Full Transcript for Palliative Care vs. Hospice: When and Why to Choose Each

or less prognosis. Palliative care does not require any prognostication. It can be given at any time. And hospice also means giving up treatment while palliative care does not involve that part Sam Greenberg (Host): So you said it can-- palliative care can start at any time. Are there certain markers that families should look for to start considering palliative care and really who can refer to your team? Or is it more if you just think it's the right thing, then give a call and see if that's the right route to go? Kirti Joseph, MD: anybody can give a referral to palliative care. I've given a lot of talks to our lo- local, primary care doctors and from the hospital team to what I, what I say to the doctors is, you know, the surprise question, which is, you know, would you be surprised if in the next year this patient has multiple hospital stays or a decline in their general what they can do for their activities of daily living? If we start to see that, that's a good time to consider involving palliative care to start talking to the patients. I've also had a lot of patients self-refer themselves to me because they are going through a difficult time. They feel that, you know, they're seeing the oncologist, the cardiologist, the nephrologist, and everybody's fixing one little, one organ or one disease process, but nobody's looking at them as a whole person and addressing all of their symptoms. So I've had a lot of patients self-refer, and that can be at any point. So really anybody that has, like I said, an advanced disease, and that would be, you know, advanced heart failure, advanced liver failure end-stage renal disease, and they're going through dialysis, and they're expected to live years but they're also having a lot of symptoms and difficulty coping with that illness. So, yeah, I've had patients self-refer themselves when they themselves feel like they need a little bit more extra help. And I've had primary care doctors and neurologists refer to me as well Sam Greenberg (Host): And Dr. Joseph, you mentioned those symptoms and managing those symptoms. So what are the main components of good symptom management for palliative care, and how are those typically treated? Kirti Joseph, MD: Sure. So I specialize specifically in pain management. You know, for me it's so a lot of our local... There, there is also pain management, which is its own specialty, but most pain management doctors are dealing with, doing interventions, right? Like, injections or nerve blocks and things like that. I don't do interventions, but my spec- what I specifically do is opiate management and medical marijuana certification. Opiate management can be very delicate. It's very difficult because we have to, like, give the right dose, make sure that the patient is not getting addicted. So I do a lot of that close follow-up for that. Medical marijuana, like I mentioned, is good for both pain, nausea, vomiting, and lack of appetite. I also sometimes talk about like, you know, things like a little bit of amphetamines for this chronic fatigue that patients often experience. You know, so those are... So, and nausea, vomiting, there's a whole list of medications that I use for nausea, vomiting. Lack of appetite is another thing that I address. So those are the physical symptoms. Then of course, there's a psychological aspect of it. you know, there's very, appropriate anticipatory grief or anxiety you know, complicated grief. So I do have a social worker that works with me that can help with that and reach out to patients for that. You know, and she also deals with a lot of the financial burdens and getting extra help. So a lot of the times patients come to me and they just want extra help at home. But, you know, and the family members also want because everybody's working and they just don't have that kind of around the clock care things like medical equipment that they may- might need at home. So I kind of help set that up and visiting nurse services and managing that as well. So those are some of the... And the spiritual aspect, I do have a wonderful chaplain that voluntarily works with our team and is based in Newberg. So she does a lot about each work as well. Sam Greenberg (Host): Yeah, it's awesome that you have the help and the whole team to speak with these patients. And it can be a very overwhelming situation, these people with these chronic illnesses and serious illnesses. So how do you approach conversations about, say, goals of care, values, treatment preferences with patients who may be frightened or extremely overwhelmed with their situation? Kirti Joseph, MD: Yeah, absolutely. So I mean, this is something that I, have a lot of talks for our hospital doctors and our resident doctors as to like how to properly have these communication. 'cause like you said, it is very difficult. And one of the things that I always tell our residents is that, you know, we are scientists, but not all of us are good science communicators, and we need to be because we're scientists, we're on the forefront, right? Like that science communication is so, so difficult, and unfortunately, it's a little bit lacking in our field. It's something that we can all do better in especially when delivering difficult news such as approaching like cancer might be worsening or their disease might be worsening. So there is this thing that we follow that's sort of studied. It's called SPIKES. It's just a way to kind of make the patient feel more comfortable, that talks about the right setting, making sure that you're trying to listen more than give a bunch of information that nobody can retain. So always like reading the room checking on their perception, checking their knowledge of what you just said so that you're not just going in the room and like vomiting a whole lot of words that nobody really understood, right? So pausing, listening, this is all a big part of that communication. So-- And the other thing I'd say is, you know what? This is

