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Episode 008

Professor Hare: [00:00:00] Hey folks, this is professor Hare and today on the Be Excited podcast, we have Courtney Alesandro who is a palliative care CRNP, Nurse Practitioner, in Fredericksburg, Virginia. And we are going to talk through the palliative care service that she works on there.

Professor Hare: Thanks for being on the podcast, Courtney.

Courtney Alesandro: Oh, thanks, Jason. It’s great to be here.

Professor Hare: We appreciate you being here. So I should mention that we used to work together in somewhat separate, but related departments at the psych hospital. So I got to know you pretty well there.

Professor Hare: and then of course she left us and moved on to greener pastures down south.

Courtney Alesandro: Yeah, exactly. I don’t know if Virginia is greener pastures. Well, sometimes it is. It is actually, now that I say that our flowers are in bloom already got daffodils coming up, so, but it’s good to see you again,

Professor Hare: You as well, and we really appreciate you coming on. Can you tell us about your background and how you got to become a palliative [00:01:00] care NP.

Courtney Alesandro: that certainly can be a long story. So I’ll try and make it as succinct as possible suffice to say, this is the perfect job and cumulation of experiences for me.

Courtney Alesandro: And I had no idea that it existed before I got into it about six, seven years ago. I went to college after high school. It was four years of fun, but I never graduated. And I went off to San Francisco to find myself as many people do, I suppose. When I got there, I got into massage therapy.

Courtney Alesandro: I became a massage therapist. Yoga instructor and a personal trainer. And at about age 27, I decided, hands on my hips, I’m going into nursing which really had endeavor been discussed. so I went to a community college there, city college of San Francisco became a nurse.

Courtney Alesandro: And.

Courtney Alesandro: Then I moved to [00:02:00] Pittsburgh had a business doing again, massage therapy and yoga and folding my nursing practice into it and quickly decided it was to my advantage to become a nurse practitioner. So I went to Pitt, became an adult nurse practitioner in 2006. And my first job is where I met you.

Courtney Alesandro: I was specifically in an inpatient outpatient eating disorder clinic, and I did that for gosh nine or 10 years. And then moved down to Fredericksburg Virginia. And when I was looking for a job, I went to a job fair with the hospital here, which is Mary Washington hospital. they were recruiting heavily for a palliative care nurse practitioner.

Courtney Alesandro: I thought I would do something in behavioral health but the recruiter, really pushed palliative care and. [00:03:00] having no idea what it was, but I’m always agreeable said, sure, I’ll apply to that. and through the interview process, what I learned was all my experiences. But most heavily my experiences working in eating disorders really prepared me for the communication that is needed in palliative care.

Courtney Alesandro: Having hard conversations. I have been doing palliative care since 2015, I’m in with a system now in Northern Virginia the I Nova system. And I love it. I think it’s a wonderful combination of medicine and gosh connection.

Professor Hare: I think it is a very interesting a short digression to talk about, the fact that I am to this day, surprised that you haven’t had any true formal psych training other than your RN training Is that correct.

Professor Hare: Right. [00:04:00] you spent a short period of time in the hospital and that’s it. And that to me is always surprising, but it also speaks to your skillset. That’s you know, this is what you bring to the table is often as much or more than just the degrees or any of the certifications that you might have in that area.

Professor Hare: I talk to my students all the time about this, and I think this is always a good conversation for students to hear is that, you know, you walk in the door with this experience, the set kind of thing that you do on a day-to-day basis. Or you came into school with that background and you think I need to do that.

Professor Hare: As my PA career or my NP career I was one of those people, he has an athletic trainer. I thought I had to go into orthopedics and musculoskeletal, and then it wasn’t exactly what I liked. I, I discovered that athletic training was more like being in primary care and so moved to primary care for my second job as a physician assistant.

Professor Hare: And I try to impress upon my students. The thing that you think you need to do often gets superseded by something that you’re just exposed to, or some [00:05:00] opportunity that’s put in front of you to pick up is that other area of medicine where you look at that and you say, wow, that’s that’s something I think I would enjoy.

Professor Hare: Or if you get lucky enough to get the experience as a clinical rotation, for instance, you might get to see that as something that’s really interesting and something that really pulls you in and I won’t say leave behind because you take all those experiences with you, but you certainly can move into those areas and really be energized by that kind of experience.

Professor Hare: What brought you into that, and then how that how that really worked well for you?

Courtney Alesandro: I can talk about that. Till the cows come home, I think being open to what is being put in front of you is so crucially important. I think about how small my life would have been.

Courtney Alesandro: If I dictated it all because I did not have the imagination. Or the knowledge to know what could be my life, what could be my career. And certainly when I started in nursing in [00:06:00] 2000 palliative care, wasn’t what it is today. being open to hearing what other people have to offer and what you really enjoy and, and respond to using that as your north star can really direct your career and direct your life in ways that you just could not have imagined.

Courtney Alesandro: when I did interview for the initial palliative care position, what I relied heavily on was discussing how I can have conversations. You know, I had no idea how to do the quote unquote medicine of palliative care but having great faith In myself that I could learn because I managed to learn all this other stuff.

Courtney Alesandro: And as your students should know if they’re getting through PA school, their ability to learn is intact. So you could always learn the medicine aspect of something go with what [00:07:00] speaks to your heart.

Professor Hare: I wholeheartedly agree with that. I think, the north star of your own wishes and what you want to do is it’s a good way to put it because I think oftentimes it’s there and you don’t even recognize it.

Professor Hare: You don’t even see that as the thing that might be driving you, or might be something that you can hitch your desire and your career to, and follow it and speaking of north star that is an expression I use with my patients and my patients, families a lot.

Courtney Alesandro: So I do palliative care in a hospital. And the acuity is high and the timing. Is is condensed, but one of the conversations I like to have with a person is saying, Hey, what is your north star? What do you want out of this time in your life? And let’s direct your medical care to that goal as opposed to having a medical goal and directing your life to that medical goal.

Courtney Alesandro: So just taking a slight shift. I also think, keeping the north star [00:08:00] is, is just a good way to orient yourself to life.

Professor Hare: I like it. let’s dive into that a little bit because we’ve discussed the differences between palliative care and hospice care, which are two very separate things.

Professor Hare: And although in some ways, and in some services, you’re going to see some overlap of that. Tell me, your sense of the big differences between palliative care and hospice care.

Courtney Alesandro: Absolutely.

Courtney Alesandro: They are often conflated and I will answer that question with. your audience in mind and knowing that they are going to or are in their career acting as a provider. think of palliative care as a consultative service. It’s, multi-disciplinary, it’s usually made up of a medical doctor, an APP, a social worker and a chaplain and

Courtney Alesandro: you want to consider palliative care for your patient when your patient has a serious. So [00:09:00] you would think that this disease would some time in the future take their life. And they would benefit from exploring their goals of care or you see that your patient has no understanding of their disease process and the expected trajectory, or you could see that your patient could benefit from understanding the benefits and the burdens of potential interventions coming down the way how that’s different than hospice care is.

Courtney Alesandro: By the time somebody’s choosing to go into hospice, those goals of carers have been determined already. The goals are for hospice care, you would consider hospice when your patient doesn’t have viable treatment options available to them. Either. They’re saying, gosh, my goals of care, aren’t in line with any of these treatment options, or there are no more treatment options, palliative care being a consultative service can [00:10:00] coincide with treatment of any kind.

Courtney Alesandro: So if you’re thinking you know, certainly cancer is an obvious specialty. Oncology is an obvious specialty to be linked to palliative care, but say your patient has heart disease and their stage three heart disease. So you wouldn’t want to necessarily consider palliative care for your patient at the very beginning of having heart disease, which is just, you know, some high blood pressure.

Courtney Alesandro: Although technically we can. Start being part of somebody’s care. As soon as they’re diagnosed with a chronic condition that will eventually take their life but there aren’t many palliative care providers. So you don’t necessarily want to say, gosh, 35 year old person who just got diagnosed with high blood pressure.

Courtney Alesandro: You need to start having a palliative care consultation.

