I'm Dr.

Mary Owen, associate dean of Native American health and director of the center for American Indian and minor minority health at the University of Minnesota Medical School.

I'm also a family physician for the FondeLac band and I'm your host for our episode tonight about caring for patients with serious illness and end of life concerns.

The success of this program is very dependent on you the viewer.

So please call in your questions or send them to our email address askpbsnorth.org.

And our panelists this evening include Dr.

Timothy Bordon, doctor of osteopathic medicine is a palative medicine and supportive care physician with Essentia Health in Duth where he helps patients and families navigate serious illnesses with compassion and expertise.

Dr.

Dr.

Amy Greinger, internal medicine physician with Essentia Health in Duth, brings decades of experience for caring for older adults, including long-term care and geriatric medicine, and is also a medical school faculty member focusing on education and elder care.

And finally, Dr.

Chrisa Kaidy, board certified internist with Aspirus St.

Luke's and Duth combines years of experience in hospital and primary care, supporting adult patients health and wellness across a range of medical conditions.

Our phone volunteers tonight are Stephanie Kefir from Pualup, Washington, Ava Hill from Aurora, Minnesota, and Eda Ian D. Ralph from Duth, Minnesota.

They're standing by to answer your calls.

And now on to tonight's program on caring for patients with serious illness and of end of life concerns.

Thanks for being here, all of you.

Thank you.

So, I think there's lots of um uh uh basic questions.

First of all, what is why do we combine serious illness with end of life?

Some people would say, "I got a serious illness.

Why are you combining that with end of life?"

Why do we put that in the title that way?

Tim, you want to start us out?

Um, sure.

I'd be happy to.

Well, when it comes to serious illness, uh, it can cover a broad range of things and it can include a lot of things.

Um, even chronic illnesses, we can consider it to be quite serious.

So, when we talk about serious illness, um, it can cover quite a breath of things.

It doesn't have to be just the acute, just the thing that brings you in the hospital this time.

It can cover quite a bit.

Uh one thing we talk about is in serious illness we talk about pali of care a lot and pali of care can cover a huge breadth of people from the time of diagnosis all the way through uh if they have a terminal illness all the way through the end of their life.

Thank you for that.

Anything to add you to?

No, I think for people who might not be familiar with the term paleative care, um paleative care is care that is really geared toward treating symptoms for people that um might have a serious disease state.

So people that might have issues like nausea or shortness of breath or pain and so when we talk about paleiative care a lot of times those are the kinds of things that that pe we are focused on.

Sure.

I think sometimes um serious illness just gives us an opportunity because we are all finite unfortunately to think about end of life.

It gives us an opportunity to pause, think about what we'd like as a patient and a provider um to anticipate possible um progression of disease outcomes um hospitalizations and even end of life care.

So they often do go hand in hand.

I'm getting pretty tired as I age.

So, I'm a little happy about the finite myself, but not everybody is.

I understand that.

Um, I do want to go back to one thing.

You said paliotative care could start at any time.

We think of I know another term or another concept that we'll talk about here is is uh hospice care and we think about hospice care starting at six months, right?

Because of the de, you know, we have these definitions and and insurance of course and all those things just help us decide that timeline, right?

But palative care, when does it start?

Um well palative care can start from the time of a diagnosis of a serious illness and that could be from the initial time of a di a di diagnosis of a cancer.

Um and it could even be a curable cancer.

Um it could also start from the time of a serious illness such as COPD even.

Um so it can start right away.

Um over time the kind of the concept is over time as a disease progresses the pali of care involvement increases.

um until such a point where you might think well you might have less than six months left to live and then we might talk about hospice um and Dr.

Ginger uh knows more about hospice than I do.

So the way to think about pali of care is it is just the care for very serious illness.

It's not end of life care necessarily like I think a lot of people assume it is and it can start years ahead as you said a diagnosis of COPD.

Right.

Absolutely.

Okay.

Anything else to add?

Go ahead.

No, I I would say I think sometimes people um maybe have a trouble with the distinction between paleative care and hospice.

And I think as Dr.

Bordon pointed out, oftentimes they have similar goals.

We're trying in both cases to support patients in a holistic manner.

