reduction due to atrial fibrillation, you know, we have numbers and data and, you know, Chad's VASC and has blood scoring tool to guide us. And so it just really takes physician-led determination on, you know, this is something that actually should have been done outside of hospice. You know, the de-escalation of this type of anticoagulation that, you know, I think that we just get about half as hospice that we stop all the medicines, but when we tackle anticoagulation, when it is really truly indicated, we stop it at three to six months for DVT-PE like you're sexually supposed to, versus staying on it lifelong, stopping Plavix when your drug-eluting stent is, you know, however, wherever you are and what it is. It really takes physician leadership, which I think is, you know, we have to get the right records to understand why those things are being prescribed. Does anybody de-escalate medicine outside of hospice care? So, yeah, nobody does, but so that interesting you brought up the Plavix issue. So I've always stopped Plavix and continued a baby aspirin. Did anybody else see a study that looked at aspirin and Plavix and GI bleeding risk and actually it's higher with aspirin than Plavix? So I've sort of gone back and actually stopped the aspirin and continued Plavix. What does everybody else think? I didn't know that. I think it again comes to the point of the individualization because now that I'm more aggressively deprescribing, I see all this aspirin for zero reason, period. So I think when you know better, you do better and we're still learning on lots of these things. But I would love Tom, if you could share that article. Yeah, that would be good. Please. Absolutely. I'll have to dig around. My record keeping system is not as good as it should be. I guess the only other comment is I don't think anything should be a barrier for appropriate admission to hospice. So, I think just because a patient is on an anticoagulant applying the same approach to deescalation of these medicines should not be applied. Standard of care around deescalation should be applied and it shouldn't be a barrier to coming on to hospice. Absolutely. Yeah, I think very well said. Couldn't support that more. Hi everyone, my name is Danielle. I don't do hospice in the hospital setting. I'm all outpatient. I'm a medical director. Our census is about 100. I've been doing this since 2015. Had my first patient, an 80 year old gentleman with end stage COPD, who was deemed not a suicidal ideation, no suicidal behavior, who did make an attempt on his life in his personal care home. He was in a benefit period where he had to do the face-to-face, no signs of depression, no plan or anything like that. And then we got word about a week later that he did try and attempt to harm himself. I didn't know if anybody else had any other experiences with that. He is fine. The ethical question for me was sending him to the hospital. He's a hospice patient and sending him to the hospital. And he did return and we've readmitted him and he's fine. He has not made any other overtures or attempts or anything like that. As a group, does anybody have any other anecdotes, experiences, anything to share? Thanks. Hi, this is Tom Browning. Again, boy, I'm pretty chatty today. I don't know. Anyway, so yeah, this is pretty fresh. So we had a patient who was the youngest kind of guy with a metastatic melanoma. No, I'm sorry. ALS, he had ALS. And his question for us, and he had a palliative care team in the ALS clinic, was we're in Massachusetts and in Vermont, they do physician-assisted deaths. And there's some ways that you can move to the state and take advantage of that. But it's a little bit onerous for good reason. So anyway, so he was asking me, he was asking his ALS clinic how this could happen. And he got pretty excited because somebody at Mass General said that he could help him do that. He made an appointment up there. And the guy said, no, I can't do that, but we can help. I have somebody in Vermont. You know, sort of all practices. So the guy came back and he said, well, I guess I'm not gonna do that. I'm not gonna move to Vermont. And he got better. He suddenly was, his mood was better. And that was the bad thing because a week later he hung himself. And so, you know, it really was just the same thing that I, when I had a primary care practice, you know, when people are sick, sick, sick, and all of a sudden they think everything's better, they've got a plan. So that was pretty challenging. So I'll just share with you my thoughts that I have not been an advocate of physician-assisted death for a lot of reasons, because I have to talk to him. I think I can manage these things, which turns out to be arrogant that this was terrible, that this guy really did have a terminal illness. He knew exactly what was going to happen. He wanted to be in control and he did not want to suffer. So I have flipped. I formally announced that I will support any legislation to allow physician-assisted death here in Massachusetts, which I've not done in the past, just because this guy didn't need to suffer. I feel terrible about it. Everybody does. We don't think there was anything we could do about it other than recognizing that his mood changed. So clearly that was an indication that he had a plan. Anyway, I'll leave it up to the rest of you. Anybody else have experiences? It was my first week as an attending, as the medical director, I was called that a patient had achieved suicide and I had to come on site and he had used a gun and I had to meet with the JPE and the police. And I mean, it just, I mean, we all think counseling and therapy 100%, I mean, with the career that we have, but really processing the idea of like, when someone makes that decision, it's, you know, that's the choice that they make. We can only do the best that we can do. And Tom, I've been going through a similar transition in my career of not supporting physician-assisted death, but I'm pretty open with that. I do now because it, I mean, you can, we've watched ALS patients. I mean, some of us may be not from diagnosis to death, but I have, and ALS in particular. I think that just is, there are to me worse things than dying. So interesting and hard. What are people's thoughts on VSDV if a person has multiple chronic illnesses, but maybe they're not terminal per se? There's a person that's been floated by me that's actually young in her early thirties with a