Professor Hare: can I ask a simple question, but [00:11:00] does your service ever, don’t want to say refuse a consult, but do you ever say to them, this patient is probably not at a stage that we’re concerned about at this point, or is this a rare enough instance at this moment in medicine, which, you know, we need to expand this, I think, but is this a rare enough moment in medicine that very few of those are going to be refused because it’s not as common a consult,

Courtney Alesandro: I think the latter. because there is not a strong understanding of how palliative differs from hospice getting us on earlier rather than later is, is rarely. A problem what’s more common is that somebody who maybe doesn’t have a life limiting disease but has chronic pain is consulted to our service and that’s not an appropriate referral.

Courtney Alesandro: Those are challenging patients. They are better served with a pain management service just [00:12:00] for, for innumerable reasons. if you find one to consult,

Courtney Alesandro: exactly so pain management services are about as plentiful as palliative care services. So a lot falls on the provider, you know, the primary care provider, which I would hope is changing in time.

Courtney Alesandro: But it has been my experience that having initial goals of care conversations, initial conversations about say code status and advanced directives primary care providers don’t have confidence in it. They don’t know how to begin those conversations. I think again, I think the training is, changing.

Courtney Alesandro: Younger providers coming in are a little bit more versed, but it’s an area of, of discomfort for a lot.

Professor Hare: a lot of those discussions could really be and probably belong in those settings where someone can approach the patients that they know well and have known well for some period of time, [00:13:00] it’s not just, you are a new consult.

Professor Hare: You’re a new person in that person’s life. And I think is possibly what you have to deal with more often than not is I’ve been introduced to this person. And now we have to have this discussion that could have occurred in a better mindset, maybe in a better timeframe with the person who’s been their lifelong practitioner.

Courtney Alesandro: Absolutely. Absolutely. These conversations are so better served when a relationship has been established because the thing that drives people to make their decisions is almost never interventions, it’s always more meaningful to a person. It’s their husband, their wife, their children, the fact that, their first grandchild is going to be born in six months.

Courtney Alesandro: Those are the things that drive a person to consider what their goals of care are. And if you know that patient and you know that person’s family and, you [00:14:00] know, what’s important, you can reflect that to them and have a meaningful conversation that doesn’t take an hour and a half and be

Professor Hare: in a better place to make that kind of decision consider it without the whatever acuity is being imposed on that patient’s health is not the primary driver in that moment.

Professor Hare: It’s, it’s actually the bigger picture. there’s a grandchild coming along the way. of all of the documents that you like to see, or the, the discussions that you have liked to have seen happened that are then documented in your charts, for instance, that. Help you maybe make this process and the decision making for that person a little bit less acute a little bit right now.

Courtney Alesandro: hard question to answer with one, one point above all else, having a medical power of attorney is a lifesaver and that’s an easy conversation to have with somebody varies from state to state in terms of what happens. If you don’t have a medical power of attorney people have [00:15:00] lives and lives are messy.

Courtney Alesandro: if Mr. Smith has coming into the hospital and Mr. Smith, hasn’t named a power of attorney, but he has an adult daughter who he lives with, who has been his caretaker, but he has an estranged wife. You haven’t seen in five years, and they’re not legally divorced. That’s going to go straight to that wife.

Courtney Alesandro: Decision-making will go there or say he doesn’t have a wife, but he has four children. And the worst are even numbers because decision-making then would go equally to all four children. It doesn’t prioritize the eldest and these are the laws in Virginia. So, you know, please take that as a caveat.

Courtney Alesandro: Okay. So coming in with, who would you want to make decisions for you in the event that you cannot make your own decisions? Simple question. It does not mean that [00:16:00] you being within your sound mind automatically can’t make decisions that would only go a medical power of attorney would only go into effect.

Courtney Alesandro: If you could not make your own decisions. And you can make really bad decisions for yourself. It still won’t go into effect. You have that, right. It’s just in the event that you can not.

Professor Hare: So you’re allowed to make perfectly bad decisions up to the point where somebody decides that you can’t make the decision,

Courtney Alesandro: Absolutely.

Courtney Alesandro: You can make the worst decisions for yourself of left, right. And center until you become encephalopathic. You’re fine.

Professor Hare: Yeah. And people do it every day, you know, what I ate for breakfast was probably a bad decision today, but I did it anyway. It doesn’t take freedom of decision away.

Professor Hare: Those next steps put into the hands of somebody when you can’t make those decisions.

Courtney Alesandro: Right. And being elderly is not a reason for not being able to make decisions. You could be a hundred years old. Chances are, if you’re a hundred years old, you’re hard of [00:17:00] hearing.

Courtney Alesandro: So it’s real important that you don’t get dismissed as, oh, got some dementia might be hard hearing, but you still get to make a decision for yourself if you can.

Professor Hare: So accommodate the, difficulties, but, but don’t take away the decision-making in those instances.

Courtney Alesandro: Right. And so, but to continue with your question, once that happens, then.

Courtney Alesandro: Your patient’s going to need to explore their advanced directive. An advanced directive can be as simple or as complicated as that person wants. And in it, that person would say you know, I want my second child to be my medical power of attorney. If I can’t make a decision for myself or the doctors determined, I have a terminal illness, what do I want, do I want to be resuscitated?

Courtney Alesandro: Do I want artificial feeding? Do I want repeated antibiotics for aspiration pneumonias that goes into needing to have a [00:18:00] larger conversation and ideally having repeated conversations. It’s such a better outcome. If you have 12 conversations with a person exploring these things, then one moment where you’re all running down the hallway, screaming at each other, going, what do you want for your dad?

Courtney Alesandro: What do you want? You know, it’s a terrible way to have it.

Professor Hare: Yeah. Also, the, repeated revisiting of that discussion with changing life circumstances is also something that primary care and family medicine might be better at as well. If the time is taken to actually have that conversation on a, relatively ongoing basis.

Courtney Alesandro: Absolutely. The choices you’re gonna make for what you want in terms of life-prolonging interventions gonna change dramatically. Again, going back to heart disease the trajectory, if you’re the 35 year old who has high blood pressure. Yeah. You’re probably gonna want at that moment, a lot of those interventions, but as that person [00:19:00] progresses and now is repeatedly in the hospital repeatedly coming in and volume overload.

Courtney Alesandro: and now has gone from like maybe nasal cannula to now needing high bi-pap occasionally those conversations are going to be much different.

Professor Hare: That certainly makes sense. you like to see the power of attorney and?

Courtney Alesandro: think having a power of attorney and having familiarity with, oh, this is a goals of care conversation.

Professor Hare: And then, you know, it’s happened that that conversation has happened in other words. Yeah.

Courtney Alesandro: Or I know what they’re getting at, or I’ve given this some thought, because my primary care provider in the last three visits has brought it up. We haven’t completed an advanced directive. We haven’t gotten to that point yet for whatever reason, but, oh, she’s talked to me about you know, the burden of dialysis.

Courtney Alesandro: I don’t now think [00:20:00] dialysis is just something that I go do and get to continue my life without any impact. I now understand what is needed to have it you know, and that could go down to the transportation needs. The impact to my overall wellbeing, I chances are I’m going to be fatigued. So it’s going to be three days a week, but it’s going to eat into other days.

Courtney Alesandro: I have a better understanding of this. So now when the lady in the hospital says you are here because your kidneys have gone south or more south, and now we need to talk about dialysis. That framework has been established.

Professor Hare: And do you see, someone has initiated a conversation, but nothing ever got documented.

Professor Hare: So we don’t have an official record of their wishes, but they’ve had the discussion with family. That’s been cued by someone in primary care, family medicine, you know, you should have that discussion. They go home, they start to have that discussion. Nothing has ever documented, but then they come in and then you’ve got a family member [00:21:00] who at least has a sense of where they’re coming from or what their wishes might be in that moment.

Courtney Alesandro: Yes. I love when that happens. I think, although it makes everyone’s life easier, if you have the actual documentation, you know, it absolutely does. But when push comes to shove, what’s more important is. Mom has had this conversation with you. you being the power of attorney. and when I say power of attorney, I want to be clear that I’m talking medical power of attorney.

Courtney Alesandro: A lot of times people come in with their financial paperwork, all in great shape and have a financial power of attorney talking to medical power of attorney. But for you to understand what your, your loved one would and would not want, takes away such a burden for the loved ones.

Courtney Alesandro: In other words, for the loved ones and the person who’s dying in that situation does not want to burden their family. It would just benefit everybody to, you [00:22:00] know, normalize, dying. I mean, at the risk of sounding macabre and this is probably why I don’t get invited to a lot of dinner parties, you know, I think it’s important to normalize dying.