We're trying in both cases to work on symptom management.

The difference is paleative care is usually designed for people that are continuing to undergo other disease treatments like chemotherapy or radiation or uh hospitalizations.

And hospice is really designed for people that have a prognosis of six months or less.

And and I will say doctors are bad at predicting how often how long people will live.

And so I've worked in hospice for a while and and sometimes we do have people on the program for longer than six months, but their prognosis is typically six months or less.

And at that point in time, they're usually only focused on the comfort, but they oftentimes have very similar goals.

I think sometimes too when we think of paliotative um when I think of it, there are times when it's used just a nuanced differently.

For example, you might have a cancer and sometimes we think of a cancer as cur curative and sometimes we think we can't cure it but we palate it.

In other words, so if you have a curative cancer, we can get rid of that cancer and be done with it versus sometimes we can't cure it and so we paleate and we try to give that patient a good quality of life while trying to keep that cancer in check.

So that's another way that paliotative care is is used in terms of just the nu the nomenclature I guess.

Yeah, that's helpful.

Anything to add, Dr.

Tim?

Oh, no.

Okay, great.

Now, let's answer a question from the audience.

My elderly parents live across the county from me.

How can I support them during extended hospital stays that I can't be there for?

We've all had these patients.

Family can't be there because they're a long ways away.

I'm from Alaska.

That happens a lot.

Yeah.

Dr.

Ky, you want to take this?

Sure.

This happens every time I work.

So, um, ideally there's a there's a whole team of providers that take care of a patient in the hospital and so many of the providers that are involved with the care may reach out to family, especially sometimes it's on a daily basis depending if the patient has changing needs and different things that we're anticipating and we may need more family involvement.

And other times the patient may be more stable and just waiting to get to rehab for example.

And so there might be less communication.

But as long as I think you've made the um the it clear that you are the next of kin and ideally you fill out a healthc care directive which we should talk about maybe.

Um then you identify who the patients family members or loved ones would be that would assist in communicating needs, wants, desires for a patient's care.

you guys might have more to add.

I would say um I think it's wonderful when patients have families that care for them and and are supportive of them and and we know that that can't always take place in the same physical location.

That doesn't mean that families aren't continuing to be really important in terms of being that support network for the for the patient.

technology has changed a lot of times what people are able to offer.

And so phone calls or Zooms or, you know, those kinds of things.

I think when I'm sick, I always want to know that people care about me and that they're there for me and they support me.

And I think family members are often able to provide that kind of really important emotional support regardless of physical location.

And so I think um that that can be something that families can do that can be really helpful for patients.

Now, Zoom came along after I left hospital care, hospital medicine.

So, is that common to use Zooms to contact with to have communication between patients, family, and provider sometimes if they're far away?

Have you seen that?

Yeah.

Um, yeah, I I will say um we have seen that sometimes we do a family meeting.

So, we'll include family members in a Zoom call.

So try to get them in in the room as much as possible uh with the family member um with the other um per uh medical personnel could be nurses could be other doctors and we have a family meeting and go over everything and that can be a huge help to family members just another voice in the family or another set of ears in the family hearing the medical information so everybody's kind of on the same page.

You can support your family member a tremendous amount just by being involved.

Um, and it doesn't have to necessarily be a formal meeting like on Zoom.

Um, but just being involved, being another set of ears for your loved one because it's we take in so people get inundated with so much information and they have to sort through it and somebody might hear something somebody else didn't hear.

Um, just doing that for your family member can be huge.

That's a really good point.

And remember that you have the right to ask the case managers or whoever else is on that team about how it's going with your family.

Yeah.

Yeah.

Okay.

Let's go back to that paperwork you talked about.

What's the difference between a health directive and a power of attorney?

Patients often ask me that.

Anybody?

Dr.

Ginger.

Go ahead.

Um, a healthc care directive in general is a kind of document that talks specifically about what we want with our with our health and different components of that.

Sometimes they might ask you um what you might want in a catastrophic um situation, but almost more importantly, they're going to ask you questions like who would you want to make decisions for you if you weren't able to make a decision for yourself?

