 Our next speaker is Lisa Vig. Dr. Vig is an associate professor of medicine at the University of Washington. She practices geriatrics and palliative care at the VA Puget Sound Healthcare System, where she is also chair of the Hospital Ethics Committee. Dr. Vig completed her MD at NYU and her residency at Northwestern University. Dr. Vig's research focuses on end-of-life decision-making. She's currently involved in a project to learn more about advanced care planning in patients with advanced kidney disease. Please welcome Dr. Vig. So my talk's gonna be a little different. In the last couple years, I've talked about research projects that were completed. This year I am working on three projects that are just getting started, so I'm not talking about any of that. But I'm gonna talk about a clinical project that I've been working on. And this is actually more of a work in progress than we've heard here, so it's gonna be a little different. But I'm hoping you guys can give me some helpful tips as we go through this. And so a disclaimer, because I work at the VA, that what I'm gonna talk about does not represent the views of the Veterans Health Administration or the National Center for Ethics and Healthcare. And I don't have any financial disclosures either. So a little background to get us started about this. There's evidence in the literature about the effect of ethics consultation in intensive care units. There was a randomized control trial a while ago now, but it found that there were decreased number of ICU days and number of life-sustaining treatments in the consultation group in comparison to the usual care group. If we look at the effect of palliative care in the intensive care units, a recent systemic review found that most studies that they looked at found decreased hospital and ICU lengths of stay in patients who'd had a palliative care consult. And Dr. Toll mentioned this earlier, but the Institute of Medicine's report that came out a couple months ago, one of the things they mentioned was that our healthcare system is set up so that a lot of people get lots of procedures and aggressive care at the end of life that they may not necessarily want. So I think both ethics consultation and palliative care consultation may be one way to help with this. So in ethics, we talk about contextual features. So I figured I would also give you guys some contextual features. So I'm one of the VA ethics fellows and as part of that fellowship in the first year, we participate in the University of Chicago's Clinical Ethics Fellowship, which was great. Thank you for the opportunity. I appreciated that, that was really fun. Got over my fear of flying, got a lot of frequent flyer miles, et cetera. And in years two through four, we have protected time for ethics work at the VA. The chief of staff at our facility, i.e. my big boss, suggested that I round in our medical intensive care units. So he said that, so I took it on. But I'm also a palliative care and a geriatrics attending. And so I wear these different hats and I've found it sort of hard to just wear one hat only. And so we're going a little digression here. So in putting this talk together, I was trying to figure out, well, what hats do you have to represent each different discipline, right? And so I thought, well, in ethics, we do a lot of slew thing, right? And so the Sherlock Holmes, that's the ethics hat. Just bear with me. In my geriatrics clinic, a lot of my old guys wear that hat over on the right. So that's the geriatrics hat. And palliative care is all about living life to the fullest and having fun. So I found the festive red hat. You will see these hats again as the talk goes on. So back to the project. This is a clinical project where I attend morning rounds in the medical intensive care unit once a week as an ethics advisor. And my aims for the first year of the project were to evaluate the feasibility and acceptability of attending rounds once a week. And also to start trying to figure out how I could figure out if the project really is having any positive and negative effects. So let me give you a little information about our ICU. So this is at the Seattle VA hospital. There are 18 beds that are shared between critical care and the cardiology teams. It's a closed unit, meaning if there's a patient on the medicine floor who gets sick, who needs to go to the ICU, they come to the ICU and the MICU team takes over their care. That changed a couple years ago. There are almost a thousand admissions per year and the average length of stay is about three days. The medical staff in the ICU. So there's one attending. There are 10 different attendings who rotate every week. There's usually one to two pulmonary or critical care fellows who rotate monthly. One to two medicine residents who rotate monthly. Occasionally there's a sub intern and there's a physician assistant who's there one week on, one week off. And there are pictures here that I've put to make the slides more interesting. These are pictures from the internet because I think it's illegal to take pictures within a VA facility. Maybe I should have tried for fun, who knows. The docs are not the only people on rounds though. It's a pretty big group with lots of different disciplines. So the other people on rounds include the bedside nurse, the respiratory therapist, a dietician. Within the last two months, we've gotten a pharmacist who attends rounds, which is fabulous. The chaplain like me comes once a week and a family is present, they also join rounds. So it gets to be a pretty big group. So my plan for the first year was to attend morning rounds once a week to gain acceptance and trust of the team. And while they're answer ethics questions, bring up some ethics issues that they may not have thought about and make quick teaching points without slowing down the team because they're really busy. And they didn't ask for me to be there. Other services I could provide during the year would be to answer palliative care questions, make points relative to palliative care and geriatrics, and also serve as a liaison between the ICU team and both the palliative care team and the geriatrics team. So if one of their patients ends up in the ICU after rounds I can call them to let them know what the ICU team was thinking, et cetera. So this is the hard part of this. Does this really make a difference? How do I figure that out to go back to the chief of staff to let him know so he decides whether I get to keep doing this or not? So what are the appropriate outcome