Psychiatry & Psychotherapy Podcast - Courage to have the tough conversations in the COVID-19 Pandemic

Episode Date: April 16, 2020

In the US, people do not talk about death often or even acknowledge their own mortality. Instead, we act as if we just work hard enough we can do anything, even refuse the grim reaper. In this episode, we wrestle with the current issues created by COVID-19. Join us as we think more about death and the necessity to have conversations around it.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the psychiatry and psychotherapy podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast. Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. We're not trying to take care of insurance companies, pharmaceutical companies. or hospitals or hospice companies. Right.

We're trying to take care of patients. And not patient's families primarily. And that's an important distinction. The patient is who comes first. That's a great introduction. And with that introduction, this is Dr. McDodden. He is a ER physician here in Redlands. We're close friends with his family.

He also works hospice half time. and he is a very intelligent person. I think you'll find before he was a physician, he actually worked research doing things like what NeuroLink, the Neurrelink episode talked about. And we're going to get into this episode. And the episode is on, in this sort of season that we're in, we're going to be talking about end-of-life care.

You have a lot of these conversations about end-of-life care. And we're going to be talking about COVID. We're going to be talking about what your day-to-day looks like with cancer patients in the hospice setting, in the ER, what you see some of the mistakes that physicians make for patients and what physicians make decision-wise for themselves. But kind of going back to this early sort of life research experience, one of the things that you said that was very interesting to me there was that it was really hard for these things that you were inserting into the brain to not get some sort of. sort of slight scarring around. Is that what you said? Or some sort of thickening? Yeah. It turns out interfacing to biology is challenging. One of the fundamental limits in bioengineering is the tissue interface. And one of the things that really sort of led me away from that world and into clinical medicine was coming to grips with the intrinsic limits of

technology as applied to biology. Now I've spent almost 20 years doing clinical medicine. And I've been throughout that period of time, I've sort of been very also aware of the fundamental limits of technology as applied to medicine. And I think that's kind of, that will be one of the themes that we talk about here tonight as we think about end of life issues,

especially with respect to, in the, during the pandemic of COVID. That's really interesting because I see that as a direct tie, between what we were talking about before. The limits of technology. The limits of technology. Yeah. It's a big deal. I think in our culture,

we've, you know, Western culture has done extraordinary things. We put a man on the moon. We split the atom. We have a consumer society that every year companies roll out a better product.

And it's better in all. It's cheaper, faster, better, shinier. We expect that from medicine, I think. People think that medicine. and will just keep getting better and better. And pharmaceutical companies promise that. This new medicine is expensive, sure, but look what it's going to do.

There's a big effort to try to justify the high cost of medicine. Pharmaceutical companies lead this sort of cheer to justify the high cost of sophisticated pharmaceuticals. Some of them are good. A lot of them can't beat the old standbys. But you can't, you know, American medicine, in particular is extremely expensive, extremely technological. And a lot of it's cultural. Like I said, it's this feeling that medicine is just like another,

just like the consumer world where things get better every year. And my experience is, like you say, my experience is I'm just very aware of some of the fundamental limits in that we're dealing with biology. And biology doesn't change very fast. So millions of years, right? Millions of years, exactly. Yeah, you know, and we're in an interesting time. So we're in this sort of time of the COVID-19 where in some places in the world there are more patients than resources.

You know, there's this difficulty in having the capacity for emotionally charged conversations. I'm imagining in providers that are in the trenches day by day. I think that that is certainly something you hear out of New York and out of Italy. It's not the experience of most physicians right now. Most physicians' days are really light. We've shut down outpatient services. Elective surgeries aren't happening. The hospitals have cured up and are preparing for a surge.

And so there's sort of an eerie, quiet in a lot of places that are away from the hot spots of COVID. The COVID pandemic is interesting. We don't exactly understand why it penetrates so viciously in the some communities, but in other communities are really largely much less affected. I mean, orders of magnitude difference. So it's sort of an interesting environment. We hear about the terrible, and it's kind of like, probably like what war often is.

There are hotspots in war, but you hear talk to people who actually been in battle or been in, you know, involved in a war, and a lot of us sitting around awaiting. Yeah, I think that for most of us, the idea isn't, it's not this, this, it's not what's happening in New York City on the front lines where they really are profoundly overwhelmed, or in Lombardi, where they were profoundly overwhelmed. And big issues, a lot of effort was going into deciding how to parcel out inadequate resources. Those are hard problems. We don't typically face that problem in America.