And and usually those are the kinds of things like what kind of care would you want and who would you want to help make the decisions that get asked in a healthcare directive.

A power of attorney is a very specific legal document.

it and it can be either a financial power of attorney or a healthcare power of attorney.

A healthcare power of attorney is essentially that surrogate decision maker that we talked about in a healthcare directive.

And that is different and distinct from a financial power of attorney.

And so I think sometimes people can get confused.

It's confusing if they think that they have the power of attorney and then they're they're maybe thinking of financial when they mean health care or thinking of healthare when they need financial.

Uh and and um they do distinctly different things.

And Dr.

Quite you're an internist.

You still have a panel of patients I believe.

I don't.

Okay.

Because you're hospital right?

Hospital based.

Yep.

Okay.

Does any of how does any of you advise patients when you see them?

Which ones do you advise?

Do you advise first to healthcare?

Is there a a one before the other or how does that go?

Uh Dr.

Tim, Dr.

Yep.

I'm pretty much hospital based.

I I don't advise necessarily one over the Well, I guess I do.

I advise the power of attorney aspect of it.

And the reason being is a healthcare directive um can be helpful to kind of think through things, but the truth is nobody can see foresee everything that's going to come up.

So, what's really important is having those people that you've had conversations with before.

That's that's the important part.

The people that would um kind of understand you as a person, as a as a whole person, not just um not just a bunch of tick marks on a on a form to check off like I want some of this or some of that.

It's not just a menu kind of to choose from because there's so many other things that go into decision- making that are not tangible, uh not quantifiable.

Um, so it's important to have those people to name those people and then that way the health care people can look at your form and say, "Oh, this is the person we should talk to."

I'll I'll add if people are thinking about doing a healthcare directive, I think major life changes oftentimes might prompt people to reconsider that.

Um, sometimes people that might have been named in a previous directive may have passed away or may no may no longer be like sometimes there are like divorces that happen and and and family circumstances might change.

Um, so when there's been a major life change, I typically recommend thinking about if you need to update that if you've done in the past.

also transitions like going if you've been recently hospitalized it's a good time to kind of step back and pause and think about is what you had wanted before still true if you've had a big sort of transition or change in your health status.

Likewise, people may have transitions when they maybe move into a nursing facility.

And oftentimes nursing facilities will require that some sort of paperwork um around these issues gets filled out at around the time of admission to that just so that they know what people's wishes are.

Yeah.

Good.

Dr.

Bordon, what's the difference between an advanced directive and a post and when would each be needed?

Um the um well the advanced directive um could be something like somewhat like a healthcare directive where you kind of saying I kind of have these things in mind um things that are important to me, things that I would want or would not want.

A pulse form is pretty specific to what we refer to as someone's code status.

There are a few other boxes on there um that are considered optional, but it has to do with questions mostly around what do you if your heart were to stop, would you want somebody to try to restart it?

That would be like chest compressions and and electrical shocks and things of that nature.

Um then the second that's part A and part B would be would um what would you do or would you want how aggressive would you want your care to be after that?

So one big part of that is would you want to be on a ventilator?

Um another response could be I'm just interested in my comfort.

That's all I'm interested in.

That would be um more of like a hospice type plan and that's what you see with the pulse.

So, a poll stands for either provider or physician, uh, orders for life sustaining treatment, and that's what it's specific for.

Um, and there's a spot on there for your, uh, healthcare provider to sign it.

There's a spot on there for the patient or the representative to sign it.

And there's a couple other questions on the back that are optional with regards to antibiotics and feeding tubes.

Um but it's really a forum set up to um talk about the CPR, the chest compressions and intubation and how aggressive you want to be with that care.

Thank you.

Yeah, I did some work or my team did some work at the center of American Indian Minority Health on with pulse and for the native community and one of the things we advise is to put them somewhere where if emergency people show up like on your fridge with a magnet that so people are always aware of what your wishes are and that's the point of all of this is to make sure the patients know what are are able to say what their wishes are at the end of life or in serious illness.

All right, people really want to know this stuff.

Dr.

Ky, I have papers that say my grandson can make decisions for me.

How do I make sure that these papers are enforced?

Oo.

Well, they are legal documents.