Courtney Alesandro: It’s going to happen to everybody doesn’t happen just to 99% of people happens to a hundred. And it’s not a moral failing, it’s not a giving up. It’s not not trying hard enough it’s gonna happen

Professor Hare: well, and unfortunately, I think medicine sometimes ends up in the position of trying hard, no matter what, whether there’s a moment in which you know, not talking about palliative, but I’m talking about, cardiology or, you know, the ICU staff, they come to the point where they are trained to keep someone alive and, and do that job and not doing that job for them.

Professor Hare: Then it feels like a failure And it’s hard for them to even consider reaching out to a service like yours, because they don’t want to it’s giving up somehow, that, I think that is a big part of that discussion with modern medicine.

Courtney Alesandro: Oh, [00:23:00] absolutely.

Courtney Alesandro: There’s an aspect of palliative care that jokingly I call it the, save us from ourselves which, you know, going back to the dialysis example, nephrologists comes to me and says, gosh, we’re going to offer this person dialysis, but we don’t think it’s a good idea. could you talk about of it essentially?

Courtney Alesandro: I think, well, you don’t have to offer it to them. You know, we don’t have to do all these things, but that’s going to take a larger shift in the way we conceptualize ourselves and the way society, conceptualizes medicine as well.

Professor Hare: Granted you end up doing a lot of psych I call it off the books, but it certainly is a part of your job.

Professor Hare: Do you get consults or do you consult, or do you ever have the primary service in that instance, consult psych for some of those folks who are really having a significant crisis in those homes,

Courtney Alesandro: I am. Hospital-based so no in those crisis moments, [00:24:00] I rely very heavily on my social worker who very, very good at processing supporting, providing dignity therapy, providing to the extent that they can tolerate it.

Courtney Alesandro: Some CBT where I use the psych service line is if a patient comes in they’re expressing suicidal ideation helping tease out, is this an expression of, you know, I’m done I’m this, and this is the only way I can express it, but I’m done with this disease process. I’m at a point of ready to consider changing my goals of care to comfort.

Courtney Alesandro: And the only way I know how to express this is by saying, I want to die. I want to die. I want to die. Thereby activating everybody around you. Or is this an expression of, I do not want to live anymore and I want to actively take my life. in that sense, I would want to [00:25:00] protect my hospice colleagues from being complicit in somebody’s elaborate suicide plan.

Courtney Alesandro: So for that, I would bring in psych to help me tease out, is this depression, is this person not able to express what they want? And it’s realistic to think that they’re at end of life and we need to support them, or are they saying, no, I want to kill myself.

Professor Hare: Are you parsing out dementia and delirium related issues like that yourself?

Professor Hare: Or are you bringing them on in that instance?

Courtney Alesandro: For capacity, I bring in psych. So to throw the final gauntlet of capacity, if it’s nebulous, I’ll bring it in psych. But in terms of saying what I’m looking at is delirium. What I’m looking at is dementia. I do, and I would make that call.

Professor Hare: that’s, I assume, at least somewhat nice to be able to make that call yourself not pleasant maybe, but certainly nice to be able to not have to then pull in [00:26:00] another service and, the time that that takes to make those kinds of decisions. And in the meantime, the patient is without some level of care there.

Professor Hare: Probably I’m making an assumption there, but I think it sounds as if that might be a little bit more certainly more direct route to getting that patient, the diagnosis and then the help that they need.

Courtney Alesandro: Yeah. And just again, referencing more of where I would use psych if a patient comes in and they come in through the ed because change in mental status, you know, increased confusion and not taking care of themselves and family members bring them in.

Courtney Alesandro: It is often that in that HPI, it will say this person has dementia and that may or may not be the case. Probably one, maybe two handfuls of cases I’ve had throughout my career where no, this isn’t dementia. This is, this is psych there’s something going on. And I can’t put my finger on it, but I know this isn’t just straight dementia.

Professor Hare: In our psych module [00:27:00] in my PA program, bring in an individual Vint Blackburn is his name. He’s a psychiatrist. He was with crisis services and he comes in and does talk about the psych presentations that often occur across medicine.

Professor Hare: And one of his big focuses in during that discussion is the delirium versus dementia versus actual psych issue going on in those patients. And so he spends a good bit of time talking through the ways in which you can help to differentiate those things in those acute presentations.

Professor Hare: And I think that’s a really good discussion to have And also kind of relates to overall medicine. You know, you’re going to see psych presentations and I would think some of these other discussions are also going to be a part and parcel of that delirium dementia, et cetera in all areas of medicine.

Professor Hare: And the example that I give my students is occasionally we would have a patient who was having a difficult time with their orthopedic diagnosis and we would get psych clearance for orthopedic surgery. in many ways we were uncertain whether that patient was going to be capable of one making the decision to have the [00:28:00] surgery was, was that a part of their abilities in this moment and where are they going to be able to follow up with rehabilitation, you know, is there mind state as such that they’re going to be able to do that?

Professor Hare: And if they can’t, then the surgery is pointless and so they don’t have the wherewithal to do those things. And it sounds like a similar thing for your service.

Courtney Alesandro: Yeah. And I think you bring up an important point which is, can this person continue the treatment after discharge?

Courtney Alesandro: Be it, can they. Get to physical therapy appointments. What are the barriers to that? Can they adequately take their medications the way they’re supposed to? Do they have the insurance? Yup. You know, I love using fentanyl patches. I think they’re, great for many instances, but if I know my patient doesn’t have insurance, I’m not starting it in a hospital because there’s no way that they’re going to be able to get it outside of the hospital.

Courtney Alesandro: not setting people up for failure is [00:29:00] so, so very important as in part of a practice.

Professor Hare: That’s a soapbox that I stand on a great deal of the time because you know, students wonder why we have, you know, you have these charts that have treatments, first-line treatment, second line treatments, third line treatments.

Professor Hare: Why do I need to know three lines of treatment? And then you point to the far right, where it is often the column that has 1, 2, 3 or 4 dollar signs. It’s like, you’re going to a restaurant and trying to decide if you can afford the meal at that restaurant sometimes, but it’s for your health. And if you send somebody home with a 4 dollar sign medication and their budget is one or $2 signs at best, they’re not going to take the medication because they won’t be able to afford it.

Professor Hare: And they are not likely to bring that to you and talk to you about that and say, is there something that can make this more affordable or an alternative that might be more affordable? And a lot of folks think, well, not what the practitioner wants. So I need to try to do this and put themselves at risk

Courtney Alesandro: right. Understand what you’re saying to a [00:30:00] person, not a patient. we want to be so prescriptive, but what is this person’s resources to get to

Courtney Alesandro: and from whatever, follow up here, discussing, all of that is so vitally important. And we, as a profession, tend to have an out of sight out of mind, once you’ve said what you need to say in terms of the perfect care plan, you know, and the perfect care plan requires they go to Timbuktu on a golden plane, it’s not gonna work.

Professor Hare: Yeah. any other thoughts on documentation legal and otherwise I talked about the power of attorney and we talked about the advanced directive. Anything else?

Courtney Alesandro: There are forms in each state called some are called POLST some are called MOLST in Virginia. They’re called POST forms, which are essentially a DDNR and advanced directive rolled into one.

Professor Hare: DDNR stands for…

Courtney Alesandro: Durable Do Not [00:31:00] Resuscitate.

Professor Hare: So not a tattoo on the neck. In other words,

Courtney Alesandro: not a tat, yep. Do not do the tattoo on the neck. And understand if mom’s signed her own DDNR, no matter how much you’re going to scream and shout at me, you cannot revoke it. A medical power of attorney cannot revoke it. If that patient has signed it. Wow. I did not know. Yeah. So a hospital-based do not resuscitate can be revoked, but a durable do not resuscitate.

Professor Hare: If the patient signed it, that is valid and cannot be revoked. If the power of attorney signed it, only the power of attorney can revoke it. And the hospital-based. When they leave, does that usually, I mean, I’m sure it’s state to state, but does the, does discharge from a hospital automatically invalidate that DNR at that moment?

Courtney Alesandro: No, lots of hospital systems and I assume you in Pittsburgh, your system that has epic, Yeah. So in [00:32:00] epic that would get scanned and put into their chart and quite often it would be carried over. But this is a good point for people who are primary providers in a hospital.