We have plenty of resources, and we can combine with a first come, first serve approach to get activity resources. But part of what I, it's what I want to expand the topic here to be, is that, in particular with end of life, we should be having end of life discussions a lot more than we do. COVID is an interesting time to, you know, to bring it up. But let's see, partly because of our social distancing measures that have been better put in place and the vagaries of how COVID infection happens, it looks like there'll be, the current projections are for about 60,000 deaths in America. And that's, you know, we'll see if

that pans out. That's about equivalent to the, to the, the, the, 2000, 2017, 18 flu, influenza. You know, it was a pretty, pretty rough flu year. But that didn't cause a lot of economic breakdown. And so we're talking about a pandemic that ends up costing, you know, in terms of mortality, about the same as something that we deal with every year. Meaning not to dismiss how I'm not trying to say COVID is not important. I'm just trying to say that this is something that's happening all the time. And end-of-life issues are what we need to face at all times. in America, a country of 300 more than 320 million people,

three million people die per year. And end of life issues need to be addressed for those people, not just the 60,000 people that are dying of COVID. So it's a much larger problem. So it's a great time to introduce the idea of end of life. But if we're only thinking about it when it's in the headlines, then we're not doing enough. Yeah.

And so I think this is a good time to, Both we're going to try to address, you know, the time that we're in, but also kind of broaden this to talk about end of life care in general. And one thing that you said that was interesting, kind of hinted at was outpatient surgeries are non-existent right now. That was the biggest, that's the biggest moneymaker for hospitals. surgeries, low hospital stays in and out, quick surgeries, right? The longer surgeries, you know, I think it's the shorter surgeries that make the more money. Now, I may be a little bit off on that, but surgery in general makes more money than anything else. And so when you have a hospital that literally I look at the surgery board and it's like a couple, maybe four or five going on,

that's it, you know, where it before it was like 30, okay, we're in an interesting time for hospitals. Right. Like I, I'm concerned about the thousands and thousands of hospitals across the U.S. that are gearing up for this thing that may not happen and are literally subjecting themselves to huge deficits. It's an excellent point. I mean, one thing I think that people really need to take home from this pandemic

is the idea that health care is not an easily marketable sector of our economy. Treating health care like a business creates enormously perverse incentives for everyone involved. I'm not talking just about the uninsured fraction in America. I'm talking about the decisions that physicians make and that patients are forced to make because of insurance reasons. Here we are in election year, and Bernie Sanders did a good job of putting Medicare for all out front,

the notion that in a developed country, and we're the only developed country that has a for-profit health care system that doesn't have nationalized health care guaranteed for everyone. and if the COVID epidemic hasn't made clear that that medicine is a social problem, then we're sunk. Well, maybe we can touch on that as we go on. I'd be curious where your thoughts are. But with that comes like who's responsible for not having enough PPE. Well, is it the government? Is it the institutions that are private? Is it a mix?

You know, we have epidemiologists in this country who study, you know, this is outside my area of expertise, but I think that, I think that's a distraction. Again, beginning back this idea, there's this focus on, if only we had enough ventilators, if only we had enough technology, things would be quite different. And I think that it sort of speaks to this American notion that this can-do notion that we can manage things with our, you know, if we're just gung-ho about it. And I think this is, especially with end of life, I think that you have to realize that a really important thing to realize for physicians to help their patients understand is that we're in less control of the world than we think we are.

And that's scary. And so the idea that we should have had 10-fold, 100-fold masks and PPE sitting around in some warehouse waiting to be used, and that that should be expected of anybody is crazy. And that you should have 10 times as many ventilators as have ever been used at one time sitting on mothballs waiting to be used is not the right way to parcel out resources either. Let's get into how can we talk about how doctors die? Yes. There's a famous paper called Doctors Die Differently. And there's various, it's been reprised a few times. It's a really interesting topic.

And I think that it raises a real ethical quandary. Because if physicians tell, typically choose less aggressive treatment pathways for themselves than they do for their parents, for their patients, and for their parents too probably. And that's telling, because I find that to be a real ethical conundrum. If there's a big difference in the care we're selecting, the care pathways we're selecting for our patients, then the care pathways we're selecting for ourselves or our family, then we got a problem. And so why would, we can look at at why that happens, what would induce a physician to choose a care pathway that's different

from what he would choose for himself? Yeah, so specifically there was this one physician that was going to die of cancer. And this physician wrote a blog or an article about how he was basically choosing to go home, not do chemo, not do radiation, enjoy everything. every last day with his family and then die at home. And that's what he did. And I actually think, I think that's like sort of an antidote of how

a lot of doctors think who have experienced a lot of hospital life. Right. Well, I think doctors are aware of the limits of the craft and of the frailty of the human body. And we know that, we know that treatments aren't as effective as the public thinks they are. it's not that they're lying to the public.

Taking away someone's hope is a real, is really problematic. But I think we need to really address this notion of the ethical problem of recommending different treatment pathways for yourself and your patients. Why don't we talk up a little bit about the language that's used in end-of-life discussions? Because I think that will help people in the audience who are care providers as well as,

lay people. Yeah, so there was this really nice sort of summary by the worldwide hospice and palliative alliances on things to avoid saying and things to say. So avoid sentences like there's nothing more that we can do for you. Yes, that's clearly a terrible thing to say. One phrase that we hear frequently is the idea that the family says to do everything. And when I see my colleagues respond to that. It's usually with raised eyebrows and a shake of the head. And what they're saying is that what they're intimating is that doing everything is not is going to be futile. And it even is going to cause a lot of discomfort print potentially for the patient. And they're not happy to do it. But they feel shoehorned. They feel pushed to do it by the family in the medical legal

environment of America, which is vicious. So let's let's slow down on that point because I think for people who haven't experienced like internal medicine, ICU medicine, like they haven't been in the trenches. I have some people who listen to us who are psychotherapists who are, you know, they're not going to see what that's like. When I hear do everything, I think we're going to do pressers. We're going to do a ventilator. This person may be on the ventilator for weeks.

