The following is an edited transcript of an MDAdvantage podcast with Steve Adubato, PhD, and Jessica Israel, MD, that was recorded on March 8, 2021. Dr. Israel is Senior Vice President of Geriatrics and Palliative Care at RWJBarnabas Health. She answered our questions about the role of palliative care, particularly over the last year during the COVID-19 pandemic, and her views on where the field is moving in the future.
ADUBATO: I am very aware of palliative care, not as an expert, but as a family member, like millions of others who have had to face long-sustained illnesses of loved ones. How do you define palliative care?
ISRAEL: It is tough to learn about palliative care through a family member, and I think it makes you a quick expert in things that you never thought you would end up studying. I think what is most important is just to start with the basics. When I came to New Jersey to work in medicine approximately 18 years ago, it was before the field of palliative care was well-known. My mentor from the big hospital in New York that I came from said, “How are you going to explain to people what you do?” I came up with all different kinds of definitions, and she said to me, “Stop. It is good medical care for patients with serious medical illness. That’s what palliative care is.” I think about that a lot as I teach and explain to people what I do. Palliative care is specialized medical care for patients with serious medical illness, focusing on the relief of the symptoms and the stress of a serious medical illness. The goal is really to improve the quality of life for patients and their families. The thing that people don’t understand is that palliative care is based on the needs of a patient, not on the timing of a prognosis. It is appropriate anywhere on the continuum of a serious medical illness, and it can happen at the same time as a curative treatment. Many people tend to think of palliative care as happening at the very end of life, and while it certainly happens at the end of life, and is more common at that time, it doesn’t have to be. In fact, there are patients whom I have taken care of from the palliative care perspective way upstream of what we typically think of. People tend to confuse palliative care with hospice, which is very different. Hospice is really an insurance-based benefit for patients in the last six months of their life. Palliative care certainly can cross over into that last six months of life, but it isn’t confined by that time frame.
ADUBATO: Since this COVID-19 pandemic, how has the world of palliative care changed?
“So many people needed the expertise of a palliative care team, particularly the communication expertise and the symptom management expertise.”
ISRAEL: There have been so many terrible things about the COVID-19 pandemic, but in some ways, it has helped people to understand the benefits of palliative care. So many people needed the expertise of a palliative care team, particularly the communication expertise and the symptom management expertise. The palliative care physician or nurse or team very quickly became among the most important members of that hospital team because there were so many needs for complicated and difficult conversations that no one had ever had before in this context.
ADUBATO: Particularly in light of COVID-19, how do you teach, coach and mentor other physicians to have these incredibly difficult conversations?
ISRAEL: There are certain aspects of communication skills that you can teach, and then I think that there are some aspects that you probably can’t teach. That’s the advantage of having a palliative care team. More than 75 percent of hospitals in the United States have a palliative care team. Physicians should know that there is that expertise to call on, should they need it. During the pandemic, we had some experience with teaching via video, which is something we hadn’t done before. We worked with physicians and care providers on how to have these difficult conversations. One of the first things that our health system did in the early days of the pandemic, now a year ago almost to the day, is we set up a 24-hour, seven-day-a-week palliative care hotline that was accessible by anyone in any of our hospitals caring for patients. We thought that the hotline would be an advice hotline. We thought that a doctor might call and say, “I need to know how to manage shortness of breath” or “I’m about to have a really difficult conversation with a family. Can you give me some tips?” But very quickly, it turned into, “I need to have a conversation with a family, and I need your help in doing this. Can you call this person and have this discussion?” We created a separate hotline called the Goals of Care Conversation Line. There were a lot of outpatient doctors at that time, a year ago, who weren’t practicing because we hadn’t moved to telemedicine yet and wanted to help. We took a pool of these physicians and trained them with written conversation guides to be able to have these difficult conversations. Then the hospital would call and say, “I have this patient in the hospital, and here is the story. Can you call the family and have this discussion and then communicate that back to me?” That was perhaps one of the most difficult circumstances to train someone in communication skills. These are people whom I had never met, I wasn’t in the same room as them, but they wanted to make a difference. We tried very hard to script as much as we could, although it is obviously impossible to script everything.