Courtney Alesandro: So PAs or NPs who become hospitalists NPs, PAs, confirm that with your patient. Hey, Mr. Smith, we have a hospital DNR on you from your last admission. Do you still want that to be part of your treatment plan? and if he says yes, take the opportunity to quickly just sign a DDNR what I have seen more often than it timing out is, it’s put in a chart and it just keeps on going. it really is worth a moment of just, Hey, this is in your chart, where are you with this?

Professor Hare: Yeah, absolutely. it is a fascinating subject and I think speaks to a lot of the things that you deal with on a day-to-day basis. the I’ll call it soft science for lack of a better term, but, the care of the patient from an emotional and psychiatric [00:33:00] standpoint is incredibly important in your service.

Professor Hare: Moving on a little bit to the medical aspect of it, do you see any kind of set criteria for moving toward end of life care? In palliative care or is it more consulting with the service making those kinds of decisions or whether palliative is the moment?

Courtney Alesandro: When I take on students or new practitioners I think I’m a source of frustration for them because they want an answer. They want to a concrete. Yes and no. And my response to most of their questions are if you could defend it, if it makes sense in this moment, then that’s the right answer.

Courtney Alesandro: I reflect on that to answer your question. So at any point, technically within the trajectory of disease for a life-limiting disease, you can have palliative care. say you are diagnosed with a cancer, but it’s a very curable cancer, but you got to go through it in order to get to the other end.

Courtney Alesandro: And by going through it, you’re going to [00:34:00] have a lot of nausea and a lot of pain, a palliative care team can be part of your overall team to help manage those symptoms.

Courtney Alesandro: Again, taking this person who had a very curable cancer, they went through it. They had their palliative care team. They came out on the other side, but five years down the way they get a diagnosis that, that cancer has metastasized. And now this is ultimately a terminal disease. There may be treatment options for you.

Courtney Alesandro: And I’m very mindful of using the word treatment in this instance, because I think it’s up to the provider, to let them know that it’s not curable, it’s treatable. And then that gets missed a lot by patients. So now they have a stage four, they have some immunotherapy options. They have some other options, maybe some palliative radiation options.

Courtney Alesandro: and you’re thinking as their [00:35:00] provider, gosh, their life expectancy, if all this goes well, 18 months, it is at the point where this person doesn’t have any more options that you would want to consider hospice care. So think of hospice care as, a plan of care, Hmm, if you like, if you get, if you can conceptualize it as the plan of care and the hospice team would come in for that plan of care and support the person for however long they have left on this earth.

Courtney Alesandro: But palliative care can be with youth at all stages . Practitioners, As you can imagine there’s some bristling with some providers, some specialists who think, gosh, if I bring palliative care and they’re going to convince my patient not to want this TAVR or not to want to seek this treatment.

Courtney Alesandro: And that becomes the barrier when we’re seen either [00:36:00] rightfully or wrongfully, depending on the way the palliative care is presented as in conflict with treatment.

Courtney Alesandro: That makes sense.

Professor Hare: Yeah. it puts me in mind of when my kids were being born, we had a midwife on the team. And they were great because they were advocates for us in the hospital setting.

Professor Hare: We had, we had to move past the point of doing the natural side of things, but the midwife was able to speak to the OB and really because the midwife knew what our goals were in those moments and what we wanted out of that experience and what things we did and didn’t want, they became an advocate for us in those moments.

Professor Hare: And that was very helpful. it became a more personal experience. It became more guided by our goals and those moments, it puts me in mind of on the opposite end of life cycle, what you do.

Courtney Alesandro: A hundred percent that very much sounds like you can think of that as palliative care at birth.

Courtney Alesandro: Right. That that’s exactly what we would do.

Professor Hare: The midwife may not always be able to walk [00:37:00] you all the way through that. But stepping in, it becomes an important aspect of the care in those moments.

Courtney Alesandro: Absolutely. And somebody’s care might be, for all aggressive interventions. No matter what, and as a palliative provider I’m, and I strongly believe this, I’m beholden to respect that. A lot of times the scenario of, can you go in and get the DNR for this patient? and that comes from the provider or the nurse who’s at bedside because they know this patient isn’t doing well and you want to be a team player.

Courtney Alesandro: You want to support the people you work with. But the reality is you go in, this patient is, 89 years old and 89 pounds and saying, no, I want you to attempt to resuscitate me. you got to say, okay, this is, this is their goal, and I’m sorry for my coworkers. And I will try and support you in this and validate your [00:38:00] distress, but we’ve got to respect it.

Professor Hare: Backing up just a step my students often and rightfully so because they’re, they’re relatively early in their education at the point where they come through my classes, they tend to be a little concrete. They tend to like those numbers.

Professor Hare: They tend to like that, dichotomous decision, where you’re going to go left, or you’re going to go right here. And this is, it’s a, it’s a clear algorithm. It’s not always a clear algorithm. It’s often very ambiguous and often a stressful kind of moment. An O2 sat, or a heart rate, a temperature, any number of things, cardiac output, even, you know, th those things don’t necessarily dictate because one person is, speaking at 70% O2 sat and another person is short of breath at 89% O2 sat. These are not places where we can place hard and fast lines for the most part, before we decide, this is end of life care time. There’s just no hard and fast rules for that kind of application.

Courtney Alesandro: Absolutely. More often than not it’s a journey.

Courtney Alesandro: And again, in a hospital, you got to [00:39:00] give folks some time to wrap their brain around the idea that they might be dying and getting to a point of them saying, okay, my goals have changed. I now just want to be comfortable. let’s start bringing hospice in is often a process. And to your point of vitals, I often like to point out that they are a really bad indicator of when somebody is going to die. So a lot of times people will say, oh, I just want to keep their blood pressure cuff on, just so I know that their blood pressure is going down and a person can hang out for a long time. You know, if, if their process of dying is slow, they can hang out at 80, over 40. And in somebody who’s a walkie talkie that could Herald death, but in somebody who’s on this trajectory for a long time, what is that information giving us that this person is going to be dead in three hours?

Courtney Alesandro: No, not telling us that at all.

Professor Hare: [00:40:00] Yeah. That ACLS discussion they’re hypotensive and they’re bradycardic, but are they stable? Right. When you have a discussion with them then they’re in far better shape than if they are obtunded!

Professor Hare: They’re not able to answer questions or, somehow confused or, lethargic, all those things start to indicate But the numbers don’t necessarily mean a ton in that scenario.

Courtney Alesandro: Exactly.

Professor Hare: we had talked and I think this is a kind of a fascinating Discussion and one that I don’t know much about, to be honest with you.

Professor Hare: And that’s the stages of death discussion. Can you give us a sense of what you often see and just understanding that again, this is not an objective set of stages often that the patients always go through, but a general sense of what that

Professor Hare: looks like.

Courtney Alesandro: Yeah. I speak a lot in metaphors to my patients and my patients, families. So the way I conceptualize this stage, if you will, in a person’s life, is I conceptualize it as a path our job and their job is to walk next to this [00:41:00] person on their path as they’re going on it, we don’t know how long this path is, but at some point they’re going to change and they go from in bed lethargic but alert within their lethargy. And then,

Courtney Alesandro: and then they’re not. And then It’s so hard to, to just say verbally, but they change it’s almost a tonal aspect. Their tone changes their body tone changes, and then they’ll become more and more unresponsive. Breathing will go from whatever their baseline is to a period of speeding up before it drops off and become slow with periods of apnea.

Courtney Alesandro: Their pulse will go from again, whatever the baseline is to this bounding pulse and then get very thready. They [00:42:00] will dump urine and then have, nothing in their Foley For 12 hours. when people and families are desperate for it, tell me how much longer my loved one has. Can you tell me? Oh it is at the stage where they’ve gone from fast breathing to slow breathing with periods of apnea, bounding pulse, to periods of thready pulse. That’s when I start putting their time in hours to days, are we talking 24 or 48 hours, you know, maybe 72.

Courtney Alesandro: And that is the stage where I call it. And it’s not just my term, the term used in palliative care and hospice is actively dying. They are actively dying. And it’s a term I’ve. Come to understand is not used frequently outside my profession. So a lot of times hospitals would be like, what are you talking about?