They're likely going to be delirious after they get out. they may suffer a stroke or, you know, a secondary infection or a third infection. I think about patients when I did internal medicine for a year, there were some patients I would get on a new team and there was like this patient who had literally been in the hospital like half, half of the year for the last four years of their life. And they were in an infection and now there was literally seven, specialists on board. They were on, you know, and they're miserable, right? And the family has been in and out of the hospital for for that long as well. And so I would have conversations

with them about, you know, it's normal to be worried and scared about death. And, you know, ask them what their desires were, like what they thought would happen when they started this sort of course of two years of treatment, you know, what they thought was going to happen. And, you know, introduce myself with my full name, get to know them a little bit, and then slowly have this conversation about, hey, do you want to let a more natural course take place? Do you want to focus on your, you know, reducing pain, reducing suffering, rather than, you know, you know, reducing pain, reducing suffering, rather than, you know, fighting every new little infection or, you know, going back on a ventilator, stuff like that.

I don't know. I'd like to hear from you, though, what your thoughts are when you kind of picture this situation. Right. And these are very challenging situations. In the ER, we, some things are easier in the ER because time is necessarily, we're pushed. something bad has happened. The patient has new stroke symptoms.

They've had an MRI. They come in with sepsis. And there's an acute crisis pushing the decision making. And it sort of helps you get past. It pushes you through the, any trepidation you may have about when is the right time. Well, the right time is now. So you have, so, so that's, there's some advantages there.

It is challenging to establish rapport with a family quickly. But in the context, I find that it's actually, since the context helps you really get to the point. So when I hear about do everything, like you say, it means full mechanical support, intubation, mechanical respiratory support with intubation, vasopressors, which means central line. It means ICU level care.

And the family doesn't know about whether dopamine or vasopressin or norapine are going to be used. They don't even know what that means. They don't usually. And so, but frequently I hear colleagues talking and they ask the question, should we use vasopressers? And I think to myself, that's not the right question for this person. No, they don't even know what that means.

They have no idea what you're talking about. Yeah. What the family, when the family says do everything, what they really mean is doctor, I don't I'm afraid. I'm scared. Something terrible is happening. Please, don't limit the kinds of any resources that might be used to help my loved one. But they don't mean do things that you think will be harmful for my mother and won't provide any benefit to her just because they exist.

So I think physicians, it's really incumbent upon physicians to interpret well, to really say in this context, These are the things that are important. For example, let me give an example. I hear a lot of times they're talking about whether to do CPR on someone who's with COVID illness. Now, if you've been giving someone full respiratory support, they're ventilated, and you're maximizing their oxygen and their cardiac output is falling, and they're hypoxic, and the troponins have elevated, and they become bradycardic, and you've been given them maximal support.

and despite giving maximum support, their heart stops, then they have died. You do not do compressions on that patient. That's just brutality. You don't do compressions on that patient because it's wrong. The patient has died of a pulmonary disease, right? Squeezing their heart will not make their lungs better.

And so it's an important physician's to understand that that's not a question that the family is required to weigh in on. the problem is you give the family the notion that they're the ones who are responsible for making the decision about whether their loved one is allowed to continue living or not. And again, it gets back to this notion of how much control do we actually have. Look at the other, another phrase is do not resuscitate. So do not resuscitate implies that if you say, if you refuse that, then the, then the, then it implies that you will resuscitate.

It implies that we have the choice between resuscitating someone and not resuscitating them. And that's frequently not a choice that we have. Does that make sense? Tell me some more about that, yeah. Well, imagine another phrase, allow natural death,

as if I'm the gatekeeper of death. And I'm going to either allow a natural death or delay the natural death, that I'm the one who decides that. that places a lot of power in the physician's court that I don't think is always appropriate. Again, it gets back to this theme that we're repeating of the limitations of technology and medicine and biology.

The point is, I guess an important point to make is that I don't think it's fair for physicians to place the burden on the family, for them to make the family feel that they're the ones who are deciding whether their loved one's life is extended or not. can tell you psychologically that's a really really difficult place for them to be in for years to come like though i've had patients a number of patients who have said i the doctor asked me what i wanted to do and i chose this and i feel responsible for for their death and they take that with them right of course they do so and the physician that's exactly the point i'm trying to make it was it was poor form

for the physician to give the family member the feeling that they had the choice, that it was their choice to make. Right. It wasn't their choice to make. The biology is going to happen. And to offer to say, click this box and I'll resuscitate your family member. Click this box and I won't. It's not a fair question.

Yeah, that is a question that we, that's what they ask in general in medicine, right? D&R, D&I. Right. And it's a terribly poor choice. I think the physician should both take responsibility to explain to the family the limits of what we can do. That it's the physician and the patients that the disease is the problem.