measures? Are they patient family outcomes, staff outcomes, trainee outcomes? So let me start with some process measures for you guys. Between September 2013 and August 2014, I was able to attend around 39 times. So sometimes they're meetings or other things that get in the way of going. I rounded on 218 patients. Now because of the notes I took, I couldn't tell for sure if there were patients who were there multiple weeks. So this is not 218 unique patients. The mean was five patients per week with a range of one to 10. And rounds lasted anywhere from one hour to three and a half hours. Who were the patients? I think this represents probably a usual MICU population. So 63 years old with a pretty wide range. Most were men because I'm at the VA. About 40% were intubated and on ventilators and about 8% were receiving pressers. I kept track of the comments I made on rounds trying to get a sense of what kinds of comments I was making. And so of the 218 patients, I made comments on 99 patients which is about 45% of the time. And you may say, well, that's not so much. And that's true, but you gotta remember another contextual feature is that I am a shy introvert. So when I figured this out, I was actually pretty impressed that I'd made that many comments. And so looking at the categories of comments, and I think we could probably spend a whole another 15 minutes sort of arguing about which bucket each comment went in, but I tried. And so this, oh, okay, here we go. This is what I came out with. Of the 99 comments I made, 25 of them were ethics comments, 42 of them were palliative care comments, 10 of them were geriatrics comments, and 20 of them were sort of more than one comment that encompassed two different areas. Let me give you some examples. So what I categorized as an ethics comment were often questions about legal decision makers that either they asked me or I asked them. In our electronic medical record, we have a way to actually pull up somebody's advanced directive if they've brought one in, which I'll show you. And so sometimes the team would be talking about a patient who to meet in sound like they were in very good shape. And so we'd look to see if they had a directive and actually pull it up. And sometimes I'm hoping that was helpful to the team to get a sense of what the patient had thought. And also for the trainees to know where you actually find this in the medical record. Palliative care comments, sometimes I would ask questions after hearing all this awful stuff about the big picture, or ask about the patient's trajectory to try to get the team to recognize that despite everything being done, maybe the person was sort of slowly getting worse instead of getting better, or ask about the goals of care. I also made recommendations about symptom management issues. Geriatrics comments had to do with, they would present somebody who was, frankly delirious and the room is totally dark. So saying, well gosh, shouldn't we maybe turn the lights on if the person is delirious during the day? Or we had a few older patients who didn't have their hearing aids with them. And through our audiology service, you can actually get a little device called a pocket talker, which can help facilitate communication. So this is just our medical record and what the advanced directive, it's just like looking at an x-ray, you can pull it up. And this is way too small probably for you guys to read, but the VA has its own advanced directive that I actually think is pretty good and pretty helpful. One of the sections has all these awful situations where you sort of imagine yourself in that situation and decide whether you would want life sustaining treatment, whether you wouldn't want life sustaining treatment or whether you're not sure. And these don't answer all the questions, but often looking at the directive and seeing if the person has checked off, yes, yes, yes, yes for everything, no, no, no, no, no, or something else can be helpful to the team. And if you guys wanna find this, if you just Google VA advanced directive, you'll get a PDF of it so you can look at it. There's another section which I also think is really good where it asks how strictly you want your preferences followed. So is this making any difference? So one thing I thought I could look at for this presentation was to look at new consults, new ethics consults and new palliative care consults coming in from the ICU. So I'll tell you a little about that. So looking at new ethics consults from the ICU, if I looked at the 12 months before I started rounding, three had come in 12 months after seven. So you could say, oh, look, it's doubled. Yeah, but the numbers are so small. I'm not gonna take credit for that. But then I thought, well, maybe it would be fun to look at the day of the week the consults came in. Okay, so the orange bars is before I started rounding and the consults are coming in on different days. And after is after, the blue bar is after I started rounding. And so I will tell you that the day of the week that I round in the ICU, any guesses? It's Wednesday. So maybe, you know, you could argue, you know, trying to think of going to my chief of staff and making this argument. Could I say, well, I suggested it on Wednesday and sometimes they listened to me and sometimes they hemmed and nod for a couple of days. I don't know. If we look at the palliative care consults that have come in from the MICU. So in the six months before I started rounding, 32 came in, six months after 48 came in. So that's a big jump. And if we look at our total consults, it hasn't increased that much in this period. So maybe I could take some credit. Again, looking at the day of the week beforehand, consults are coming in all the time. After in the blue bars, again, I'm rounding on Wednesdays. So I think I can take credit for some of those that have come in on Wednesday, but who knows. Another thing that I've found has been really helpful about this project is I have developed a new ethics elective for our palliative care fellows. And so one of the activities they do during this elective has come with me on rounds in the MICU. And what I try to encourage them to do when they're on rounds is sort of step back and try to observe a different interdisciplinary team in action. They've seen our palliative care team in action, but to see a different team and try to see how they're interacting and what's working well and what's not working well because palliative care is all about teamwork. Another thing I try to get them to think