Courtney Alesandro: That they’re actively dying? What, what is happening?

Professor Hare: A scary term, I would imagine for those not in palliative.

Courtney Alesandro: Yeah. or [00:43:00] I thought they were dying three weeks ago. Well, they kind of were, but now they’re now they’re really dying.

Professor Hare: That’s tough.

Professor Hare: That’s a tough thing to hear. I would imagine for anybody not accustomed to that terminology.

Courtney Alesandro: Right.

Courtney Alesandro: So then you, I reflect back to the path metaphor. Yes. When this patient came in, you could have said that they were on their path. but now they’re at the end end. With that said everyone goes through the process the way they go through it. And for everybody who I could spot on, I come out looking like, a genius, cause I’ve, been able to, get the time of their passing within hours.

Courtney Alesandro: There’s a patient that I’ve just not been able to do that with. No. So. in palliative care, you got to be real comfortable with not having the right answer or the answer anybody wants, or you gotta eat humble pie a lot, you know, and, and still maintain a [00:44:00] trusting relationship.

Professor Hare: The moment in which you recommend somebody gets a plane flight to come to be with their loved one when they are not doing so well, that’s a hard call.

Professor Hare: I would have assumed that that was a really hard call, but it certainly sounds like that’s a difficult moment. Because I think a lot of folks want to hear that they want to know those things, and that’s not easy to predict far from it.

Courtney Alesandro: Right? Absolutely. Families are scattered throughout the country.

Courtney Alesandro: That’s normal. When should I tell, cousin Fred, he needs to come my answer to that. His cousin Fred needs to come now because

Courtney Alesandro: for me and my practice. Missing that opportunity is a failure for me. I want them to have whatever time that they need. The other, the more burdensome is the family that can’t take off of work. The family that is, everybody works and they’re right at the poverty line and they don’t [00:45:00] have PTO and trying to support them and their overall safety, because it’s not going to be safe for that family.

Courtney Alesandro: If they miss rent, but also being able to, to be there. And that again, takes conversation and takes creativity and takes planning and see what works and, think outside the box.

Professor Hare: it does sound like back to our earlier discussion. If cousin Fred has something to unpack with that person before they pass away, then both the person who is on their bed going through this process and cousin, Fred would probably benefit from that discussion.

Professor Hare: Even if it’s not time, even if it’s not that time.

Courtney Alesandro: Exactly something might need to be said that it’s none of my business. So tell Fred to get out there and when I’ve supported hospice teams, everyone who works in this field, has stories about a person who just- this sounds flippant, won’t pass away, [00:46:00] you know, gosh, Mrs. Jones is still here? She has been, breathing two to four breaths a minute for the last two days. And she might be holding on for somebody. Seen it more times. Then is coincidence.

Professor Hare: I can absolutely imagine that being in that, in that situation from either side would be hard.

Professor Hare: And certainly if the moment is missed the regret that might come along with that for someone who’s living.

Courtney Alesandro: Yeah. And in palliative care and and in hospice care this particular part of the conversation is making me think of it. we can’t give. More often than not what the family and the patient really wants, which is for mom not to die. the 15 year old kid who’s huddled in the corner because his mom is dying. you could provide comfort by making sure mom is not distressed, that she’s not agitated. You can support and [00:47:00] guide, but what everyone in that room wants you to do is make this from not happening and you can’t do it.

Courtney Alesandro: being very comfortable in and finding your meaning and your wins in bearing witness to suffering is where you’re going to find your wins and making sure that they have what they need. that means Cousin fred gets out here. Right. and I think to some extent, maybe where the decision making can be a little bit more clear for students is in their career path.

Professor Hare: I think personally that is not. My path as a practitioner. I appreciate so thank you for your service. But, I don’t know that I could do that on a regular basis. Everybody has those things, that it really takes away from their bubble, so to speak in their energy level. And I think a lot of people would look at that and say, wow, that seems difficult.

Professor Hare: I just recently did an episode on heme oncology and leukemia and lymphomas, and also a [00:48:00] situation where it’s certainly gotten much better in recent years. But it’s a hard road when, when you have a diagnosis already.

Professor Hare: And when you have a set of circumstances that the, the win is not a standard Western medicine win in any way, shape or form.

Courtney Alesandro: and for your students at, I agree a hundred percent, you would not want me as your gynecologist NP. You know, you don’t want me to do an, a pelvic on anybody.

Courtney Alesandro: I’d be terrible at it. You do not want me to. As your ed provider, I’d be terrible at it. not be a good fit for me

Professor Hare: You’d be fine, not in your wheelhouse. In other words,

Courtney Alesandro: it’s not in my wheel house that it’s not in my temperament and it’s not just, I’d be terrible at it. And, and that’s okay. You know, you, everyone has to find what speaks to them.

Courtney Alesandro: What I would for all students moving forward is that they have the opportunity, at least once in their education to, to [00:49:00] sit in a room with a family when their loved one is dying to learn the skill of, and again, I’m going to be flippant of shutting up, you know, less is more of being invisible when you’re giving medication orders.

Courtney Alesandro: And you’re coming in every 15 minutes to see if your patient is calm, not in distress, having the opportunity to do that. is invaluable because it’s going to speak to somebody not going to speak to everybody, but the skill is, is valuable.

Professor Hare: No, absolutely. And I think, certainly we should be using your skills more often

Professor Hare: and it sounds strange, I think to some people, but I think that better deaths would be a really valid goal for our healthcare system overall.

Courtney Alesandro: I think so. Absolutely. going back to the fact that a hundred percent of us die

Professor Hare: yep. Change is inevitable as they say. So let’s talk about your symptom [00:50:00] management, then the things that you as you approach a patient and you’re looking at the things that they’re going through, what are you looking for what kind of medication are you applying in those instances?

Courtney Alesandro: go in and you see a patient. And first thing you notice is, this patient is breathing 36 breaths per minute. That is not a sustainable. Situation, that person is going to poop themselves out and they’re breathing ineffectively. So you got to slow that down and you’re going to slow that down with an opioid.

Courtney Alesandro: And this is where hand wringing comes in. Oh, you’re going to, create respiratory depression. Well, you kind of want to do that a little bit. So you can slow this breath down and they can be more effective in each of their breaths Your opioid would be at a much lower dose than you would use for pain management.

Courtney Alesandro: I would start with one milligram of morphine. And if it’s for dyspnea, I would want that frequently to see what they needed. And then, then you back off if this person is in [00:51:00] pain, they are in pain and that needs to be treated. If, you get your patient and their breath is all now.

Courtney Alesandro: Nice and calm. And now you have a patient who’s in pain and say this patient has been. For the last four months taking MS Contin, which is a long acting medication. 30 milligrams, every eight hours with breakthrough medication and they take their breakthrough medication, 15 milligrams, and they’re averaging three times a day.

Courtney Alesandro: And you’re looking at your patient and your patient for whatever reason, can’t take oral medications. Do your opioid conversion, do not just say, this person is on morphine at home. I’ll give them Dilaudid 0.4 every six hours because you’re gonna have a distressed patient. You’re going to have a frantic nurse and you’re going to have an upset family.

Courtney Alesandro: I like Practical Pain Management. [00:52:00] PracticalPainManagement.com. Our opioid conversion calculator. Find what you like and use it.

Courtney Alesandro: Every time I pull it up, I just do opioid conversion, practical pain at any computer I’m sitting at certainly you can do the math yourself.

Courtney Alesandro: I find it much easier just to plug it into a website. And what I like about that site specifically is it’s very clear. I got this patient, he takes 90 milligrams of morphine oral at home. I want to, for whatever reason, transition him to IV Dilaudid. How much do I need to match this? And until you get comfortable with it, you’re gonna think that can’t be right.

Professor Hare: If you call the pharmacy, which, you know, in an inpatient setting, calling the pharmacy to talk to them about dosing is a, is a frequent occurrence. But if you call the pharmacy, that’s probably what they’re doing. Right? So some of them might have it off the top of their head, but for the most part, they are, they are doing the conversions like that with online [00:53:00] resources and you know, far better to have.