couple of chronic illnesses. And she's been saying that she doesn't want to live like this anymore. And she has tube feeds. Striving for excellence at her facility. And I don't know if she takes anything by mouth at all, but I struggle with this idea of, and I went through our old list on AHPM. I went through and used the search for V-SED and things like that. And it seems like most people wouldn't take someone on hospice until they actually did do that. And then we're in the trajectory then of being terminal because they have committed to it. And I just wonder what people's thoughts are. Hi, this is Yoli Suarez. I'm from Oregon and where we actually have medical aid and dying laws. I'm a pro bono physician for End of Life Choices Oregon. And this is a question that we deal with all the time. Will we take on patients who have started the V-SED process and now are ready to come on hospice? And I actually struggle with that a little bit, because I mean, I support everybody's choice in ending their life on their own terms. But yeah, I mean, I think once they've reached a point where they have declined, and if they do come to me, I will certainly take them on service. But yeah, I don't know. Our End of Life Choices is contacted frequently by people who want to do the V-SED process and then transition on to hospice. And I don't know, I struggle with that. So I don't know if I have a clear answer to that. It is an issue. Excuse me, what is V-SED? It's voluntary stopping eating and drinking. I'm from Oregon also, and I'll just type in what we do. I mean, we have people that do medical aid in dying. It's a very small percentage. A lot of them get meds and never use them, but more and more, they are using them. And it's really about, seems to be not symptom management, but lack of control. But we, and we do have people that do V-SED. And our policy is that if they're referred to hospice, and we know that, it doesn't affect what we do. If they're appropriate for hospice with a six month prognosis, then we admit them. And then we support them in the process. Where we are challenged is sometimes we have people that don't have a terminal six months prognosis, but are just done. They're elderly, they just, they're done with it. And at that point, if I can't bear it, if I can't certify them, then what we tell the family is to, we refer them to End of Life Choices Oregon, because they will give them a lot of information about V-SED and support them. And- I have to say though, that I am a pro bono physician for Elcor, and the V-SED volunteers do struggle. They give them physical, they give them support as far as volunteer work, but the struggle is in the symptom management that they have. That, and we have one right now that wants, she's not advanced enough with dementia, but she wants to end her life before she gets institutionalized. And so she is struggling because she wants somebody to, she wants to stop eating and drinking, but she also wants support from her PCP, who says he is absolutely not willing to support her V-SED process. But she doesn't meet criteria to come on hospice at this very moment. And so it is very definitely, and she's not in, like when I've talked to her several times and she's still going to the gym and she's doing all of these things that does not, like, I mean, to me, it does not speak that as, you know, end of life. So, but it is incredibly challenging. I've had patients on hospice who request V-SED and I have helped them, especially patients in a facility where I will write MPO orders, I will help them through that process, but it is a very challenging process. And again, I do qualify them if they, if they're into the V-SED process and they meet criteria. But- What I was gonna say is that once they start, we tell them to stay in touch with us so we know about them and we can get them quickly on, because at some point, you know, and we start talking about when they get really weak and they're not getting out of bed anymore to call us, and then we can get in quickly, admit them. Cause at that point, if they stick with it, their prognosis is limited and then we can support them, the family, and also provide symptom management. So that's kind of how we balanced it. But we wanna make sure that, I wanna make sure that I'm following guidelines and, you know, certifying them appropriately. And that's- And then what is your diagnosis? What the chronic illness was? If they have a chronic illness, we can use that. But if not, I'll use something like inadequate oral intake, dehydration. Doesn't, it's not real comfortable, but, you know- But dehydration is an acceptable code? Protein calorie malnutrition is something I- Protein calorie malnutrition, you know, and then add in the other things. But yeah, I will find a way to certify them once they get into the process and it looks like they're changing and they're, you know, committed to doing that. Yeah. And I realize in Oregon, things are maybe a little bit different from elsewhere. I just wanna say, I think with stopping tube feeds, I feel more comfortable admitting because that's a medical intervention, not food. And so, but sometimes people can take more orally than we thought. So I would probably wanna get a sense of their oral intake before I would admit them. Otherwise, I would admit, the tricky thing with VSED, if you admit upfront, is that so many people are not able to continue and pull back. And we've had situations when somebody was kind of, the borderline had a diagnosis that would qualify them for hospice, but the plan had been VSED and I was trying to get them on proactively. And then they were on longer than I expected, but it's still, we were able to support them and they did ultimately have a prognosis of less than six months. And Danielle, I think that realistically for you, I mean, I'm very sorry that that happened to you, but I also think that maybe decompressing with your team as one of your kind of things, because I'm sure if you're feeling this, everybody on your team is feeling it as well with your kind of, oh my God, what happened. So I do decompress with my team a lot. Next time I see them in team, just to make sure that we're talking about it. And I mean, our, as physicians, we've got so many suicides among our peer groups just because of being physicians. So just remember that you don't have to be resilient. So you need to talk to somebody too about it too. And often talking to my team