Wednesday, September 27, 2017

Palliative Care in the Time of Hurricane Harvey

by Ishwaria Subbiah (@IshwariaMD)

Trouble Brewing
Between the network news and many institutional emails on hurricane preparations, we at MD Anderson knew were in for something ‘big.’ Harvey made landfall on August 25th as a Category 4 hurricane about 190 miles southwest of Houston. The outer bands brought rain without any major disruptions to our practice. As expected, upon landfall, Harvey rapidly weakened but stalled over Texas. The subsequent two days brought a level of rainfall best described as apocalyptic. The institution’s leaders activated the ‘ride-out’ team where the core essential physicians and staff remained in-house for the duration of the disaster.

Bare Bones Palliative Care? Interdisciplinary Team of One
‘Skeleton’ staffing seemed inherently counterintuitive to the model of Palliative Care through the interdisciplinary team (IDT) of physicians, Integrative Medicine team, psychologist/counselors, social workers, case managers, and chaplains. Of course, all the bayous and retention ponds were no match for 50 inches of rain that fell in a matter of a few days. So the roles of the IDT were condensed to the Palliative Care staff who were riding out in the hospital. Our in-house Palliative Care ride-out physician, Dr. Marvin Delgado, embraced his several roles and adds how he was open with his time, and ensured that he and the patient had “the opportunity to cover aspects of symptom management, the physical, emotional, and spiritual, as well as time to discuss and counsel about what’s been happening.” Dr. Delgado adds, “As I realize that I cannot do much about what’s happening outside, but the simple fact of sitting down and listening to [the patient] helped them a lot.” Dr. Delgado goes on to reflect how striking it was that despite their own struggles and suffering, the patients were still worried about others around them; they were very open to sharing their thoughts and sentiments about the situation with him.


Multimodal Care!
Harvey became a test of a multimodal care model during any disaster (natural or otherwise). Overall the Palliative Care team cares for about 155 people (and their families) on a daily basis between the Supportive Care clinics, inpatient consult team, and inpatient Acute Palliative Care Unit (APCU). It was amply clear that access to the Texas Medical Center was neither safe nor feasible. Within our faculty and staff, several were experiencing active water damage to their homes, and many more were under mandatory evacuation orders. The remainder of us were ‘hunkering’ down at home. So how do you provide care when your traditions of practice (i.e. face-to-face encounter, etc) are simply not possible?
Soon, emails started floating around to our department mailing list – ‘my streets are flooded but I have power and internet access and can help from home.’ Faculty, fellows, nurse practitioners, and physician assistants announced their availability to help via phone. As a priority, the in-house physician for our service first rounded on the APCU patients, for whom we were the primary inpatient physicians. From their home, our medical assistant and Palliative Care fellows took charge of the department pager. They answered the calls from two sources – the inpatient consulting teams and our outpatients.

Telephone Care
As is standard practice, when the inpatient primary teams paged to report sub-optimally controlled symptoms, our responding Palliative fellows (with the assistance of faculty available via telephone) provided recommendations and, for those consult patients with the highest level of distress or a suspected toxicity, the in-house PC physicians evaluated them in person. The underlying sentiment among all in-house at MD Anderson during the ride-out was clear – this is an exceptional time and we will all deliver as effective a care as possible under the circumstances.

For Palliative Care, this translated to a level of understanding from the primary consulting teams that whereas at any other time, we as PC team would be there to evaluate most patients in person, during these times, we will get as much relevant info over the phone prior to giving recommendations to them to order and execute if they feel it is appropriate.

Outpatient Calls – more than pain!
Our Outpatients paged us, mostly concerned about the institution’s closure and their cancelled Oncology and Supportive Care clinic appointments particularly because they were due for a refill of their opioids for cancer pain. With a telephone assessment for opioid-associated toxicities and efficacy and based on their electronic medical history (in particular any prior concerns for aberrant opioid use), as a departmental decision, we transmitted an e-script for a 2-4-week supply of their controlled substances until their next visit. By the 3rd day, a Palliative Care clinic crew of 4 physicians and 2 nurses assembled in the clinic to individually call each patient who had contacted us as well as those with missed appointments. Patients shared the overwhelmingly positive, qualitative response to have a clinician directly speak to them during this time of distress.

Uncertainty ruled in every aspect of life
Beyond pain or whichever symptom prompted the patient to call us, the universal sentiment we observed was distress of varying degrees as a direct consequence of uncertainty – an uncertainty extending through nearly every aspect of their life from disease management to their own homes/lives to the state of their medical care providers’ facilities. Regarding their cancer treatment, questions ranged from the cancellation of a scheduled infusion, the consequences this delay and interruption to this treatment and disease outcome, and the limited communication (since the clinics were closed) during the early period of the worst rains when it was not clear when the clinics and infusion centers will be back up and running. Patients were also concerned about their home (flooding, electricity, flooded cars, access to food and water) as well as access to care (flooded roads at home or near the hospital, most pharmacies being closed, major hospitals being inaccessible even through 911). Ultimately, the amalgam of all these elements of distress presented with a greater need for Supportive Care.

“An Army of People”
On Monday August 28 and Tues August 29, when the medical center was inaccessible, we had an in-house ride out team led by Dr. Marvin Delgado and our Chair Dr. Eduardo Bruera as well as 6 faculty, 4 NPs/PAs, and 4 fellows (many of whom had sustained damage to their own home) provided telephone care for all new inpatient consults, our current inpatients, as well as clinic patients.

The Supportive Care “Army of People” (as our Chief Medical Officer Dr. Karen Lu phrased to NPR) was out in full force in support of our patients, families, and consulting teams during these trying times! By August 30, when the rains slowed, water in the Texas Medical Center receded, and a handful of roads became accessible, the larger IDT recognized the distress that disruption of a person’s scheduled care can cause. The Supportive Care team mobilized 12 Palliative Care physicians along with our department administrator, 2 Integrative Medicine physicians, 2 Rehabilitation physicians, 8 nurse practitioners/physician assistant, 4 Palliative Care fellows, and 2 psychologists/counselors – all of whom came into the hospital during the ride-out phase voluntarily to take care of the comprehensive needs (both physical symptoms including management of pain, nausea, vomiting, shortness of breath and psychosocial symptoms including high level of distress, anxiety, depression) of over 100 inpatients and their families, in addition to calling many more clinic patients with a management plan during the outpatient closures.

“It was a call, a necessity to help!”
Ultimately, we as Palliative Care practitioners observed that the uncertainty and associated distress of a large scale disaster can be mitigated to an appreciable extent by the presence of the medical team and sense of ‘normalcy’ brought on by the care of the palliative care provider, and, knowing that in due time, the logistics of missed appointments, infusions, etc. will be sorted out. (Indeed, in the subsequent two days, the hospital leadership and clinic teams effectively rescheduled a majority of missed visits and infusions including the medical teams opening full clinics on Saturdays and Sundays.)

As the rains began while he was home, Dr. Delgado reflects on the compelling overwhelming sentiment to come to see patients. He notes, “I believe that people with advanced illness are people who are having their own Harvey in their lives and on top of that they are experiencing something else that is happening outside that they cannot really control. It was a call, a necessity to help!”

Ishwaria Subbiah, MD, MS, is a medical oncologist and Palliative Care physician at the University of Texas MD Anderson Cancer Center. When she's not chasing after her 3 young kids, she and her husband can be found at the opera (sans children, of course).

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