never a one one-hour conversation. This is multiple conversations involving not just the patient, but their family members and loved ones. So it's setting up family meetings that can sometimes last one to two hours and making sure that... And that's why sometimes this has to be its own different specialty because as you know, our primary care doctors and our hospitalists are not equipped with that kind of time Sam Greenberg (Host): That leads right into my next question perfectly. In what ways does palliative care support those family members? What resources are there for family members and caregivers who are often under a great deal of stress themselves with the situation of their loved one? What sort of resources do they have? Kirti Joseph, MD: Yeah, absolutely. So I-- That's a great question, right? So that is-- And what we're seeing a lot of is that caregiver burnout. What's great nowadays is that we also have a home-based pa- Two of the local hospice agencies also, provide a home-based palliative care service. Now, that is just a nurse practitioner that goes out to the homes to have these conversations with the patient and family. It's not a lot of manual support. But coming back to that, what I had mentioned before is I do work with the, with a lot of the local visiting nursing services like WickCare, ArchCare, Good Sam to try to provide some extra help at home, which is a lot of times what the caregivers need. And the social worker, my social worker also has a whole list of the local voluntary agencies and aides that can come to the house and help the caregivers provide the care that the patient may need. And that's a big part of, you know, keeping patients out of the hospital and repeat hospitalizations and relieving the caregivers sometimes a little bit. The other part that's very important that I would say is like, you know, a lot of times the loved ones and caregivers don't feel that they have any autonomy. So involving them, just involving them in the discussion and, you know, the knowledge of what's happening gives them that sense of autonomy, and it really does relieve a lot of the burden just kind of knowing Sam Greenberg (Host): So Dr. Joseph, what are some of the most common misconceptions that the public has about palliative care, and how can health professionals such as yourself effectively correct these misunderstandings that people may have preconceived notions about palliative care? Kirti Joseph, MD: oftentimes what I see is people hear the word palliative care, they automatically assume that it's hospice or... A- and even hospice there's a lot of misconception, right? So I'll talk about that as well. But they hear the word palliative care, and they think, "Oh my God, somebody's coming to talk to me because I'm dying tomorrow," you know? And they're coming to talk to me about just death and dying. And that is not at all what palliative care is, right? Where... So I've had a lot of patients that I've seen as my outpatient because, the oncologist or the radiation oncologist will send me a patient that's going through a head and neck cancer or a blood malignancy. All of those have good outcome that they're going to get cured and get better. But they may need very, very high-dose opiates while they're going through the radiation or chemotherapy. So I see them during that time to help them with their pain so that they can tolerate all the treatments that they need. And once they are done, I help them wean off of the opiate medications. A lot of patients are worried about addiction, you know, so kind of giving that extra support to make sure that they don't get addicted because they needed to be on high-dose opiates during treatment. so that's what I always have to tell patients, is that, you know, this doesn't... I'm not here just to talk about death and dying. Certainly, any advanced illness, that's going to be part of the conversation. But that is absolutely not at all the only thing that palliative care is. Palliative care is to... The goal of every doctor is to try to help you live the longest and the best quality of life that you have, right? That's the goal of palliative care. And, and, you know, ironically, that's actually the goal of hospice as well. So hospice, also people hear hospice and they think, "Oh my God, they're here to give me morphine and kill me within a couple of days." And that's not at all what it is, right? So hospice is a great benefit that Medicare pays for 100% for a, an entire home care agency to come to the house. And that is usually initiated when we think that the treatments are actually going to affect not just your quality of life, but also your longevity, right? So if you continue with treatment and, and the treatment is... and you're not responding to those treatments, then the treatment itself can make your life shorter and harder. So hospice comes in at a time when we don't wanna do that. So hospice comes in to live your best life at that time where unfortunately the disease may be progressing but to provide you with really good symptom control, keep you home, keep you with your family. And patients actually end up living longer a lot of times than they would have if they continued with aggressive treatments Sam Greenberg (Host): Doctor, I know you and your team at Montefiore St. Luke's Cornwall have the palliative care space well taken care of, and your patients can feel safe in your hands. Thank you very much for your time and expertise today Kirti Joseph, MD: Thank you. Of course, that was great. Sam Greenberg (Host): Thanks for listening to DocTalk, presented by Montefiore St. Luke's Cornwall. For more information, please visit slcmedgroup.com. That's slcmedgroup.com. Please remember to subscribe rate and review this podcast and all other Montefiore St. Luke's Cornwall podcasts