good evening my name is Craig Dury I
have the fortune of growing up in a
household with parents that spoke two
languages one of those languages being
English the other language being offered
kant’s I married a wonderful woman that
speaks some French and throughout my
life I’ve taken some Spanish lessons
from time to time and I work as a
translator now the funny thing about
standing up on a stage and presenting
myself as a translator is the only
language that I have any fluency in is
actually English and as you might see at
some points I periodically stumble with
that but I am being sincere when I say
that I’m a translator because what my
lab code at work says is nurse
practitioner palliative care and what I
speak is a little bit of the dialects in
that world dialects like cardiology
pulmonary critical care oncology and
they also speak and listen to a core
contingent of the layman’s language
because the translation work that I and
my team members are called upon to do is
bring the information together in a
manner that’s understood by all parties
involved in the health care of a patient
so imagine yourself for a moment in an
ICU you’ve got a wonderful caring family
there’s five devoted family members that
are each taking shifts visiting you in
the ICU throughout the course of the day
and throughout that same day you’ve got
your cardiologist that’s visiting her
you’ve got your nephrologist who’s
checking in on your kidney function
you’ve got an oncologist that you’ve
never met before that’s also checking in
on you you’ve got a variety of different
team members they’re all meeting
different family members of yours during
the course of that day and they’re
talking about your health status from a
little bit of their own perspective from
what they’re responsible for and the
next day a lot of your team members kind
of switch out after being on call and
you’ve got kind of a different subset
you can imagine if at the end of that
week you’re called upon to navigate some
very complex and difficult decision
making about how you want elements of
your health care managed that that might
be a very complex and daunting task what
I’m often called upon to do is step into
that
environment learn about the patient and
I might start by asking tell me what
what you’re hearing from the rest of
your healthcare team because then I can
begin to comprehend what they know what
they’ve heard how they’ve processed that
where those gaps are but I’m also going
to ask them tell me what you used to do
for a living
tell me what you do for fun what puts a
smile on your face today and some of the
questions that are deceptively easy can
also be deceptively difficult tell me
what you’re worried about the most help
me figure out what the concerns are
whose your support network and as I
gather this information I can begin to
look at what they’re motivated to
receive in terms of health care what
their priorities are and I can begin to
match that up with what we’re offering
we call that clarifying the goals of
care that’s one big role that palliative
care is called upon to do and in doing
that we reduce a lot of anxiety and
distress within the family unit and for
that patient themselves not to say these
conversations are easy but when people
have an understanding of what some of
their options might be and what they’re
up against they can actually grapple
with that in doing that in reducing that
stress and anxiety I’m also focusing on
what are their physical symptoms and
cognitive symptoms emotional symptoms as
well and trying to medically manage some
of that at the same time so we’re really
engaging in work that helps protect the
quality of life as best as we can but by
clarifying those goals of care we’re
also bringing efficiency to the care we
provide for that patient we’re avoiding
unnecessary tests or things that might
not make sense with what the patient’s
objectives are and at the same time by
doing that with that efficiency in that
clarity we find that people are spending
a bit less time in the ICU and there’s
also less readmissions to the hospital
as a result of that so we may clarify
things like do you have an advance
directive
what should your code status be what are
your thoughts on being on a ventilator
for a long period of time would you ever
accept a tracheostomy to make that
semi-permanent is artificial feeding
through a two
something that would make sense our more
readmissions to the hospital serving you
well should we continue that high-risk
diagnostic testing do those have enough
benefits to outweigh the risks from the
patient’s perspective and with a good
understanding of their health concerns I
was called upon about three years ago to
see a patient that really opened my eyes
to an unmet need in doing this kind of
work it was a woman who had been life
flighted in from a hospital in the
Pocono Mountains to our hospital and the
order for the consult read clarify goals
of care patient refusing everything and
that usually means that we’ve either
done a rather poor job of explaining
what we’re offering or we’ve done a less
than stellar job at listening to what
the patient is asking for I arrived at
the bedside to find a woman in the ICU
who was alert not on life support
perfectly able to have a rational
conversation with me and in talking to
her she was flown in for valvular heart
disease and evaluation for valve
replacement surgery and I began to
explore why she was refusing the cardiac