will be helpful for me to sort of decompress. You didn't miss any signs if it happened and it's unfortunate, but definitely decompress with your team. And if you need help too, certainly reach out to somebody else. Thank you. I wanna agree with Jennifer on that, because in our hospice, and I'm sure everyone has some protocol that we go through when we identify somebody with suicidal ideations. And of course this person tried and failed, which I mean, there's a whole nother thing I'm sure, but we embed those debriefings with our bereavement team for staff so that we don't forget it. And I think it's really important in a lot of what we do, vent withdrawals, bad withdrawals, a lot of these things that we do, embedding those debriefs is really important and has been really helpful to our staff. One thing I just wanted to throw out and see what everyone thought regarding that. If someone, like what you do, what's your chain of events. If somebody says to a nurse, I wish this were, you know, I could just end this tomorrow. Tell me how much morphine to take. And so what we would normally do is make sure all our team members are in there, you know, the chaplain, the social worker, maybe even bereavement for anticipatory grief, everybody we can, our whole team, make sure the home is safe, the medications aren't within that person's reach, guns, things like that. But honestly, I remember back to another patient where I wanted to have them see a psychiatrist and really how can you do that in this day and age with mental health being such a difficulty. And now of course, telemedicine has made it better, but the time I'm thinking was before COVID. So, you know, it's really hard to, other than your own team, what else are you doing? And it's so hard to parse too. I mean, how many hospice patients tell you they want to die, right? Right. I mean, it's right. And here you give them this bottle of morphine with 600 milligrams in it. And yeah, it's just like, gives me a little bit of heartburn sometimes when I think about, I go back, I had recently a friend committed suicide and I feel like people who are really committed to doing it, it will happen even with the best of everyone's support. I feel like we're almost doing it to help ourselves and I just think we've done all the best that we can do by having all our team members go into a person's home, if I'm talking about a home-based hospice patient. And as you were saying, just in terms of medical aid and dying, if that's really someone's wish, it's sort of sad that someone has to do that without real support or real, and I live in Pennsylvania, so there's, we don't have that. So I feel I'm really, I wouldn't personally want to help someone do that. So I'm glad I live in Pennsylvania, so no one can ask me to do that, but I hate that others feel so bereft. Go ahead, Ron. Becomes where medicine and religion and philosophy all start to intersect. I live in Texas, which is like Pennsylvania, I don't have to face that question and I'm glad I don't, but in general, I think we view suicide as a way that people choose to relieve their suffering when we have failed to do so, at least that's kind of how I used to view it. There is a book called God, Medicine, and Suffering by Stanley Hauerwas. He's a theologic philosopher, which has at least helped me redefine suffering. So I don't think about it that way anymore. I've gone back to pain and distress. I don't think about suffering so much anymore because I don't think I can really impact on suffering anymore. I used to, but I don't think that way anymore. So if any of you have struggled with that as I have, I recommend that book. Natalie, last comment, go ahead. Lee Jones, last comment. Oh, I just was wondering kind of at a side thing, but if people ever use mental health as the primary hospice diagnosis, I'm thinking of a patient who had a failed suicide attempt, eventually came to our IPU and died. I mean, do you ever, in a long history of depression, bipolar, et cetera, has anybody ever used those diagnosis as the primary diagnosis? I have before in that specific situation. You know, a lot of these questions that we have about what diagnosis, because they apply so well specifically to what you're talking about, that is what you should do because that's what's gonna cue the auditor into what's really going on. You know, like I worry about putting a diagnosis as the principal diagnosis if you haven't defined malnutrition before you admit the patient. As long as physicians are leaders and guiding in our documentation and how we're taking care of these patients and we're dealing with these real situations, which clearly everyone on this call sounds very engaged and is helping their team through this, those diagnosis codes should be the last thing that you're gonna put on the list. Those diagnosis codes should be the last thing that you're worrying about. You sound like you're doing excellent guided work and that's the key. So, yeah. Thanks everybody for such a great discussion. I'm gonna leave a discussion chat up to Gina and Bruce and we can open it up. People can stand if they want to. We just, I just wanna say one thing. Ron, someone was asking what the name of that book was that you had just mentioned. Could you recall or reshare what the name of that book was that you had just mentioned? Yes, it's actually was sold under two titles, but the one most people know is God, Medicine and Suffering, Stanley Hauerwas. It was originally sold as Living in the Silences or something like that, but same book. Thanks for sharing that. And thanks to all of you for sharing your questions and being vulnerable with one another and sharing all of the good resources that you've been able to share during the call today. I guess we can leave it for, if anybody has any final thoughts or questions and then we can finish this up. Jennifer, thanks for leading. Appreciate you doing that. Thanks for the great discussion, everybody. All right. Thanks everyone. Next one is in October. We'll look forward to seeing you again then hopefully before that we've got a webinar in September, as I mentioned at the beginning. So check our website, learn more and we'll look forward to seeing you again soon. Thanks so much. Thank you.

Bruce Hammond

Executive Director

HMDCB

Dr. Jen Burke

controlling agitation

hospice patients

medications

non-pharmacological interventions

electronic medical records

end-of-life choices