The disease is what's making the decisions. But how do we know, like in the case of COVID, how do we know if they're going to get on the ventilator? and be on it for a couple days and then come out, you know, and versus not, you know, and just pass away. And if someone is young and they, and, and. How young? Like, what do you mean young?

Physiologically young. Okay. Meaning they don't have a lot of comorbidities. And they've been recently ambulatory. They've been on walks. They have full capacity. That's going to help us decide whether this person can, has a meaningful chance of real survival.

What's difficult, there's certainly there's a big gray area of difficulty of trying to predict the future. You know, patients will say, my doctor gave me two months to live and here I am five years later, you really get into trouble when you try to predict the future.

Yeah, those don't tend to go really well. Yeah, and also they're psychologically harm, they can be psychological harmful, especially if patients take that to heart, like, oh, I guess I'm going to die. But what I'm getting at, so you ask you a good question, there's when the patients there, when there's a gray area, when they have pre-morbid, pretty good pre-morbid health,

and yet they're very ill right now, maybe a time on the ventilation later, ventilator will tell us a lot of information. And that's frequently my default, is the idea that aggressive care can get, has a chance of getting you back, to where you were recently. But aggressive care can't get you back to better

than you were before you got sick, right? And a lot of patients will think, so does that make sense? So someone who's carrying a lot of pre-morbid conditions into their illness. Yeah, just to give a picture of a lot of these patients, like sarcopenia, right? Very low muscle mass, can barely walk.

Or has had a recent stroke. Several of the patients I've seen recently, you know, from nursing homes, you know, recent terrible pneumonia with long period on the vent has a tracheostomy feeding tube fully contracted then i found out then i find out from the family that they that they've been non-communicative non-responsive for months and now they have covid and they're quite hypoxic these would seem to be no-brainer decisions yeah right this patient's quality of life and something went wrong in this patient's course of care already and here we are here we are now with

hypoxia and additional severe illness on the top of on the top of really catastrophic pre morbid condition okay so like so walk me through this because this this does get me energized and you're right like it's a tragedy that this person got this far already right and i i can't tell you the hundreds of patients i don't know hundreds maybe more than hundreds but that i've seen like this where it's like, what are we doing? Why are we just pushing the care to the degree that we're pushing it? And this person has no resemblance of the life that they had before. And we're pushing things that, like, I think that the doctors who do it

are just going through the motions. And it's a difficult conversation to have, right, with the family. and if you're a doctor on call in the ER, you're like, okay, this is a five, 10 minute decision, or this becomes what, how long do you end up talking to the family for? Well, you don't have much time in the ER. But remember, because I do hospice as well, there are really different kinds of decisions, kinds of conversations. When someone's brought to the emergency department, almost invariably something acute has

happened to them. They've had an acute change in health status. And my approach is this. It's very difficult to make this decision right quickly in the emergency department. And so frequently, if there's really any, unless they've been really, unless they've been considering hospice before this latest event, then we don't want to look back 24 hours later and say, what would have happened if we tried to give them a little support early on in this illness? you know, at the beginning of acute illnesses, it's very hard to predict what direction things are going to go. So unless the family has a pretty clear idea that they already were leaning towards

hospice because of the patient's other comorbidities, then we're going to give them full support. So it's not that I'm trying to, that's not that I'm arguing for not initiating aggressive care. What I'm arguing for is the idea that we need to pay attention to the idea that once you get from an aggressive care path, you want to prevent the inertia that develops where that you can just keep kicking the can down the road

and not addressing these important issues, even though the facts are that, you know, as the clinical condition continues to not recover, then that new information is what should be used to help guide, you know, further decisions about how hard to keep pushing. So this person that came into the ER that had COVID, that had all these comorbidities, you did aggressive treatment for this person.

You did not talk to the family. I did what, no, I talked to the family. I wanted to find out what they're like on their best days. Can they communicate with the family? And the person I spoke with at 3 in the morning indicated that they could. And so I have to take that. I have to believe that. And so what we gave, he was actually an easy one because he was.

he was already on a trache, so we can easily support him on a ventilator because we have ventilators. We weren't making that decision. And we could give, but what I did say was, let's avoid central line access because we could get, we did get adequate peripheral access, and that was enough to continue to rehydrate him. His primary problem is infection. And so we could give selective care, which is frequently what I end up doing, is withholding the more aggressive interventions and giving the things that, that giving antibiotics and fluids, which are the mainstay of support for infection anyway.