cath and a bit fed up with some of the
consultants the lab work in the
echocardiogram that was being ordered
and the one statement that summed it up
beautifully was she looked at me and
said nobody said anything about cutting
on me 12 to $25,000 for a flight and
we’d kind of missed the most fundamental
question before she left her hometown
hospital of asking what are your goals
what would you like us to accomplish
with this transfer to this hospital we
did clarify her goals she accepted that
being hospitalized one to three times a
year
was acceptable enough as opposed to the
option of surgery for her not everybody
would make the same choice wasn’t my job
to tell her what the right choice was
but to help her articulate that so she
went back up to the Poconos back to the
support of her family and it was about
three days later that I was sitting in
front of a telemedicine modest monitor
that it occurred to me I could have had
that same conversation with this woman
likely with her surrounded by her
family from a hundred miles away or
quite literally from the opposite side
of the planet that set me to exploring a
little bit further because what I wanted
to understand better is how big of a
need is there for palliative care in
these smaller hospitals that dot the
Pocono Mountains and are also really
throughout our entire country hospitals
that aren’t as big is the tertiary
Center where I practice so I pulled data
from three of those hospitals over a
one-year period I looked at diagnosis it
would be appropriate for a palliative
care consultation complex life limiting
disease and what I found is in the
course of one year at those three
hospitals there was one thousand three
hundred and sixty-nine patients who
would have been appropriate for a
palliative care consultation palliative
consultation also has an impact on rate
of readmission because sometimes if we
clarify the goals or effectively manage
things people don’t need to come back as
often what I found is there is about 300
sorry 3,600 readmissions in that
one-year time period that’s the
difference when I compared that with
hospitals that have a palliative care
program the difference being about 17
percent greater readmissions at those
hospitals without access to a palliative
care team so this matters it matters
partly because we also have a national
shortage in palliative care providers so
I started to wonder are people doing
telemedicine consults in this capacity
to meet that need and as I looked at the
national data and publications I found
that doesn’t really exist yet so I
started to explore a little bit further
I spent some time with one of my
colleagues it does infectious disease
consults remotely and I observed him
doing a consult with a patient with
moderately advanced dementia and he was
really talking to the patient’s son that
was at the foot of the bedside he was
being treated for recurrent infections
and cellulitis and at one point he puts
the family on mute turns to me and says
is this a good place for a palliative
care consult and I said well I would
probably ask if there’s anybody in the
family who’s power-of-attorney to
navigate
decisions have they talked about a
living will at an earlier point have
they had any thoughts about recurrent
readmissions at the end stage of
dementia and when they might want to not
engage in cyclical admissions for that
recurrent phenomenom of infections that
typically ends the life in dementia have
they talked about artificial feeding
they said okay took the family off mute
and rolled me in front of the camera and
I found very quickly that that
conversation was just as natural from a
few hundred miles away as it was if I
was sitting face to face in front of a
family member it was eminently doable I
wish I could say that some of these
consults were that simple
there are also consults that I see as
emergency and high impact I had a
conversation with one of my ICU
colleagues who really told me a story
that hit me to the core she was
receiving a patient eighty-seven years
old who was going to be flown in from an
outside hospital and in receiving that
report she was hearing information of
lab values that were frankly
incompatible with life for all intents
and purposes this is a woman who was
actively dying with multi-system organ
disease and we would most likely be
successful than prolonging a dying
process for her as opposed to reversing
it or leading to a different outcome so
she asked if anybody had talked to the
family about whether or not they wanted
this transfer or how they would perhaps
support end-of-life care there and the
response she got was well we don’t have
the time to manage that we don’t have
the time to to talk to the family about
all of that it’s your job to take her
we’re sending her she got off the phone
and it was about 15 minutes later that
she heard the nurse getting the nursing
report on that same patient and she
happened to overhear the phrase we’re
not sure the patient has a pulse anymore
they were in fact preparing to send a
patient that had died she did ask that
they go back and check to see if there
was a pulse so she didn’t they didn’t
send the patient but the reality is that
was probably a family in crisis that we
could have rapidly talked to them
clarified some of the goals also
explained what we could offer
and accepted the patient if that’s what
they wanted or perhaps provided
end-of-life care in that patients own
home community surrounded by a family
