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Mar 31, 2020

In the latest in our series of talking with front line providers in the midst of the COVID pandemic, we talk with Drs. Craig Blinderman, Shunichi Nakagawa, and Ana Berlin of the palliative care service at Columbia University Irving Medical Center. We cover a host of topics, including the urgent need to conduct advance care planning with our outpatients (including Craig's new Epic dotphrase below, and guide to COVID advance care planning); the need to be flexible to suit shifting demands; to stock up on iPads to engage patients/family members in goals of care discussions from outside the room. We mention the new JAMA papers on "informed assent" to DNR/I orders by Randy Curtis and colleagues (and Craig's prior JAMA paper), and on rationing scarce resources by Doug White and Bernie Lo (see also our prior podcast on rationing with Doug with links to the practical framework). I cried after this one. Maybe it was Ana talking about how hard it was have an agenda when discussing goals of care with the family of a 90 year old woman with dementia. We're taught in palliative care to match patient/family goals, and to not bring an agenda. But we do have an agenda now, as Ana says. The patient will not survive a code or prolonged intubation. Coding her would expose Ana's colleagues to COVID, and use scarce PPE and ICU resources, including a ventilator. We can't check that agenda at the door anymore. This is hard. You can hear their moral distress as they talk through these experiences. Maybe it was the three of them talking about the pace of change. Last week they felt "impotent" as they awaited the coming storm. Then the ICU called; they want palliative care. Then the ED called; they want palliative care. Today Shunichi spent the entire day having goals of care conversations with likely COVID patients and their families in the crowded ED. Today they say they want a new inpatient palliative care service, ASAP, maybe even tomorrow. They thought they would have until next week. The tsunami hit Wednesday. Maybe it was Ana saying her daughter had a fever and might have COVID, and that one thing she is thankful for is that kids are spared serious illness. Maybe it was the song choice, the Ghost of Tom Joad by Bruce Springsteen, with its inspirational and haunting message. Craig says he chose this song because the lyrics are about standing up to meet the challenges faced by the most vulnerable. As he notes, COVID is the AIDS crisis of our day. We're all in this together. -@AlexSmithMD FYI - for links to referenced material, please visit our website at