But things like central lines raise the risk of pneumothorax, which would require further intervention. And so really, that's, I see this sort of crossing a line from, and also putting a central line in, sure makes you feel like you're ready to use pressers now. And so that it's just sort of a, it's an easy way to demarcate between aggressive care and supportive care. Okay. So one thing that you shared with me before this conversation that we recorded was it's hard to tell who needs ventilators or who doesn't. However, there are certain people with, you know, multiple corpabilities in high age and maybe low function.

at baseline where you would say that maybe a ventilator is not a good idea at all. The very first patient I saw during the COVID pandemic was a very elderly lady. And she was profoundly hypoxic with, we did labs, we observed her. We tried BIPAP for a while, which actually is considered a risky procedure, but we have a negative pressure. her rooms. We did, my assessment from our initial, our initial valuation was that with her significantly elevated lactate, very acedotic at her age, I made the decision that this was, that aggressive care was going to be futile for her. And so I talked to the family about that, and they were extremely receptive to the notion of not causing, of not wanting to

cause her any discomfort. And so you mentioned earlier the importance of reassuring people that that we can control, we can direct our attention towards managing discomfort and easing anxiety and comfort-focused care. That's a great term. Avoiding, avoiding harming patients and limiting distress. You can sort of, as you're talking to a family, you can get a sense of what, of where they were already in terms of their goals for this patient. And so that was quite an easy decision for them to make. Okay. To avoid doing aggressive measures. In our culture, we do, there are phrases like, you know, people don't want to be kept alive on machines. They don't want to be in a persistent vegetative state. You know, they don't want to have CPR performed on them, perhaps.

when when people have already sort of thought through the beginnings of those of those pathways it's remarkable because the family is as soon as you open the door to that you get this sensation of this this flood of relief where the family says thank you so much doctor for for being so honest with us for being so frank for telling us the truth and then it becomes easy There's something since I've started doing hospice. I used to have sort of this, you know, we've all heard the phrase heroic care, heroic measures. And when I was early on in medicine, I thought of heroic measures as running into the room and doing CPR and intubating someone and bringing them back to life. That seemed heroic to me.

Many years of doing this and very, very rarely seeing that happen. Yeah. I'm pretty, like many physicians, I'm pretty convinced that. that sort of heroic care doesn't actually occur. It never ends heroically. But I've sort of come to grips with a different kind of heroism. Now my definition of heroism is creating a space for dignity and peace and acceptance among the family members, among the patient, among my staff. That's actually heroic. And so heroic care sometimes is choosing hospice, is helping families and patients face the inevitable with courage and without fear and without pain.

And so everybody feels like this is a good thing. And there's no panic and there's no terror. That's actually heroism. Yeah. I actually think having these conversations. learning to have these conversations, right? And it's okay if they're clumsy at first. But learning to have these conversations,

these end-of-life conversations, is the most heroic thing. And that's a shift in myself as well. Like I think the medical student me back in the day like would have said do everything, right? We don't want to give up on people. Code blue, I'm there, I'm sprinting, I'm sprinting across the hospital.

I want to get in there, do chest compressions. Absolutely. Absolutely. We really want to help people. There's nothing like that sort of feedback as a physician when you really feel like you've saved a life. It's extraordinary. That's why it's, and to turn and to feel like you're giving up, that's another phrase that that is, that I have issues with. We never give up on our patients. But sometimes giving up, we never give up caring for the patient.

But switching focus from aggressive care to creating an environment for dying with dignity is something that's far more rich. Yeah. Yeah, that's good. It just struck me, there's so many patients along these. This patient I saw who brought his mother in for wound care, and she had a terrible, terrible coxics ulcers, stage four ulcers with, you know, exposed bone.

And those are challenging wounds to heal. So basically, like this patient has been lying in their bed in the same way for so long that there is a hole in their body, like an open wound all the way to the bone. Right down to the bone, yeah. And the odor, the very challenging to take care of these patients that require infection, pain, cleansing,

really involved dressing changes, moving them around a lot. Every two hours you have to roll the patient. This man had done an extraordinary, extraordinary work for his mother. And he was bringing her into my wound care clinic. And I could tell right off the bat that he was ready for a fight. He had been to many, many specialists, he had been and fought for the right to be referred to my wound care clinic.

And he came in and I could tell he was just ready to, to really fight for what he thought his mother needed. And I examined her and she's sarcopenic, catechic. So low muscle mass, probably couldn't walk on her own. Yeah, I mean, by the time you start developing pressure wounds and you don't have paraplegia, you don't have neurosensory loss, you're really in trouble. It means you're so weak and debilitated

and have lost so much weight from some other, typically from some of the process, cancer frequently. that you're not going to heal the wound. So I sat down with him, and the first thing I said to him was, it is so clear to me that you have an extraordinary love for your mother, and you've done an incredible job providing care for her.

And that's all I said to him initially. He started crying. Yeah. I validated to him. I think that was, he was, he was, that was his fear was that, was that he hadn't done enough, that it was his fault. And caregivers are bigger saints than myself. It's one thing to go to a clinic and help patients all day and then go home.

It's another thing to be on 24-7, 365 days a year. So my acknowledging to this man of just the extraordinary work he had done caring for his mother and how that indicated how much he loved her, it completely changed his approach from somewhat adversarial initially that he's going to have to fight for the care that his mother deserves to trusting me because I'd recognize that in him. And then I said, but you're not just saying that to make him feel good. You're saying that because that's true. Oh, it was obvious to me that this guy really, really had devoted himself. And then I said to him, there's no way she can heal these wounds. She'll die of these wounds. She'll die of the process that's causing these wounds to occur. And no matter what we try to do for,

we will never be able to close these wounds. But we can take good care of her and we can keep her comfortable. We can prevent her from having pain. And we can teach you how to, we can help you. I can set you up with home health services that can help you manage her and provide a safe environment for her. He was extremely pleased.