network we risk doing that from a few
hundred miles away with likely the same
outcome so in this work that I do I do a
lot of difficult consults and that
drains my emotional tank at the same
time but I do this work because it helps
improve quality of life
it helps shorten the length of stay it
helps reduce cost and is deeply
emotionally meaningful some of the
family stories that refill that
emotional tank for me or as follows I’ve
met sailors from World War two that were
among the first to cruise under the
polar ice caps in submarines that
crashed airplanes and survived
I met a major league Hall of Fame
baseball player recently she was an
amazing woman she worked for 30 years as
a welder after that I met a skydiver
that had done over a thousand jumps some
of those during the day time some of
them at night some of them with clothing
some of them without I also recently met
a woman with purple hair and end-stage
COPD and she was astute enough to be
fearful that her family would allow her
life to end on a ventilator in an ICU or
in a nursing home with a tracheostomy
she was clear those were things that she
did not want for herself but she had
trouble conveying that to her family
they were all arguing for aggressive
things and they were doing so out of
love for her so we called the family
meeting we brought that family together
i sat next to this woman her family sat
on the bed and I talked through the
advancing nature of COPD and what those
aggressive interventions would offer and
what they wouldn’t offer and then I
explained that she didn’t want that and
that we weren’t going to do that that
family was able to hear that message in
the context of her disease process
parallel with her wishes and her goals
and were able to come together and
support that I thought the meeting was
over I thought we’d clarified the goals
and then she said and
when I die I want to be cremated and
then the argument over funeral
arrangements broke out I couldn’t quite
get out the door they were blocking my
pathway with some of their seating
arrangement so they just continued to
argue and bicker it’s not normally my
purview to figure out the after death
concerns and with pregnant pauses in her
COPD and deep breath she says and when I
die and when I’m cremated they can take
my ashes they can put them in an
etch-a-sketch and they can play with my
knobs all day long and when that family
broke out in the laughter they also
understood those wishes were valid that
family was together with her and able to
understand her wishes and honor them
this is the work that palliative care
does we can bridge the gap across
geographic boundaries to do this through
the use of telemedicine and we should thank you
have the fortune of growing up in a
household with parents that spoke two
languages one of those languages being
English the other language being offered
kant’s I married a wonderful woman that
speaks some French and throughout my
life I’ve taken some Spanish lessons
from time to time and I work as a
translator now the funny thing about
standing up on a stage and presenting
myself as a translator is the only
language that I have any fluency in is
actually English and as you might see at
some points I periodically stumble with
that but I am being sincere when I say
that I’m a translator because what my
lab code at work says is nurse
practitioner palliative care and what I
speak is a little bit of the dialects in
that world dialects like cardiology
pulmonary critical care oncology and
they also speak and listen to a core
contingent of the layman’s language
because the translation work that I and
my team members are called upon to do is
bring the information together in a
manner that’s understood by all parties
involved in the health care of a patient
so imagine yourself for a moment in an
ICU you’ve got a wonderful caring family
there’s five devoted family members that
are each taking shifts visiting you in
the ICU throughout the course of the day
and throughout that same day you’ve got
your cardiologist that’s visiting her
you’ve got your nephrologist who’s
checking in on your kidney function
you’ve got an oncologist that you’ve
never met before that’s also checking in
on you you’ve got a variety of different
team members they’re all meeting
different family members of yours during
the course of that day and they’re
talking about your health status from a
little bit of their own perspective from
what they’re responsible for and the
next day a lot of your team members kind
of switch out after being on call and
you’ve got kind of a different subset
you can imagine if at the end of that
week you’re called upon to navigate some
very complex and difficult decision
making about how you want elements of
your health care managed that that might
be a very complex and daunting task what
I’m often called upon to do is step into
that
environment learn about the patient and
I might start by asking tell me what
what you’re hearing from the rest of
your healthcare team because then I can
begin to comprehend what they know what
they’ve heard how they’ve processed that
where those gaps are but I’m also going
to ask them tell me what you used to do
for a living
tell me what you do for fun what puts a
smile on your face today and some of the
questions that are deceptively easy can
also be deceptively difficult tell me
what you’re worried about the most help
me figure out what the concerns are