Professor Hare: More than one check on that kind of dosing than to just call a pharmacy have them do it and make sure that, you know, and feel comfortable with that dosing as well

Courtney Alesandro: Find what works well. And then reflecting back on something that we said earlier in a hospital, if your patient isn’t in a situation where they’re going to die in this hospital, does it, they’re going home. So know what they can afford. don’t start a fentanyl patch if they don’t have insurance. And then some real good pointers are, if your patient has acute kidney injury or CKD, really look at their labs before you prescribe morphine, morphine is metabolized through the kidneys.

Courtney Alesandro: It can be hard on the kidneys. don’t be afraid of methadone, but that’s easier said than done, lots of people are afraid of methadone. But it’s a wonderful medication for neuropathic pain. You want an EKG at baseline and you want to know that this patient knows how [00:54:00] to take medication. with methadone, it’s got such long half-life you want to prescribe it, you take this every 12 hours. You don’t take one and then, oops, I didn’t take another. Or for 24 hours now I’m going to take two or I’m the kind of person that I’m feeling better. So I’m not going to take it. you’re going to feel okay for a day, day and a half, three days from now, you’re going to have a world of pain.

Courtney Alesandro: And then if you’re the type of person who’s loosey goosey with medications, you don’t want that person then being like, now I have a world of pain, I’m going to take three, you know, cause then three days from now you’re going to have an obtunded patient. So that’s something to be mindful of.

Courtney Alesandro: Fentanyl is cleanly metabolized. I like it. My favorite combo is a methadone fentanyl combo. When you’re thinking about pain management your heavy lifter should be a long acting. So if your patient needs a couple of PRNs throughout the [00:55:00] day, start thinking, you know what? I gotta put this person on a long acting.

Courtney Alesandro: Otherwise you’re going to be chasing pain all day. There is another website called Fast Facts, Palliative Care Network of Wisconsin has Fast Facts, Palliative Fast Facts.. And you can put in, I think the last thing I looked up was hiccups. looked up hiccups and good old Baclofen was there.

Courtney Alesandro: if you’re as a provider, not frequently needing to do this type of symptom management, know that there are resources out there that you can pull on. with delirium if your hospital has the ability to have sitters. Sitters, maintaining a schedule. There’s not a lot that you could do for medication to change that.

Courtney Alesandro: you certainly don’t want to use benzos. You’d rather want to use Haldol. Just a wee whisper of Haldol to help with any agitation, but a lot of it a lot of management is non-pharmacological. I actually like Haldol for [00:56:00] nausea and vomiting it really does a good job.

Courtney Alesandro: Then it comes in a liquid form.

Professor Hare: Oh yeah. More easily. Yep.

Courtney Alesandro: Yep. If somebody comes to the hospital and , they’ve just been told they have a terminal cancer and they’re going to go home and they’re going to try some treatment, but they’ve got some pain and some understandable anxiety.

Courtney Alesandro: I’m going to treat that. I’m also going to say you need to work with somebody. I, my heart really goes out to smokers who now have, advanced COPD, they’ve been smoking since they were 12. It is their skill. that is how they manage anxiety. And then at a time in their life where breathing isn’t easy.

Courtney Alesandro: We’re saying, gosh, you can’t rely on your skill and I’m not going to give you a benzo because I, I think you’re gonna just abuse it.

Professor Hare: that is difficult. No doubt about it. I can, I can fully imagine that. You walk a bit of a line between polypharmacy [00:57:00] and not enough pharmacy in those instances, especially when you’re talking about what the service is prescribing for patients, the anti-cholinergics are through the roof and they’re not peeing, you know, those kinds of questions have to be addressed or the patient’s not going to get better.

Professor Hare: challenging polypharmacy as I think you said it in one of our early discussions I think that’s a good way to put the process that a lot of us should be going through. If you see poly-pharmacy challenge it or at the very least make some contacts to understand why they’re on all those medications.

Courtney Alesandro: Absolutely.

Courtney Alesandro: And at every meeting and independent of where this meeting is taking place as a practitioner, you should be looking at their medications because. You know, as well as I do those things have a way of just sneaking up. Those lists can get longer and longer. And in my world, what people may be attributing, somnolence that people would easily attribute to say pain medication can easily be seen as polypharmacy and [00:58:00] acknowledging that that polypharmacy may be too much pain medication, but it may not be.

Courtney Alesandro: And is it worth putting this person into a pain crisis?

Professor Hare: To try to remove some of those things. In other words, it would be more stressful than anything And I feel like that’s something that , with the geriatric population. In general, not just as we get into the, into the palliative care realm the poly-pharmacy of a lifetime of seeing different practitioners and maybe having medications that were never challenged or considered or taken off.

Professor Hare: And then another one’s added on. And then where are we considering all those those potential overlaps, the respiratory drive is definitely up there when it comes to medications, but anticholinergics also really in my setting are one of those things we have to watch to make sure that they’re not overwhelming that mark is there QT getting prolonged, you know, every one of those QT prolonging medications added in prolongs it a little bit more, and then they’re in an arrhythmia. I think it would be easy just to say, well, you know, this patient we’re helping them through their last days in this moment.

Professor Hare: why, [00:59:00] why limit that in those moments, why limit the amount of medication that they’re getting in those moments? Because we want them to be comfortable and you know, still breathing, but still comfortable in these

Courtney Alesandro: That’s a really important point because. you don’t want to be necessarily sloppy when you’re a palliative care practitioner, you don’t want to just be like, well, this person is, dying. So I’m going to just gork them. That’s when you get into a discussion about palliative sedation, that’s probably not appropriate for this conversation, but reality is if you go back to what this person’s values and goals were for this time in their life, they may want to be somewhat alert.

Courtney Alesandro: They want to understand that people are around them. So are you meeting their goal by gorking them? Not necessarily. So you know, I, I’m getting a little bit on a bunny trail, but going back to what this person’s goals of care are, and having [01:00:00] an honest conversation about it, say, I’ve got these medications, they’re not the most elegant medications I can be your, your ship’s captain, but you need to drive the ship.

Courtney Alesandro: If being alert and responsive and being able to not frighten your three-year-old grandchild with your presentation is important for you. Maybe you can accept a certain level of pain and say, okay, yeah, this level of pain is okay. Or no, I, you know, I don’t need to see my grandchild pain management is very, very important.

Courtney Alesandro: So it’s always going to go back to what is this person’s goals? Let’s have an honest conversation. I almost always tell people that I can’t get their pain to a zero without hitting them over the head with a frying pan. so let’s mitigate that expectation and let’s come up with Your goals and how you would identify it.

Courtney Alesandro: You know, ie, I want to [01:01:00] maintain a certain level of freedom. that’s a frequent one, people will say, and I asked them to qualify that, what does that look like for you? That means I can walk 15 feet. Okay. Now we have something where we’re working with. So you want me to work on symptom management while trying to meet your goal of being able to safely ambulate 15 feet.

Courtney Alesandro: Let’s work on this. Let’s come up with a plan

Courtney Alesandro: and then go for it.

Professor Hare: Well, that middle ground sounds like it certainly relies on the expertise and skill of practitioners like yourself in those moments. But there is a middle ground right. Between I wish to be gorked as you put it. I wished to be perfectly lucid for the duration of this process.

Professor Hare: but acknowledging that there’s going to be pain, there’s probably some middle ground there that relies on your expertise to make that happen.

Courtney Alesandro: Yep. And saying I think I can do better. Yeah. I’ve. A lot of times to people. Oh, okay. We’ve, you know, we’ve done [01:02:00] X, Y, and Z with your medication and through a discussion, it becomes clear that I can tweak that medication and do a little bit better.

Courtney Alesandro: And let me try it, let me try increasing your short acting. If it doesn’t work for you, let’s back off. I have no horse in this race. It is for you. Right?

Professor Hare: still love that concept though, as a practitioner, often we are faced with those moments or, maybe even our institution doesn’t want us to admit that this isn’t quite going as well as we want it to it’s a bit of humility being expressed there.

Professor Hare: Also a little bit of hope moving forward, but yeah, I can do better with this. I think we can make this better for you. It’s not what I want it to be right now. Let’s make this a little bit better. I think for some practitioners that’s a hard thing to express it’s a thing that many have been trained not to express

Professor Hare: being able to admit that and being open to that with the patient, it’s probably helps them a great deal to understand that you’re working on it.

Courtney Alesandro: We’re working on it and we’re working on it [01:03:00] together. And I think you’re right. I think it’s the training. I, I don’t think people necessarily start medical training. well, I know they don’t, nobody goes into any kind of medical training thinking I got this, I know everything. Everyone is absolutely terrified.