And so, um, if when we were speaking about putting them somewhere where they can be found, I would also say they should be scanned in your doctor's office into your medical record.

We have this beautiful medical record that's electronic now.

So, I can see what, let's pretend I have a patient that Dr.

Dr.

Bordon took care of at Essentia and that patient comes over to St.

Luke's and Dr.

Bordon did the wonderful job of um documenting a pulse with the patient.

If the patient comes in not able to tell me their wishes, I can pull up that document and see.

Now, in clinical practice, when I'm in the hospital, I make a point if the patient can interact with me to go over that every time that I that they come into the hospital because it may be different.

They may have different ideas at the certain moments.

You know, things change.

We're people.

But having that document in the electronic medical record is of utmost importance, I think.

So, bring it to your doctor's office.

Your primary care doctor is a valuable person and they can scan it into your record and then we can always have access to it.

I'm glad you said that.

I think sometimes people are wondering why do we always ask them this question when they come into the hospital, but it's for their own, you know, to make sure that we have their what they want again.

So things change, you know, um sometimes people get a terminal diagnosis.

Um maybe in the interim they've grown older and they're not wanting everything done anymore or maybe they're scared and they've changed their mind and they they do want everything done.

I mean, I've seen the whole gamut of we're people, we change our minds, right?

And so I always like to have that conversation.

It also allows you to interact with the patient in a way that um is very personal.

Um it makes them know that you know this illness might might be serious and um it's a way to have that conversation about you know just in the event that this happens and sometimes it's not serious but we need it on the chart anyway.

So I'll say I will even ask this to somebody who has a sliver today you know just making sure we have to have a code status on the chart when we admit a patient to the hospital.

So, and that's a good idea, too, just getting people used to us asking that question, even if it is a sliver, like, okay, you're not going to die from the sliver.

This is a matter of practice for doctors, you know, it's universal screening.

All right, Dr.

Ginger, is medical marijuana useful during palative care and how is it used?

Um, Minnesota has a kind of a unique system with medical marijuana where oftentimes the physician is not the one writing the orders for the medical marijuana.

like providers will certify that patients have a condition for which it can be used but they oftentimes are not writing the order or dosing.

I have had um I've had patients that go on multiple sides of this.

I have patients who wish to avoid it and I have others that wish to engage with it.

Um I think that I have seen patients for which it has been helpful in the past um uh for nausea at times um and and um some of those kinds of issues.

That being said, I want to be really careful to say that there are also lots of side effects that can come with that.

And so I think it's always like with any medication a matter of understanding the side effects that might happen for somebody and and looking at the rest of the medications that they're on and trying to make sure that it's not interacting.

I think where we would could get into trouble is if we don't know that somebody's taking something and then we might be prescribing other things that might negatively interact with it.

So I think it is an option.

It's an option in Minnesota right now.

I've had it be the right thing for some for some patients and not the right things for others.

Um, but I think regardless of what where people come down, it's important to be talking about it with the physician even though the physician is not the one dosing it so that they understand what's going on.

Dr.

Bordon, anything to add to that since you do palative care?

Um, yeah.

Um, I will just add to that with um the newer research out there on pain with marijuana, it make is a is kind of a muddy picture.

Yeah, that um it's less clear how much it really helps with pain.

Um I I'll just be honest about that.

I know a lot of people put a lot of faith in that and they have and I'm not discounting any of that because maybe it really does work for them, but the larger research says it might not be so good.

Um, and also it might be more beneficial for people with nausea or dealing with hunger issues and things like that.

And I'll just say too, there's a lot we just don't know.

Yeah, we just don't know.

There's just not good high quality studies out there.

Good.

Thanks.

Any experience or anything you want to add to that, Dr.

Cody?

Um, I have to just agree.

Okay.

Now, this is for our paliative care friends.

Now, Dr.

Bordon, you started out as an emergency room physician.

Why did uh you decide to be a paliative care provider first?

Oh.

Um there is um the story I share often is when I was working in an emergency room in a small town in Texas, there was um a couple that came in um the gentleman was caring for his wife and his wife was um ill but not so ill that she wasn't mobile and getting around but she would com but she had I'll just say she had dementia and she uh would complain of things and he had no idea of under you know is this real?

because it's not real because she had other real diseases.

