To get all of HBR’s content delivered to your inbox, sign up for the Daily Alert newsletter.
I am a palliative care physician and lead the geriatrics and palliative care service line at RWJBarnabas Health in New Jersey, one of the states hit the hardest by Covid-19 pandemic. Several weeks ago, at the beginning of the surge of cases in our state, an ICU attending physician at one of our system’s hospitals — Newark Beth Israel Medical Center — requested help. He asked me to call the family of a patient with the disease who was in dire condition to discuss his prognosis. I phoned the patient’s wife of 25 years.
Like so many health care systems, our system’s policy prohibited people from visiting patients in our hospitals with Covid-19. There was a good public safety reason for this, but it meant that there were no family members at the bedside. And it meant that loved ones at home felt horribly disconnected, anxiously waiting for the phone to ring.
Further Reading
His wife was grateful for my call, but the news I had to deliver was grim. I told her that her husband had Covid-19 and pneumonia. I also explained that he had had a massive stroke in the hospital and that both a neurologist and neurosurgeon had been to see him in the intensive-care unit (ICU). Both had said there was nothing further they could do. Her husband would never fully recover; he would never be himself again. I told her I thought he was going to die.
Given my job, I have been the bearer of bad news many times before. This time I couldn’t hold the family member’s hand or offer her some water or tissues. It was hard, and it made me appreciate what the frontline medical team had been doing. I had no way to know how she had processed what I said. I wasn’t ready for what she said next, “Thank you, Doctor. I knew things were bad, I wanted to know more. I have been watching the news. I knew we might need to make decisions. I’m glad you called.”
Insight Center
RWJBarnabas Health is the largest, most comprehensive health care system in New Jersey; it serves nine counties and five million people and includes 11 acute care hospitals. When patients are admitted to the ICU, our on-site palliative care teams — like those at most major hospitals or health systems — assist the ICU’s attending physicians in finding out the patients’ wishes for the use or non-use of life-sustaining treatments. We continued to do this during the pandemic, albeit on a much larger scale.
Early in the outbreak, we established a 24-hour palliative care system-wide hotline, which we advertised as an added tool offering guidance to frontline care teams for complicated symptom management or communication needs. It became clear very quickly that doctors didn’t necessarily want advice as much as they needed hands-on help — or virtual hands-on help in this case — especially when it came to the task of communicating with families. The tremendous demands of the pandemic gave frontline doctors little time to conduct these difficult conversations. This led us to form a team to assist in making the calls to patients’ families to discuss their loved ones’ serious conditions and their wishes for how we should treat them — or, as they are known in my field, their “goals of care.”
Honest discussion about serious illness is the hallmark of exceptional medical care. We should all be doing this, every day, but even in the best of circumstances there are barriers. No one wants to talk about death or unpleasant things. No one wants to be seen as taking away hope. It’s not uncommon for a doctor to tell me, “My patient is not ready to hear this yet,” even when all the clinicians involved in the case are clear about a bleak outcome. We need to give our patients and their families more credit, especially in the context of the pandemic. (Watching the news had made the patient’s wife I mentioned ready for my call.) Holding back honest discussions about serious illness holds back a family from processing a goodbye.
We piloted a “Goals of Care Conversation Team” to conduct conversations with families of critically ill Covid-19 patients at Jersey City Medical Center and eventually created other teams at four additional hospitals in our system that were also hit hard by cases of the novel coronavirus. Each team at a facility had six to 10 physicians on it who worked remotely. The teams worked from 8 a.m. to 6 p.m., and each member manned the phone for two to three hours at a time; a back-up was available in case the need for assistance was high. Every week, the emergency operations center at each hospital shared with its emergency departments and medical floors the team’s schedule, including the phone numbers of the members who were on call.
We staffed the goals-of-care-conversation teams with primary palliative care providers: mainly, psychiatrists, geriatricians, and primary care internists; but even an interested surgeon became involved. It was not hard to find these doctors. We reached out to MDs who were employed in our system’s medical group and part of our primary care system. The volume of patients visiting many of their outpatient care offices had slowed considerably, so they had the time and they wanted to help — to do something.
Team members were trained with a scripted conversation tool based on some of the wonderful communication resources available online, including Vital Talk’s COVID Ready Communication Playbook and the Center to Advance Palliative Care’s COVID-19 Response Resources. Additional training included how to handle emotional reactions that required an off-script response.
The urgent need we have to discover our patients’ wishes during a public health emergency underscores the importance of knowing our patients’ goals as a critical component of everyday high-quality health care. Our telephone service made it possible to spend more time discussing those goals with families than overwhelmed frontline physicians could have.
When our Covid-19 case numbers started to improve, we disbanded the service, but we took from the experience an important lesson: We need to expand our efforts to ensure we know all of our patients’ goals of care. To that end, we’re now looking to establish goals-of-care conversations as a best practice in our primary care settings.
A subscription purchase is the best way to support the creation of these resources.