Courtney Alesandro: And somewhere along the line, we teach them that they know everything. And yeah, it’s, I don’t know if we’re doing this a service.

Professor Hare: let’s talk about some of the other interventions then. S We talked about some of the pharmacy that goes into that. Is there, are there any more subtle things you wanted to talk about there with pharmacy?

Courtney Alesandro: Never underestimate the power of dexamethazone. And I say that for myself because I often forget the power of dexamethazone little, two milligrams twice a day, up to four milligrams, twice a day can help with pain. It can help with energy Can help to a certain extent with nausea.

Courtney Alesandro: It’s not to be forgotten about. And the value of just a little bit of hydration.

Professor Hare: so you’re giving normal saline, I [01:04:00] assume, in those moments

Courtney Alesandro: yeah, if somebody comes in and they’re nauseated and that’s the symptom that brought them into the hospital, say in addition to pharmacological interventions , you want to think positioning, you want to think environment.

Courtney Alesandro: You want to think hydration you know, relying very strongly on my experiences in the eating disorder clinic. I have been known to suggest strong peppermint tea.

Professor Hare: I do recall somebody telling you that you were in the pocket of big rest and fluids.

Courtney Alesandro: Yes, I am. And I remain firmly there.

Professor Hare: I always loved that. And it’s one thing that students could be reminded of periodically during their training as well. There are a lot of comfort measures, a lot of symptomatic measures that don’t involve writing a script or entering a medication into EMR.

Professor Hare: This is as important as those things I think you’re right, that eating disorders side of things is often where those kinds of practical applications, That’s where they kind of live. padded sleeping arrangements and [01:05:00] seating arrangements for instance, is just one of those little things that I think a lot of people really benefit from But some folks forget about it if you’re not thinking about it on the regular.

Courtney Alesandro: And the other aspect of this that I think is worth mentioning. And I mentioned it cautiously, but I’m serious which is sometimes what could help your patient the most is breaking a little rule for them. Know when to do it, know when not to do it.

Courtney Alesandro: I’ve smuggled more dogs into a room than probably my employers should know. I’ve done it and everybody else in my profession has done it. Maybe, keeping in mind that your patient is a person and they feel terrible. They know their life is limited and know, when the barrier to getting them, what they want is self-created did we create this barrier because it’s our system and it’s our policy.

Courtney Alesandro: And is that serving them or is this a barrier for their own wellbeing? And we should respect it,

Professor Hare: yeah, the [01:06:00] risk reward of such things. And I think patients probably appreciate that a great deal. when your service is on board that their life expectancy is on the shorter side, they’re going to appreciate those things and appreciate what you’re bringing to them far more. Because you’re willing to break that rule. They’re gonna appreciate you a lot, and I’m sure families appreciate that.

Professor Hare: Sometimes, probably sometimes, probably not all the time.

Courtney Alesandro: Ha Ha! You do what you do.

Professor Hare: So the last thing I wanted to talk about, your discussion of communication with the teams because a lot of us are, and many of the students will be associated with the team meetings over time, working with other services, working with the people around you being aware that goals are not always aligned in those situations.

Professor Hare: What kind of advice would you have for students about dealing with other services and making sure that your services and the patient’s needs are being heard?

Courtney Alesandro: That is a big question. There’s lots of ways to approach advocating for a patient. [01:07:00] Some of the themes, if you will are not to be confrontational. there are some providers who in their, their desire to advocate for the patient can be very confrontational. I don’t think that gets yet anywhere, any time quickly. if your student has had a conversation with Ms.

Courtney Alesandro: Jones and Ms. Jones says, all I want to do is be alert enough for a family reunion in six weeks. Okay. This is, this is what this person wants more than anything. Then going to the team and understanding what. Interventions they are offering and the interventions are innumerable. I can’t be really more specific than that because Ms.

Courtney Alesandro: Jones could have any numerous diseases, but okay. Will this get her to the goal? Hey just because we mentioned TAVR.. Okay. Which is a cardiac procedure.

Courtney Alesandro: Yes. That can [01:08:00] get her to this goal, but gosh, we gotta get her in sooner rather than later, because she has something that she has to be at in six weeks. So it’s not saying do or don’t do there’s the palliative radiation options for her. Can we get her in what are going to be the side effects?

Courtney Alesandro: How long should we expect those and have the specialists talk that out with you. To say, this is the goal. quite often, if you engage people in that manner it almost comes, becomes conspiratorial. Like, okay, we’ve, we’ve got this end goal. Let’s do X, Y, and Z. we all know Ms. Jones is her time is limited.

Courtney Alesandro: We know this is our end goal, six weeks family reunion. She wants to be participating in it. How do we do this? And if somebody is offering something that doesn’t get to that goal what I would suggest is being in a meeting when that provider comes to [01:09:00] Mrs. Jones bedside and saying, okay, you are offering X, Y, or Z. Can you talk to us a little bit about that?

Professor Hare: Yeah. it sounds, you have, whether you realize it or not, you’ve said it multiple times already. And our discussion today that it’s all about the patient. Right. It’s all about the patient’s wishes. And the earlier in that process that you can make those determinations the better the decisions can be on the far side.

Professor Hare: you also one of our discussions mentioned that you have to be comfortable being the lone voice in a treatment team. So tell me, tell me about that. Tell me why the, the lone voice assuming you’re in a treatment team meeting or a gathering of ducklings around it and attending, talking about treatment goals for this patient.

Professor Hare: Then I assume that’s the moment in which you become the lone voice at times

Courtney Alesandro: you could be the lone voice on either end. we earlier we talked about getting a, do not resuscitate on a patient and having to come out and say to the treatment team, that’s very worried about [01:10:00] having to do CPR on this frail person that listen, their goals are not in line at this time with what you want and in that situation

Courtney Alesandro: being a support to the team. That’s one aspect of being the lone voice saying, I’m trying to think of an expression or a question I have heard numerous times quote, unquote, don’t they know they’re dying and this is in response to, they want this intervention. Well, don’t they know they’re dying.

Courtney Alesandro: Well, yes they do, but they still want it. And if it’s being offered, we have to respect that this is where this person is. Right. The flip side of it would also be you’re talking about putting in a peg tube, which is a permanent feeding tube.

Courtney Alesandro: We need to have a discussion with the family. Do they understand the ramifications of that? And you have said discussion with family that it’s not recommended for somebody with advanced dementia, it won’t [01:11:00] prevent aspiration. then you let that scenario play itself out. Once you empower the family to say.

Courtney Alesandro: This is what this is going to look like in practicality. Then you let that process play out between the patient, the family and the provider.

Courtney Alesandro: , to

Courtney Alesandro: take your ego out of it, I spend a lot of time taking pictures of quotes. this, I think speaks to my practice a great deal. So here it is, train yourself towards solidarity and not charity. You are no one savior. You are a mutual partner in the pursuit of freedom.

Courtney Alesandro: And I think really speaks to the way I approach my practice.

Courtney Alesandro: I think it’s in relationship to social justice situation. But for me, it spoke to my practice taking in mind that this is not charity and you are not a savior to anybody.

Courtney Alesandro: You are here to really help.

Professor Hare: Yeah. And that is something that I think all [01:12:00] practitioners on some level need to remember that, you know, you can’t be the end all be all at every moment. Even if you’re the rural practitioner in the middle of nowhere and the only practitioner for an hour, it’s still, you still have limits to what you’re able to do.

Professor Hare: And acknowledging those limits at times is really hard to do I think, for some of those folks.

Courtney Alesandro: Yeah. Well, I think that then leads to a whole discussion again, probably not for here and now about boundaries.

Professor Hare: Yeah.

Courtney Alesandro: Got to keep those boundaries up. Otherwise you’ll be no good to anybody.

Professor Hare: Yeah. I, I refer to that with my students.

Professor Hare: Is clinical remove being just a little bit removed from that. From that decision-making process and not associating your worthiness, your day-to-day life, your ability to function with every single decision that you make. You have to be able to, to pull back just a little bit from that. And I think that’s especially true in things like substance abuse issues that success is, is difficult to get and you can become really [01:13:00] discouraged and those moments, and it can really take a lot out of you on a day to day.