whose your support network and as I
gather this information I can begin to
look at what they’re motivated to
receive in terms of health care what
their priorities are and I can begin to
match that up with what we’re offering
we call that clarifying the goals of
care that’s one big role that palliative
care is called upon to do and in doing
that we reduce a lot of anxiety and
distress within the family unit and for
that patient themselves not to say these
conversations are easy but when people
have an understanding of what some of
their options might be and what they’re
up against they can actually grapple
with that in doing that in reducing that
stress and anxiety I’m also focusing on
what are their physical symptoms and
cognitive symptoms emotional symptoms as
well and trying to medically manage some
of that at the same time so we’re really
engaging in work that helps protect the
quality of life as best as we can but by
clarifying those goals of care we’re
also bringing efficiency to the care we
provide for that patient we’re avoiding
unnecessary tests or things that might
not make sense with what the patient’s
objectives are and at the same time by
doing that with that efficiency in that
clarity we find that people are spending
a bit less time in the ICU and there’s
also less readmissions to the hospital
as a result of that so we may clarify
things like do you have an advance
directive
what should your code status be what are
your thoughts on being on a ventilator
for a long period of time would you ever
accept a tracheostomy to make that
semi-permanent is artificial feeding
through a two
something that would make sense our more
readmissions to the hospital serving you
well should we continue that high-risk
diagnostic testing do those have enough
benefits to outweigh the risks from the
patient’s perspective and with a good
understanding of their health concerns I
was called upon about three years ago to
see a patient that really opened my eyes
to an unmet need in doing this kind of
work it was a woman who had been life
flighted in from a hospital in the
Pocono Mountains to our hospital and the
order for the consult read clarify goals
of care patient refusing everything and
that usually means that we’ve either
done a rather poor job of explaining
what we’re offering or we’ve done a less
than stellar job at listening to what
the patient is asking for I arrived at
the bedside to find a woman in the ICU
who was alert not on life support
perfectly able to have a rational
conversation with me and in talking to
her she was flown in for valvular heart
disease and evaluation for valve
replacement surgery and I began to
explore why she was refusing the cardiac
cath and a bit fed up with some of the
consultants the lab work in the
echocardiogram that was being ordered
and the one statement that summed it up
beautifully was she looked at me and
said nobody said anything about cutting
on me 12 to $25,000 for a flight and
we’d kind of missed the most fundamental
question before she left her hometown
hospital of asking what are your goals
what would you like us to accomplish
with this transfer to this hospital we
did clarify her goals she accepted that
being hospitalized one to three times a
year
was acceptable enough as opposed to the
option of surgery for her not everybody
would make the same choice wasn’t my job
to tell her what the right choice was
but to help her articulate that so she
went back up to the Poconos back to the
support of her family and it was about
three days later that I was sitting in
front of a telemedicine modest monitor
that it occurred to me I could have had
that same conversation with this woman
likely with her surrounded by her
family from a hundred miles away or
quite literally from the opposite side
of the planet that set me to exploring a
little bit further because what I wanted
to understand better is how big of a
need is there for palliative care in
these smaller hospitals that dot the
Pocono Mountains and are also really
throughout our entire country hospitals
that aren’t as big is the tertiary
Center where I practice so I pulled data
from three of those hospitals over a
one-year period I looked at diagnosis it
would be appropriate for a palliative
care consultation complex life limiting
disease and what I found is in the
course of one year at those three
hospitals there was one thousand three
hundred and sixty-nine patients who
would have been appropriate for a
palliative care consultation palliative
consultation also has an impact on rate
of readmission because sometimes if we
clarify the goals or effectively manage
things people don’t need to come back as
often what I found is there is about 300
sorry 3,600 readmissions in that
one-year time period that’s the
difference when I compared that with
hospitals that have a palliative care
program the difference being about 17
percent greater readmissions at those
hospitals without access to a palliative
care team so this matters it matters
partly because we also have a national
shortage in palliative care providers so
I started to wonder are people doing
telemedicine consults in this capacity
to meet that need and as I looked at the
national data and publications I found
that doesn’t really exist yet so I
started to explore a little bit further
I spent some time with one of my
colleagues it does infectious disease
consults remotely and I observed him
doing a consult with a patient with
moderately advanced dementia and he was