And he didn't have any other recourse other than just to go to the emergency room.

That's all.

And he was frustrated by it.

There's nothing else he could do.

He didn't know if it was real, if it was not real, if it was something minor.

Um so he would come in and he was just clearly frustrated by it.

And I thought um I mean there's there's got to be a better way to do this.

This uh and then some friends of mine, I wasn't really familiar with paliative care.

Some friends of mine uh talked to me about palative care.

I went and shadowed some kind people and uh became interested in it and so I guess I've kind of had an interest ever since.

That's a great story.

Doctor shadowing doctors too.

I love that.

Dr.

Ginger.

Um yeah.

No, I I I'm still kind of in the process of getting trained and certified in it and I'm doing a fellowship right now to develop more skills in it.

But I have been I I really love taking care of older people.

Um, I I I I really enjoy hearing their stories.

I feel like people have lived so much and they deserve really high quality care and making sure that people get what they want and help them reaching their goals is um something that I think um piative care can can provide help with and that that that is really meaningful and fulfilling work to me to to work with people to understand what what what is important to them, what is valuable to them and then to really try to match the care that they receive to what they value.

I I just love doing that with people.

Thanks for that.

Anything to add, Dr.

Cody?

I know you're not palative of care, but I'm not.

I'm a hospitalist though, and I do take care of a lot of people who are very ill and also who are dying, and it's a it's an art definitely to take care of a patient who is in that state.

Um, it requires good communication.

Um, it requires enough experience to know if the patient is dying or not.

Um, I'll never forget being young and not knowing and learning, right?

It definitely required experience, I would have to say.

And, um, also there's just a a human touch to it, I think, especially now having gone through it with some family members and appreciating it being done well and it being not done well.

So I always have felt if there's somebody that is in the hospital that I can help transition to the end of life care and um make it a more comfortable experience for the patient first and also the family who's or loved one who is equally as part of it then it's a very important part of being a good physician.

Thanks.

Okay, that we're almost to the end, but I want to squeeze in a couple important ones.

Is there an age limit you have to be to fill out an advanced directive?

It's one of my favorite questions.

No.

No.

Okay.

No.

We have our medical students try it at one point in time.

They they don't have to certify it, but they do try it.

They do try it.

I think there's this um mis mis this idea that you're promoting death, but it's not.

It's just getting make sure that our patients have the autonomy they need toward the end of life and and we never know when that is, right?

Could be at any age.

How much does paliotative or hospice care cost?

And what about sniffs or other care facilities?

We only have about a minute left.

Anybody want to take this one?

Hospice is a Medicare benefit.

Uh so the cost to patients typically if they're on Medicare is zero.

Um paleative care is usually paid through insurance.

Um uh that does not mean that they're paying for your stay at a sniff.

There are different payment mechanisms for that.

Thank you for doing that so fast.

Can you receive paliotative care at home?

Um it it depends where you live around here.

um we don't really have uh infrastructure for it.

It it depends where you live.

We have some clinic stuff but uh in home palative care doesn't really exist around here unfortunately.

Okay.

There's one last question.

It's how do I see my advanced directive?

I had one made a few years ago but I can't find a copy now.

And I will just say if you can't find a copy of it and you're making yourself crazy then just draw up another one.

You need those.

you need those around and uh then you can give it a copy have a copy put in your chart by your doctor and have your own.

Yes.

Yes.

All right.

Thank you all.

I want to thank our panelists, Dr.

Chrisa Koy, Dr.

Amy Greinger, and Dr.

Timothy Bordon.

Please join doctors on call next week where Dr.

Ray Christensen will host a panel discussion about neurological conditions such as dementia, seizures, Parkinson's disease, strokes, headaches, and peripheral neuropathy, highlighting diagnoses, new treatments, and prevention with experts from around the region.

And if you're looking for more tips, tricks, and conversation around health and wellness in the Northland, make sure to check out Northern Balance on PBS North YouTube channel.

Thank you for watching and for joining us for season 44 of Doctors on Call.

And good night.