Professor Hare: my mentor, James Musgrave when I first started at the psych hospital, said to me, you have to take the time to be away from this hospital. Every moment of that PTO is gold because you need to be able to get away from this a lot of the things that go on here are sad and you have to be able to step away from it and reset a little bit in those moments.

Professor Hare: Our students

Professor Hare: need to remember that stepping back is a crucial skill. And in amongst all the other skillsets that they’re learning during school.

Courtney Alesandro: Absolutely. And we are not the be all and end all people have the ability to make their own decisions and them making a decision that you do or do not agree with is no reflection on your skillset.

Professor Hare: Well, and one thing I did want to ask you on the eating disorder side of things we have had patients come through eating disorder treatment who whether at the time it was recognition or not that anorectic presentation in individuals who [01:14:00] were actually in a late stage life situation.

Professor Hare: The concept that someone who is in this situation may stop eating and that the forcing of nutrition in those situations may be counterproductive for those patients. And this, this may just be a late life stage that many patients actually go through And that’s not to say that every patient who doesn’t eat or is unwilling to eat is in that stage. But we should consider that in these late life situations.

Courtney Alesandro: So when you first started your question, I thought we were going to go down an avenue of palliative care for mental health, which is fascinating to me element

Professor Hare: to add into that discussion.

Professor Hare: I would

Courtney Alesandro: imagine. Absolutely. So when does a mental health condition become a terminal disease? And as providers, are we complicit with that mental illness or are we accepting of that mental illness? Those are the two questions.[01:15:00] that remain a challenge in providing palliative care for mental health to that discussion.

Courtney Alesandro: I don’t think we talked about it at my introduction, but I also carry a master’s in bioethics. this, to me, from an ethical perspective, not necessarily a palliative care perspective is a fascinating discussion. I think right now, it’s very much in the academic discussion. And I think there needs to be some real honest conversations and I don’t have the answer to that the way I’m now understanding your question is, at end of life, it is very natural for somebody to stop eating.

Courtney Alesandro: And you’re right to that end feeding can be very detrimental, their metabolism, somebody whose body is shutting down, because they’re on that path. They’re not actively dying, but they’re on their path. Their metabolism is changing. They’re not digesting quickly. You [01:16:00] really run a a risk of throwing this person into fluid overload or certainly making them edematous you know, the third spacing which affects quality of life is very real,

Courtney Alesandro: You’re just pumping in this case, it would be liquid feed. If somebody is not eating, the only way to force feed them is to liquid feed. So you’re just forcing all this upon them, and you’re really gonna get a lot of fluid into their lungs and make another problem for them, which is now they are dyspneic.

Courtney Alesandro: Right. hospice takes a concept of pleasure feeding, which says, There is so much more to eating than taking in nutrition. It is being part of a community. It is having somebody be with you. It is having a sensation in your mouth. you’re not eating well enough to maintain good nutrition, which then would lead to good skin integrity.

Courtney Alesandro: You know, this person to me is bed bound. [01:17:00] That’s how I’m seeing this patient. instead of feeding you, you want to have three bites of chocolate pudding three times a day. That’s great. Do it again. I’m going to take myself out of this. What do you want? And then it brings me

Courtney Alesandro: it’s important point you know, we can do so many heroic advanced procedures. We can put a pig’s heart into a man. We can, you know, we can do all sorts of things, but when push comes to shove, dying is very basic. it is increased lethargy. It is, I don’t want to eat families have a really hard time with this because why can’t you do something heroic?

Courtney Alesandro: And when push comes to shove it’s can moms swallow safely? Does mom want to swallow? Can mom move out of bed? Is she too weak? If she’s too weak, eventually she’s going to get a pneumonia, and I’m just, this is [01:18:00] a disease process aside, whatever disease process has gotten mom to this point and that disease process could be breaking a hip , something so basic, but it just shows that we are just people We are just people.

Courtney Alesandro: And we’re going to die in a way that often isn’t explosive or dramatic. A lot of times it’s mom, isn’t eating mom. Can’t safely swallow mom. Isn’t getting out of bed. She now has a blood clot. What are we going to do?

Professor Hare: Sometimes reading those s mall signs or sometimes big signs that are indicative of that level.

Professor Hare: it’s funny, as, as you were saying it, the first thought that popped into my head is, is, and they’re going from eating ad-lib to, eating per pleasure per desire.

Professor Hare: And that moment is that something that they want and if, if the family can see that if the individuals around that, the decision makers, the [01:19:00] services can see that, I feel like this is probably the thing that’s you have repeated this the most is that it really has to be about the patient and listening to the patient and making those choices based on what they’re bringing to you in those moments.

Courtney Alesandro: Yeah. You know, I don’t understand people who are ambivalent about food, but some people are, and it doesn’t matter to them. And some people really value food and taking that away really is going to impact their quality of life.

Professor Hare: Yeah, there’s a cookie place in Oakland that I would like to have on call.

Professor Hare: If I eat them, I would like them during,

Courtney Alesandro: well, just make a paste and put it in between your cheek and gum (laughter)

Professor Hare: get me a blender. Sounds good. Well, Courtney do you have anything else , any other thoughts that you wanted to to put across here?

Courtney Alesandro: No, I’ve really enjoyed this conversation.

Courtney Alesandro: I think, there are so many ways of taking this conversation that I think we did a good job.

Professor Hare: I do too. And I really appreciate your time and your effort today. I think that students really benefit from this discussion, I have some students who are interested in [01:20:00] geriatrics and whether or not they realize it’s, this might be a helpful adjunct to their learning the overwhelming impact that you could have on them to keep them going, but also the overwhelming impact that you might have to to help them you know, for lack of a better term.

Professor Hare: Dying well it would be really helpful to our students. And I think this is a great, a great way to bring this to all of those students and to anybody else who’s listening, honestly, who might have to be in the position of making these kinds of decisions, whether it’s from a personal standpoint or from a family standpoint.

Professor Hare: , it’s a great way to to show folks the options that are out there that could really be helpful in these moments.

Courtney Alesandro: Yeah, I think it’s endlessly fascinating. How, maybe starting the 1940s, certainly the 1950. Which wasn’t that long ago when dying came out of the home, everyone sort of made a quiet gentleman’s agreement that we shan’t ever talk about it again.

Courtney Alesandro: And you know, the culture did it and medical school did it. We will never talk about [01:21:00] dying again. We figured that out. You know, and that’s not the case.

Professor Hare: we have objectives from the NCCPA, and our accrediting boards as PA educators that deal with death and dying.

Professor Hare: But they’re very general vague discussions. And the standard response to that in PA school is to talk about and a neurologic sense. How do we determine brain death? how do we declare time of death in a patient? How do we make those decisions and certify those moments somehow it doesn’t involve personal side of it. It doesn’t involve the, you know, the comfort side of it bringing those aspects into that conversation, I think are incredibly helpful. And, you know, maybe someday we’ll get this in as a, as a true and real objective that really addresses the problem at the core of that,

Courtney Alesandro: the nitty gritty and again, wearing my bioethics academic hat.

Courtney Alesandro: Another thing that I find endlessly interesting is for all of our knowledge, we have never come up with an agreed upon definition of when life [01:22:00] begins or when life ends. We don’t have that. We’ve got this hubris and I say that by medicine has this hubris, and we can’t even tell people with great certainty, the heat when it starts and when it ends.

Courtney Alesandro: And that seems awfully basic,

Professor Hare: looping way back in this conversation. I’ve got a some folks who are midwives that I plan on bringing in for a conversation to talk about that beginning of life process and that, and the way That process begins and midwives are focused on mom, up to the moment.

Professor Hare: It’s a good way of thinking about it is that the end of life in the beginning of life, or just sometimes ethereal, and we just can’t, we can’t place moments on it, I think in many ways, that’s just how it’s intended to be.

Professor Hare: Many thanks to our esteemed guest and old friend, Courtney Alesandro a nurse practitioner at palliative care. That’s it for now, be sure to check out the podcast website at beexcitedhq.com for more episodes, show notes and full transcripts of every show.

Professor Hare: Email us at [01:23:00] [email protected] with questions, comments, or future show suggestions. And of course, follow us on Facebook and Instagram at be excited podcast for news, new episode notifications and maybe a picture or two. Thanks for listening. And Remain Excited!