Oh, yeah. He got to go home with his mother and be at be and have her at peace and not have her to drive her all over the Inland Empire looking for care. But the other thing that you did there, people think that they're giving up on their loved ones if they do hospice. And it's like it's not, that's not the, that's not what is happening. Not at all. It's actually the most loving, considerate, kind, gracious thing to do.

It's like, is, okay, so with COVID, would you rather die, intubated alone in a hospital? only able to talk to your loved ones by telephone or would you rather go home and die with your family? Terrible, terrible choice. Terrible choice. Very, very, very challenging choice to make. But for some hospitals, they're not even letting chaplains

into be with... Yes, these are really gripping. It's like tragic. Absolutely. In my mind. Yeah. They're having these conversations. there's an actual like how to have this end-of-life conversation by phone with the patient.

Like there's a whole description on how to do that. Yes, that's very, very challenging. And I think at some point, you know, as a provider, it's much, it takes a lot out of you to have these, to have these, to really connect to a patient and try to manage this. I mean, it's, these are, this is secondary trauma that, that can really build up. And, uh, I really, I worry about. I've opened up my clinic to the secondary traumas that are coming in. Yeah, the horror stories you hear coming out of Lombardy and that we'll hear from New York,

it's unfathomable. You know, it makes you think of what it must have been like storming the beaches of Normandy. I really think that the psychological aspect is going to be a bunch more long term than COVID itself, both for the families who lost members of COVID and for the people who went through it with the isolation, the levels of isolation that they had to have and the providers

and the people who, you know, get hit by the recession. So I really see this as like there's going to be a lot of psychological stuff coming from this. Right. Am I saying anything that's wrong? Is it

Or not true Or not true in the perspective that you have? No. And what I'm really worried about is that is that the one thing that can help that helps people manage big trauma like this is community.

Yeah, a hand holding someone. Touch. Right. The connectedness. And that's what's so sort of vicious about the social distancing concept. We all know that this is a contagious illness. Maintaining some distance is a way to reduce its spread. I wish we knew a lot more about what aspects of social distancing are really effective.

Because we know that social distancing takes a toll. My mother, my father-in-law, they're an elderly. They're isolated in their homes. depression, anxiety. Although we see a drop, we talked earlier about a drop in elective surgeries, and so certain aspects of the hospital are quiet. Some areas of the hospital are quiet. We're seeing more psychiatric presentations with anxiety, depression, overdose. I'm sure we're going to see a surge, we're going to see an uptick in suicide.

Family dynamic issues. Domestic violence, abuse. These are the sort of the, these are sort of the, the, indirect, more actual, they're indirect effects of COVID, but they're actually mortality effects. You know, we have this focus on the number of people who are succumbing to the illness, but we have to recognize how many people are succumbing to the indirect effects of COVID illness, which is our response to COVID illness. These are hard.

And so, but especially in addition to that, there's this sense of fracturing in our community. where the political divisiveness is especially painful. Because just when you need to have a unified support against an outside enemy, if you've got dissension in the ranks and you've got sort of a my team versus your team approach, that simply adds a lot of adds to the pain. Oh, and it's a way to direct the anger that is there anyways. Exactly. I'm sure you have the right words for that.

Is that transference or? You know, yeah, I mean, sure. Some people, it would be transference, you know, towards authority or towards the authority that they don't want to be the authority. You know, but if someone gets sick, a health care worker, all of a sudden it's not, you know, horrible disease that's causing it that we can all fight against. But it's like, oh, this was the poor planning by irresponsible, you know, leader. And then they put.

that anger on that, that leader. Right. And really like, you know, it's kind of like, it's kind of like there's this like Trump toilet paper that's floating around. And it's like people using this Trump toilet paper and it's a way for them to get out their, you know, aggression, which is kind of Freudian. Right. I, I don't find that helpful.

You look at, you know, I read it like a Taiwan's response, which is so impressive. There's a country of almost more than 30 million people. Not a little small country right next door to China who did everything, and they did everything right. They sent experts to Wuhan early who figured out this is a real thing. They had people monitoring temperatures on airline passengers coming off the plane. They did really effective tracking of cases.

and of contacts. They have a law that kicks in. This is a democracy. This isn't an authoritarian authoritarian country. It's not Singapore. It's not China. They have a law that kicks in.