ADUBATO: As we’re taping this, a little over a year since the first case of COVID-19 in New Jersey, what advice would you have for physicians listening right now as it relates to burnout and self-care?
ISRAEL: I think self-care is such an important term. In palliative care, we talk a lot about this, but even there it’s always what comes up at the end of a meeting. I really think, especially now, it should be at the beginning of a meeting, because there is such an enormous need for it. Within our palliative care team, one of the ways that we’ve been able to combat burnout is by creating a network. We formed a palliative care system collaborative that has representation from every palliative care provider in our system. It is a group where a single practitioner, maybe someone in one of our smaller hospitals, can go to get support, mentorship and camaraderie from someone who has been there. I think that the answer to doing self-care on a bigger level for physicians is similar. It is about creating groups where physicians feel comfortable unloading the things that they traditionally feel like they have to carry.
“Part of our training is about solving problems; It’s about taking it on and wanting to fix things.”
Doctors generally are really bad at seeking out help overall. Part of our training is about solving problems; It’s about taking it on and wanting to fix things. I think there are physicians who feel that talking about vulnerability is a sign of weakness. At RWJBarnabas Health, we have a physician hotline that we also put into place about a year ago. It is specifically physicians speaking to physicians. Because they are talking to peers, they are talking to someone who gets it. The conversations are confidential, and they can really make a difference. One of the things that I have learned in my almost 20-year career in palliative care in New Jersey is that you have to take time when you know that you need it. It is really important because life doesn’t stop. I tell medical students all the time that if someone says you can have a day off, you need to take it.
ADUBATO: What about working in the field of palliative care brings you the greatest professional or personal satisfaction?
ISRAEL: I am an instant gratification person, and being in palliative care allows me to make an absolute difference in every moment, even if it is holding someone’s hand and getting them through a difficult conversation. It is incredibly gratifying to be able to help people in times of need. I am passionate about palliative care because my mom died of cancer when she was 41 years old, and I was 20. I thought to myself at the time, even before the field of palliative care existed, that I would have handled the situation differently. Being able to do that now for my patients makes a big difference.
ADUBATO: Given the experience we have had with COVID-19 up to this point, and all of the unforgettable experiences that have occurred, what is the future of palliative care moving forward?
“Moving palliative care upstream into people’s homes and into community education programs, and having the ability to have conversations about serious medical illnesses earlier in the process, would make a big difference.”
ISRAEL: I think the future of palliative care is moving it outside hospitals. Right now, there is a lot of palliative care in hospitals because of the crisis of a medical decision that must be made, the rapid symptom management that needs to occur and the communication that needs to happen. But the truth is that much of this can happen before the crisis occurs. Moving palliative care upstream into people’s homes and into community education programs, and having the ability to have conversations about serious medical illnesses earlier in the process, would make a big difference. If I’m a practicing geriatrician caring for a patient with a serious medical illness, I know that I have a responsibility to have a certain conversations with my patient. It should be more than, “Would you ever want to be on a ventilator? Would you ever want CPR?” It should be “Tell me what is important to you. Who do you rely on for support? What are you afraid of? What are the things that are keeping you up at night?” I want to know these things because there’s a lot of work that we can do pre-hospitalization, post-hospitalization and in the places where our patients actually live every day. I think it is all about what we can conquer as an outpatient. Our health system is about to begin a project where we are part of a serious illness conversation collaborative with Ariadne Labs in Boston. We are going to be introducing serious illness conversations to the primary care setting for appropriate patients, which will be scheduled as a separate appointments, either in person or virtually. The discussions will be focused on what gives the patient strength, what they are afraid of and what things are the most important to them. Then those discussions will be documented in a specific place in our new electronic medical record system that will be accessible by anyone who cares for that patient anywhere in our system. I think that this will be critically important moving forward.