really talking to the patient’s son that
was at the foot of the bedside he was
being treated for recurrent infections
and cellulitis and at one point he puts
the family on mute turns to me and says
is this a good place for a palliative
care consult and I said well I would
probably ask if there’s anybody in the
family who’s power-of-attorney to
navigate
decisions have they talked about a
living will at an earlier point have
they had any thoughts about recurrent
readmissions at the end stage of
dementia and when they might want to not
engage in cyclical admissions for that
recurrent phenomenom of infections that
typically ends the life in dementia have
they talked about artificial feeding
they said okay took the family off mute
and rolled me in front of the camera and
I found very quickly that that
conversation was just as natural from a
few hundred miles away as it was if I
was sitting face to face in front of a
family member it was eminently doable I
wish I could say that some of these
consults were that simple
there are also consults that I see as
emergency and high impact I had a
conversation with one of my ICU
colleagues who really told me a story
that hit me to the core she was
receiving a patient eighty-seven years
old who was going to be flown in from an
outside hospital and in receiving that
report she was hearing information of
lab values that were frankly
incompatible with life for all intents
and purposes this is a woman who was
actively dying with multi-system organ
disease and we would most likely be
successful than prolonging a dying
process for her as opposed to reversing
it or leading to a different outcome so
she asked if anybody had talked to the
family about whether or not they wanted
this transfer or how they would perhaps
support end-of-life care there and the
response she got was well we don’t have
the time to manage that we don’t have
the time to to talk to the family about
all of that it’s your job to take her
we’re sending her she got off the phone
and it was about 15 minutes later that
she heard the nurse getting the nursing
report on that same patient and she
happened to overhear the phrase we’re
not sure the patient has a pulse anymore
they were in fact preparing to send a
patient that had died she did ask that
they go back and check to see if there
was a pulse so she didn’t they didn’t
send the patient but the reality is that
was probably a family in crisis that we
could have rapidly talked to them
clarified some of the goals also
explained what we could offer
and accepted the patient if that’s what
they wanted or perhaps provided
end-of-life care in that patients own
home community surrounded by a family
network we risk doing that from a few
hundred miles away with likely the same
outcome so in this work that I do I do a
lot of difficult consults and that
drains my emotional tank at the same
time but I do this work because it helps
improve quality of life
it helps shorten the length of stay it
helps reduce cost and is deeply
emotionally meaningful some of the
family stories that refill that
emotional tank for me or as follows I’ve
met sailors from World War two that were
among the first to cruise under the
polar ice caps in submarines that
crashed airplanes and survived
I met a major league Hall of Fame
baseball player recently she was an
amazing woman she worked for 30 years as
a welder after that I met a skydiver
that had done over a thousand jumps some
of those during the day time some of
them at night some of them with clothing
some of them without I also recently met
a woman with purple hair and end-stage
COPD and she was astute enough to be
fearful that her family would allow her
life to end on a ventilator in an ICU or
in a nursing home with a tracheostomy
she was clear those were things that she
did not want for herself but she had
trouble conveying that to her family
they were all arguing for aggressive
things and they were doing so out of
love for her so we called the family
meeting we brought that family together
i sat next to this woman her family sat
on the bed and I talked through the
advancing nature of COPD and what those
aggressive interventions would offer and
what they wouldn’t offer and then I
explained that she didn’t want that and
that we weren’t going to do that that
family was able to hear that message in
the context of her disease process
parallel with her wishes and her goals
and were able to come together and
support that I thought the meeting was
over I thought we’d clarified the goals
and then she said and
when I die I want to be cremated and
then the argument over funeral
arrangements broke out I couldn’t quite
get out the door they were blocking my
pathway with some of their seating
arrangement so they just continued to
argue and bicker it’s not normally my
purview to figure out the after death
concerns and with pregnant pauses in her
COPD and deep breath she says and when I
die and when I’m cremated they can take
my ashes they can put them in an
etch-a-sketch and they can play with my
knobs all day long and when that family
broke out in the laughter they also
understood those wishes were valid that
family was together with her and able to
understand her wishes and honor them
this is the work that palliative care
does we can bridge the gap across
geographic boundaries to do this through
the use of telemedicine and we should thank you
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