Their vice president is actually was an epidemiologist. He had experience in the first SARS. So they knew what to do. And they have a law that kicks in that allows cell phone

geofencing, a geolocation to be, geo-information to be, geo-information, to be derived about, so you can do position tracking of cell phones. Okay. And the people voted on this. They understood that, hmm, if there's actually actual active contagion and pandemic, yeah,

maybe I'll give up those rights for a while while there's, you know, while there's concern for that. And so this wasn't forced on them. This is a democratic decision they made. And that really significantly helped the experts, the epidemiologist, track, track the disease. And I think if we don't, if we don't, I see a lot of talk about government overreaching and I've got a right to not wear a mask and I get a little worried about that because it's, it's just very, it's just fundamentally sociopathic, right? It's a fundamentally sociopathic response to say that, that my rights trump other people's

right. It's, it's, it's naive, right? It's like the anti-vaxxers. I'm not going to vaccinate my child because it causes autism. By the way, I'm looking at some really, I'm doing an episode on autism. There's no link between autism and, you know, vaccines. Put that out there. Reenforce that fact.

But, you know, you have this group of people, the anti-vaxxers, who want to do everything natural and they wanted to do this. They've never suffered the pain of polio. They've never suffered the death of a family member to measles, you know, or like some viral illness. You know? Influenza. Influenza. 20% vaccination rate. Well, they're young usually.

Right. So there's this notion that like, that's a good example because we have all the, all our eggs in this basket of, we're going to have a vaccine against COVID. But, you know, like I said, 60,000 people died of the 2017, in the 2017-18 flu season. Same number that's going to die in COVID. And yet we only have a 20% vaccination rate. it speaks to a poorly informed society that we have. 20%.

That's the vaccination rate? I think that's... Wow. That's what I learned from my wife. She knows a lot of things. Okay. Well, it's lower than we probably need it. Oh, it should be much higher.

It should be 60%. That's what I'm saying. We have a disease that can take considerable toll on our population. Right. And when there's a vaccine exist and people don't avail themselves at it. Yeah. Okay. You know, and I think, I hope that this opens up people's eyes, you know, to something that has been, you know, one of the great levelers of humanity.

I mean, the history of plagues. I'm actually working on an episode on the history of plagues, history of viral infections. it shaped history, like how the Spanish came over to South America and Central America and their viral infections spread, and they seemed like gods because the people were dying, you know? Yeah, well, smallpox. I mean, look at the story of smallpox,

which was an absolute scourge of humanity. And it's one of my favorite stories of technology. Okay, so, I mean, I've... Go ahead. I've talked about the limitations of technology law, but mankind's, you know, I would put the eradication of smallpox up there with putting a man on the moon in terms of sort of impressive achievement.

Well, even better. The reduction of suffering, more phenomenal. Certainly, there's no question that reduced human suffering, you know. But in terms of sort of technological triumph, yeah, vaccinating everybody with smallpox, on the planet and eradicated a disease. That took, but that took a concerted social effort.

No private company evaluated or got eradicated smallpox. This wasn't, this was, this was an effective, this was effective government coordinated activity. Mm-hmm. With, and even despite, with the consent of people and even without it. Yeah. I mean, yeah, I'm with you on this. So basically what we're talking about is that there's some things that we don't have control over.

And it's, you know, in psychiatry, it's the same way. It's like, I know that if this is the third antidepressant that you've been on, it may not work very well from the Stardee and, you know, from these studies. And so if I get a patient and that's all they want, they don't want to do therapy, they don't want to do partial. they don't want to do intensive treatment, essentially, for their depression. I will tell them, like, look, at this point, there are basically these options. And some patients will come back to me every three months for me to remind them of the options that actually work. And after two years, for example, this one patient finally gets his sleep apnea machine and he

actually wears it and his fatigue is gone. He's like, why didn't I do this sooner? I'm like, I don't know. I keep telling people to try this, you know. Get your sleep study. If you have severe sleep apnea, your life will change. Or like partial. Like, I'll tell patients all the time. Like, look, at this point, like, what you need is you need more intensive treatment. And patients will go there. And then one month, two months later, they'll be like, why didn't I do this three years ago? This is life changing. This is amazing. Right. So, right. We physicians have, have a role to play in providing correct information about probable therapeutic outcomes for this patient. And we have to train ourselves. We have to review literature and we have to become expert

in these things. So particularly with end of life, we have an obligation to provide that information for our patients to correct their notion that even though CPR is shown to be successful 75% of the time on TV and they do CPR on trauma patients, which isn't done. So in reality, CPR is actually effective maybe 3% of the time. CPR, David, CPR is effective in certain contexts. It works extremely well for, say, a young person who's electrocuted, who's in a bad arrhythmia.

CPR would be incredibly effective in that situation. It's effective. The environment that it's most effective in is a casino, for example. Huh. And the reason is because time is critical. Okay. You got the eye in the sky, right? You've got cameras.

And so if someone has a heart attack and collapses at the blackjack table, you can be doing CPR on them within 15 seconds. Okay. You've got AEDs right there. These are people who are drinking, who may be a little overweight, who are smoking. So they're at high risk. So you have high prevalence. I mean, and the responders know how to use.

So CPR is effective in that environment. It's also somewhat effective in airports because of a high concentration of people who are traveling or stressed. And you can see them right away when they collapse. These are people who are having arrhythmias. They may have an MI that they may have had an MI or maybe having an MRI. But fundamentally, they're having an arrhythmia. And arrhythmia, CPR can help keep some circulation going while an AED is brought to the scene.

