Listserve Updates Blog

Folks, 

I’m thrilled that the EOLUpdates listserve has become such a significant communication tool for Aid in Dying, Palliative Care, and Coronavirus updates. But please be aware of these updates on how to best use the Listserve. 
The EOLUpdates Listserve migrated yesterday to become the Listserve of the American Clinicians Academy on Medical Aid in Dying. You can find it here: https://groups.google.com/forum/#!forum/acamaid or you can search Google Groups for the American Clinicians Academy on Medical Aid in Dying. 

By posting directly to the Google Groups Listserve at that location, you’ll reach all members, including new members. 

Please do not simply hit “Reply to All” to an old Listserve Post as a way to put up a new Post. That will only reach the members from that prior time, and the membership list is growing rapidly every day–so new members will not see your Post if you’re just sending as “reply to all.”  

The best way to Post a new topic is to send your Post to [email protected] stating “Please post to the list” (or anything close to that). I monitor that mailbox, and by sending new Posts that way I can moderate the Listserve and ask for clarifications, if needed.  I do not and will not censor anything on the Listserve other than violent or extremely inappropriate posts or replies. 

My apologies for any recent confusion as the Listserve migrated from EOLUpdates to the American Clinicians Academy on Medical Aid in Dying. I will do my best to keep this now very active listserve alive and running. 

Thank you! 
Lonny
Lonny Shavelson, MD
Moderator
Listserve of the American Clinicians Academy on Medical Aid in Dying
www.ACAMAID.org

3/21/20

All, 
Since the EOLUpdates Listserve migrated yesterday to the Listserve of the American Clinicians Academy on Medical Aid in Dying, a recent and fascinating thread initiated by Dr. Bob Uslander, along with many replies, only reached a partial membership list. I’m copying these in full here as a new Post, so that the entire membership can participate. 
Thank you!
Lonny 
Lonny Shavelson, MD Moderator Listserve of the American Clinicians Academy on Medical Aid in Dying www.ACAMAID.org
************
3/21/19: Dr. Bob Uslander (California)
Dear friends and colleagues;
Perhaps I’ve missed it, but I haven’t seen any discussion among this group on the impact of Covid-19 on our practices, our patients and our lives.  I realize that many of us are hunkering down and figuring out how to proceed among the uncertainty, while some of us are working tirelessly to care for patients and prepare.  It would be very really helpful to know what some of you are going through, so we can learn from each other and support each other through whatever lies ahead.
In San Diego, the impact has been fairly light so far in terms of taxing the healthcare system.  I’m not in the hospital setting, but friends I’ve spoken with say they are preparing for what’s coming (and feeling somewhat ill-prepared), but not overwhelmed at this point.  Are any of you seeing your hospitals and healthcare systems stretched beyond capacity at this point?  My private practice has slowed down, though I’m continuing to get some requests for MAID. Fewer since the pandemic began, though I wonder if the requests will increase as the number of infected people rises and the impact grows.
I have a significant concern that I wanted to get your thoughts on.  I’m wondering whether my concern is merited and welcome your thoughts.
Earlier this week I was contacted by a group of primary care doctors in LA who want to establish a relationship where I could be available to guide the care (consulting with them and possibly overseeing private nurses, caregivers and/or families via telehealth) of their more tenuous patients who are end-stage and might require comfort care that is not readily available.  They would like to hand this off to an expert in palliative/end of life care so their patients get adequate support if it’s not available elsewhere. This inquiry has prompted me to give serious consideration to what can be done to ensure that adequate end of life comfort care exists for people not necessarily suffering from Covid-19 but impacted nonetheless.
As communities like San Diego, LA, Orange County, the Bay Area, Seattle, etc. have increasing numbers of Covid-19 cases, it is anticipated that the ERs, ICU’s and med/surg beds will be filled and likely overflowing with patients needing support.  People will not be able to, or want to, go the hospital for care.  Hospice agencies will continue caring for the usual terminally ill patients, but it is likely that their staff will be stretched (and reduced in number) and there will be a dramatic increase in demand as people stop going to the hospital for the normal complications of terminal illness, in addition to the people infected with Covid-19. There will be many people requiring end of life comfort care in their homes who won’t have access to it through the traditional channels.
Does anyone else see this as a likely scenario? And if so, are you aware of any efforts underway to address it?
I appreciate any feedback you care to offer.  I am trying to figure out how to best support the patients and the “system” through this crisis.
Wishing you peace and grace through it all.
Be well,Bob
Dr. Bob UslanderIntegrated MD Care2262 Carmel Valley Rd, Ste HDel Mar, CA 92014Main: 858.925.7554Direct: 858.256.7868Fax: 858.281.4977[email protected]IntegratedMDCare.com

******Lowell Kleinman, MD (California) 
Bob,
It is very sobering to think about the impact of a medical surge on patient requests for medical aide in dying. In such a horrific situation palliative care providers will probably also be faced with other equally distressing scenarios such as providing comfort measures at home when there is limited access to medications, participating in decisions that involve mechanical ventilator shortages and supporting colleagues in moral distress crises. 
In my group we are having these discussions now. We are refreshing end-of-life comfort measure training for our staff and we are discussing a scarce resource algorithm.
Very interested to learn what others are planning.
Lowell 

Lowell Kleinman, MD

Medical DirectorPalliative Care John Muir HealthWalnut Creek, CA925-296-7350
Family PhysicianPalliative Care PhysicianJohn Muir Medical GroupWalnut Creek, CA925-296-9720 