about is how they would contribute to rounds as a guest. We aren't a member of that team or a guest of that team. And also to help them think about how to coordinate care between patients they've seen in the unit and the palliative care consult team. So conclusions, has this made a difference? Well, I mean we can say that there are increased ethics in palliative care consults coming from the ICU. Other things I could look at that I haven't looked at yet is within the VA there are all these surveys that are done. There's something called the integrated ethics staff survey so that every two years a survey goes out to the staff about the ethics environment of the facility and their questions about familiarity with consulting ethics, questions about end-of-life care knowledge and skills. And I think we recently did one of these and it just came back. So one thought I had was I can look at the results that came in from the MICU staff and compare that to two years ago and see if there's any difference. That would give me some information about staff outcomes. Another survey is the bereaved family survey so that anybody who dies within a VA facility, the family member gets a survey a couple months later asking about that patient's end-of-life experience. So that might be a way to look at whether patients dying in the ICU, the family is seeing the experience any different now than prior to the rounding. So next steps, I think I need to go back and talk to the ICU attendings to find out from them if this is helping them, if I'm just slowing them down and frustrating them, et cetera. One option would be to expand the teaching, doing some kind of assessment of the MICU trainees' ethics knowledge and then based on that, coming up with some teaching sessions for them. Although they're often so busy getting an extra hour may be different. Here at the University of Chicago, you guys have a lot of surgery involvement in ethics which is fabulous. At our facility, we don't really have any surgery involvement. Nobody on our ethics committee, et cetera, and I would really like that. I don't think the surgeons are unethical, but I would really like to sort of involve them more and maybe one of the ways to do that is to find a way to start rounding in the surgical ICU. So that's basically all I've got for today. But if you guys have questions or comments or tips for how I go to the boss and explain that this is helping, I got my pen, I'm ready to write it down. Thank you. Or maybe you guys just wanna get to lunch. I understand that too. I know, but that's why we gotta hurry up. We're all gonna be hypoglycemic. Noreen McGrath from MedStar Washington Hospital Center in D.C. We've been fortunate enough to have the staff that we can actually round clinically in all of our ICUs on a weekly basis. And so we've been able to see a similar benefit that it increases our consults and heads off some of our ethical dilemmas early on. One of the things we've been cognizant though is trying to be careful about whether being embedded in those ICUs then compromises our ethical judgment by being part of the team and being well known by the team. Do you have any thoughts on that? You know, having just done this for a year, I've been really conscious of not being a member of that team and trying to be sort of accepted and trusted by them but not seen as one of them. I don't know if that makes sense. But I don't, I'm just trying to think if I really thought I was part of that team, if I would respond differently. As an outsider, I think I'm more comfortable sort of asking about the patient or looks like they're about to lose decision capacity. Oh, who's the legal decision maker for this person? I don't know. Do you feel like they've been open to those kind of conversations when you're standing at the bedside? I think there was someone from our institution who did it years ago who had maybe a more forceful personality than me and one of the attendings actually said, you're more gentle about this, so they aren't as offended. But I don't know. Thank you. No, thank you. I wanna go back to the pie graph that you showed when you looked at the number of indications like palliative care. It's just what you showed in percentages. So. Or this is numbers. It's not percentages, it's numbers. Numbers, excuse me. And they're two in the gray that I didn't talk about, which I can mention. So it adds up to 99. So one of my questions that I thought of during your presentation was, did you look at what were the disease classifications or the diagnoses that were most common coming up either under ethics or palliative care, number one? And number two, when you approached going into the MICU with this collaborative team, did you have in the initial stages any period where you would meet with them in a conference room and go over what the process that you were offering to the team would be? And the reason I suggest that is, did you have discharge planning at all involved from the onset? And then did you have any metrics on the number of days that prior patients were in the MICU? And then to look at outcomes on how the MICU length of stay might have changed? So I have the old length of stay. I can, you know, next year ask them to get that for me again to compare. It's so short, who knows if it'll change. Before I started, when I applied for the VA FX Fellowship, initially I went and talked to the head of the ICU at that point to see if he'd be interested and he was and then once I had finished that first year I went back to the new head of the ICU and talked to him and his co-leader and just asked them if they thought that would be okay. But did you have a sit down discussion with like pharmacists, dietician, those individual? Okay, thank you. Yeah. Last question. Great kudos that you are rounding in the ICU. As an intensivist, I think your input is so valuable to the team. I mean, it's a multidisciplinary team that rounds on patients as we have pharmacists and nutritionists, et cetera. I think your input is valuable. So don't be timid, get into the SIC also. And also your question about being embedded, whether that compromises your ethics standpoint or something, I think not. You are a member of the team for that patient and no matter what your outlook is different. Now, just as an aside in the ventricular assist device world it is now part of the requirement that on the multidisciplinary team of the ventricular assist devices there be a palliative care physician. So like it or not, you will be part of the team. Yeah, thank you.