That's what CPR is for. the notion that CPR would be effective in someone who has died whose heart has stopped after they've been on a ventilator that's in different context yeah CPR is not going to be effective in that regard and our and my point is physicians need to need to tell family members that and so the because the family members may be under the maybe laboring under the delusion that there's a 75% chance of their loved one recovering from from cardiac arrest after after dying from COVID illness it's it's amazing how media and things that we consume you know this is their understanding of how the medical world works you know someone goes unconscious we do CPR CPR brings them back

70% of the time um okay bringing this to a close i want to summarize kind of like what were some of my big takeaways and then maybe you can summarize some of your big would takeaways. Some of my big takeaways were physicians often decide to have less treatment than non-physicians. And part of that is because we know what actually is reasonable and what is like maybe excessive or unhelpful, but are considered heroic measures, but we would not even consider them heroic, you know? So what's that? Brutal. Yeah, we would probably more consider than brutal.

When a family says do everything, that might not mean do everything. It might mean do everything reasonable. And as physicians, we need to be the ones that are leading the charge on focusing on humanity, focusing on respecting the individual, focusing on how do we help this person suffer the least, and transition the best to death if that's where they're going, you know. And specifically in the COVID season, I would say how do we, as leaders, you know, maybe have people that can be on the COVID unit chaplains full time, you know, or how do we decide when this is going to be actually best to have the family,

present or, you know, like have that human connection there, right? Because I think there's something very dehumanizing about the aloneness of the situation. Right. Maybe the heroic measure is to bring the family back and be with the patient. Yeah. You see what I'm saying? So, right, that would clearly be heroic. It's risky. Hospital's not going to like that. Right. What I'm saying? Right. What is real heroism? Heroism doesn't mean, what I'm saying is... Well, I think someone would immediately say, but they're going to get infected.

And if they get infected, they'll infect more people and that will cause more suffering. I mean, like... Sure. But the point is, like I said earlier, the idea of helping create the context for a death with dignity can be just as heroic,

can actually be heroic. It is heroic. A death with dignity is heroic. And so creating that context where that can take place. Well, shall we leave it there? Is there anything else you wanted to put out here? No, I think that's, it's an enormous, it's an enormous topic. But I would say that the things I've learned are that if I'm,

I do the best job when I really do have the patient's interests at heart. if I'm distracted by the family's interests or by concerns for medical legal issues, you're not going to do the best. You're not going to get heroic care. I think also one thing that comes to me is that it's heroic to bring meaning to the team that's taking care of the patients as well. You know, there are patients that will come in to the hospital that we need to transition to more palliative hospice care.

And that is actually something that should be celebrated, right? When it's done well and it's done properly and it's done well. A lot of the support staff can be in this mindset of we need to do everything and we need to be heroic, right? And so it's, I think, talking to them

and educating them and having episodes like this, I hope this episode can do some of that work, right? of sort of shifting the mindset of, you know, having this conversation. As I think my experience in hospice was initially with two family members. And then the hospice, then I was actually invited by the hospice company that directed their care to be a director for them. And I think as more and more people have positive experiences with hospice in their own lives, with their own family members, hospice takes

it really loses it's what used to be a sense of giving up has been replaced by a sense I think most people are really have direct experience now many people have direct experience with hospice as as life affirming and and

and a way to achieve dignity rather than giving up and so that's a hugely important trans change that's occurred in the last, certainly in the last decade, I imagine. Yeah. Yeah. And I think if, if ICUs were run with just video cameras on all day long so people could

witness like what actually happens compared to what is seen on TV, like I think people's perceptions would change. Absolutely. information is is liberating it would it would really it would really show that's i think that's the take home of why the reason why doctors die differently is they know is they know those scenes and they're making choices that that are that that are made with the full understanding of the limitations of of of our care of the our ability to extend meaningful life yeah well that's good um we will be putting notes to this episode on the website psychiatrypodcast.com

it'll go in the resource library you can go there and get a copy of it i'm going to include a lot more details on things to say and things not to say i have 29 pages of notes on this i think you have like many as well and so we'll add those together put that up in a nice sort of resource for you guys so you guys can get more details on on some aspects of this. Dr. McNaught, and it's been a pleasure having you. Thank you very much. Dr. Peter.

By the way, we do have some good distance between us doing this podcast. It's about, what, eight feet? That's right. So we are social isolating. We're social isolating while we do this. I think, I'm against that word social isolating. I think it should be just distancing. Distancing.

Yeah. Yeah, proper distancing. Proper distancing. That's a much better term. Okay. And if you, if your health care provider and you're struggling, please, one courageous thing you can do is to reach out and to the support structures that are out there. There are a lot of therapists that would love to help you. I know in my institution, California, I have opened up extra hours to see physicians and nurses who are struggling.

in the trenches. And so please don't feel alone if you are in the midst of this struggling. And reach out, get some support wherever you're at. And hope all of you are well.