*******Catherine Sonquist Forest, MD (California) 

Hi allThe palli community starting to have increased requests 
I am very interested in continuing conversation 
I will start in leadership in my county for strategy/planning expected surge next week
I have gotten requests since no more elective surgeries already. 
I am curious about your thoughts on laws to decrease the waiting period since quickly progressing/lack of ventilators predicted.
Peace in time of pandemicCatherine 
*******Diana Barnard, MD  (Vermont)
yes. this is a timely topic. 
I had several calls on Friday about this. from PCPs, from hospice agencies, from patients and families!
I’d love a triage tool with specific information to make available how can we support pt/families, esp  without hospice care 

On the practical end: here are a coupe of resources I am gearing up to distribute
Vital talk covid communication tool:https://www.vitaltalk.org/guides/covid-19-communication-skills/

a resource to support pall care providers from a friend in NZ
https://inkvessel.com/2020/03/18/palliative-care-in-the-time-of-covid/?fbclid=IwAR1smp4l30oQ7HktVJtbwZXHU2zpIjz9aSeQLJsDSEsmI0Ae_GjMkIkhips

a chapter on active dying forma wilderness manual;. it’s not  perfect, but it’s ready to go and succinct. https://oxfordmedicine.com/view/10.1093/med/9780190066529.001.0001/med-9780190066529-chapter-9

open to other ideas and resources. it seems like using consistent messaging is important.
peace
Diana
*******Constance Holden, RN (Colorado) 
This was created by the National Hospice and Palliative Care Organization.  We are working to get it into the nursing homes, with the hopes that it will help them keep their affected patients in the facility…..dying in place, so to speak.
Constance

Constance Holden, RN, MSN
Chair-Consultation Team Co-Chair-Ethics Committee
Boulder Community Health
720-318-4457-cell
********Gary Johanson, MD (California) 
Thanks for checking in on this question and proactively inquiring about EOL population in regards to hospice involvement, Bob.
As leader in Providence St Joseph which serves a large population on the west coast, we have been pursuing coordinated system-wide precautions and preparations for increasing patient census even in the face of anticipated ill (with or without COVID) and quarantined clinicians.  This includes augmentation of  our PPE supplies and rapid implementation of widespread telemedicine to be used whenever feasible.  
In our area, it appears our current collaborators for MAID evaluations and prescribing (since neither our health system nor the Federally Qualified Health Centers can fill this need) appear to be intact albeit subject to a major ramp-up in telemedicine modality rather than F2F.
Having said that, we of course will be going into homes for F2F on all of our patients, however the proportion of televisits vs F2F will change drastically for now.  Even those of our staff who will face quarantine will continue to be available for phone and telemedicine care from home.  Patients considering MAID who are considering it as a “Back up” plan rather than a Primary plan generally represent a subset of patients and families in greater than average need so will be accordingly receiving a higher percentage of F2F visits.  
For the San Diego area, you might contact Sharp which has a high penetration and likely preparedness feature for a better idea of your own local scene.  They have at least 3 inpatient homes as well (though I have no idea how they plan to utilize those during this pandemic).  Gary Johanson
*********
Emily Beers, MD  (California) 
I work at a large public hospital (LA County) and it feels like the calm before the storm – 4 cases and 60+ PUI.  No where near anything bad but a  pervasive eeriness that mounts by the day.

We have created a surge plan for our hospital that includes a temporary inpatient palliaitve care unit for patients who are not eligible for or fail vent support, with plans for  COVID and non-COVID areas since as Bob first mentioned there will be a significant impact on non-COVID patients with preexisting frailty and end of life needs.  The plan is scalable for various levels of triage burden, and of course gets progressively more grim and spartan as resources diminish.

The key part of the plan that was emphasized with our administration was that triage/resource rationing was not to be provided by or enforced by palliative care or the ethics committee.  We have enough of a ‘death-panels’ image problem on a good day.  We have been actively involved in discussions and planning, but “who gets a vent?” is a question to be decided by ER or ICU staff based on clear, transparent guidelines.  Many institutions and critical care societies have detailed disaster plans that have been painstakingly worked through based on best available evidence – I’m attaching the Mt. Sinai document that was a starting place for some of our plans (includes triage info based on SOFA score, imperfect but helpful start, page 262).   It was quite surprising to me that numerous doctors at our hospital wanted that vent decision to be made at the individual MD level – I’ve been a part of care in austere environments and it is morally exhausting to say the least.  Current news from Italy harrowingly reiterates that point.  There is an appeal mechanism so that individual docs can exert their valued expert autonomy, but the majority of triage should be guideline-based.  Some of my colleagues across the country have also talked about institution of preemptive palliaitve consults for COVID+ patients and even PUI, which I think is a potentially very hazardous position for us in the public eye in addition to depleting a workforce likely to be very taxed very soon.

Many of the large local hospices in our area have recently come together to talk about sharing plans, thoughts and even equipment/staff resources to meet likely increased demand.  We are figuring out how to interface most effectively with them, but it was a heartwarming thing to discover and I applaud them for being so forward-thinking.

Another place I think we as a palliaitve team have been helpful is in the arena of staff communication.  We have surveyed clerks, janitors, respiratory techs, med students, etc to get a sense of their specific worries and desires for communication, and have used that to try to help administration be sure we are supporting our staff the best we can.  The ‘biweekly town hall with the CEO’ can be a very intimidating forum to try to get your questions answered, and I think the more tailored palliaitve approach has been welcomed by our admin structures who are unused to needing to message on so many channels.

My deepest gratitude to everyone out there doing what you can and for sharing your wisdom here.  Stay safe and healthy.
Best,-Emily

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