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Infection Prevention at End of Life: Should Our Approach Be Different? · The SHEA Podcast

• 0:09
  SPEAKER_01: Welcome to the Infection Prevention and Antibiotic Stewardship at End of Life podcast series, brought to you by the Society for Healthcare Epidemiology of America, Shay.
• 0:18
  SPEAKER_01: I am Dr.
• 0:19
  SPEAKER_01: Lindsay Gottlieb, Assistant Professor of Medicine in the Division of Infectious Diseases at Emory University School of Medicine, Hospital Epidemiologist at Emory St.
• 0:27
  SPEAKER_01: Joseph's Hospital, and Associate Hospital Epidemiologist at Emory University Hospital Midtown, and I will serve as today's moderator.
• 0:34
  SPEAKER_01: Shay is excited to launch this episode entitled Infection Prevention at End of Life.
• 0:39
  SPEAKER_01: Should our approach be different?
• 0:41
  SPEAKER_01: In the end of life setting in particular, IP policies like isolation requirements and visitor restrictions have the potential to cause harm.
• 0:49
  SPEAKER_01: This podcast will delve into the risks and benefits of such policies in the acute care setting and how they might or might not be adapted at end of life.
• 0:57
  SPEAKER_01: I'm happy to introduce our speakers for today.
• 0:59
  SPEAKER_01: First, we have Rupak Dutta, assistant professor in the section of infectious diseases at the Yale School of Medicine, and assistant hospital epidemiologist at the Veterans Affairs Connecticut Healthcare System.
• 1:09
  SPEAKER_01: Dr.
• 1:10
  SPEAKER_01: Datta conducts health services research focused on improving antimicrobial use in older adults receiving home-based primary care.
• 1:17
  SPEAKER_01: His work has been supported by the National Institute on Aging Impact Collaboratory, Yale Claude D.
• 1:22
  SPEAKER_01: Pepper Older Americans Independent Center, and the Society for Healthcare Epidemiology of America.
• 1:27
  SPEAKER_00: Thank you so much.
• 1:28
  SPEAKER_00: It's a really pleasure to be here.
• 1:30
  SPEAKER_01: Glad you're able to join us.
• 1:30
  SPEAKER_01: Thanks, Rupak.
• 1:32
  SPEAKER_01: We're also joined by Melissa Wachterman.
• 1:34
  SPEAKER_01: Dr.
• 1:34
  SPEAKER_01: Wachterman is a physician specializing in hospice and palliative medicine.
• 1:38
  SPEAKER_01: She works as an inpatient palliative care consult attending, primarily at VA Boston Healthcare System, and also does some clinical time at Dana Farber Cancer Institute.
• 1:47
  SPEAKER_01: She also conducts health services research and is particularly passionate about conducting policy-relevant research that aims to improve the access to and quality of palliative and end-of-life care.
• 1:56
  SPEAKER_01: Great, I'm really excited to be here.
• 1:58
  SPEAKER_01: Welcome, Melissa, and thank you both for joining us.
• 2:00
  SPEAKER_01: Let's jump in.
• 2:02
  SPEAKER_01: While infection prevention policies are designed to keep our patients, staff, and visitors safe, they can have unintended negative consequences in some settings.
• 2:10
  SPEAKER_01: What are some examples of infection prevention policies that make end-of-life care in particular challenging?
• 2:15
  SPEAKER_01: Melissa, I'm going to start by getting your thoughts on this.
• 2:18
  SPEAKER_02: Absolutely.
• 2:19
  SPEAKER_02: So I think that you've really categorized it well in sort of talking about two of the biggest policies that I think are an issue for patients, particularly with serious illness at the end of life.
• 2:29
  SPEAKER_02: So, you know, isolation requirements and then even more strongly, just the visitor restrictions.
• 2:34
  SPEAKER_02: I think that we'll talk more about it, but you know, anyone who's lived through the COVID era has sort of seen the impact of that.
• 2:42
  SPEAKER_02: And particularly for patients when time is short, family becomes even more important.
• 2:47
  SPEAKER_02: And visitor restrictions, I think, were really heart-wrenching to see.
• 2:50
  SPEAKER_01: Thanks, Melissa.
• 2:51
  SPEAKER_01: And I definitely appreciate your highlighting the COVID pandemic when I think a lot of these issues really came to light.
• 2:56
  SPEAKER_01: Rupak, any other challenges that you wanted to highlight?
• 2:59
  SPEAKER_00: Yeah, thank you.
• 3:00
  SPEAKER_00: No, I I completely agree with what Melissa has uh shared.
• 3:04
  SPEAKER_00: You know, I think in addition, the use of personal protective equipment, particularly um, you know, masks, gloves, gowns, as part of isolation protocols, is also another another key issue that create barriers for human connection, physical touch, visual cues, facial expressions.
• 3:20
  SPEAKER_00: We lose lots of that meaningful contact with the use of personal protective equipment in particular.
• 3:26
  SPEAKER_02: Absolutely, Rebecca.
• 3:27
  SPEAKER_02: I completely am glad that you highlighted that because I think that it's really important and thinking about particularly patients as time gets shorter, delirium can come into play where they're confused.
• 3:38
  SPEAKER_02: And so things like not being able to see somebody's face or those that have problems with hearing, it becomes a real, a real barrier.
• 3:45
  SPEAKER_02: I'm glad you raised that.
• 3:46
  SPEAKER_01: Yeah, those are those are important points about PPE.
• 3:48
  SPEAKER_01: And again, I think things that sort of we became more aware of given all the masking during COVID.
• 3:54
  SPEAKER_01: Melissa, I know you've done a lot of research on end-of-life care and hospice policy in particular.
• 3:58
  SPEAKER_01: What do you see as the impact of these infection prevention policies on the various stakeholders in the acute care setting?
• 4:04
  SPEAKER_01: So including patients, visitors, and healthcare workers.
• 4:07
  SPEAKER_02: I mean, I just have to say, as a palliative care doctor in the trenches, it's really the patient stories and experiences that we had that really drives my perspective on this.
• 4:18
  SPEAKER_02: I think we need to think about the policies.
• 4:20
  SPEAKER_02: But when I think about the question, I just think about, you know, a couple of patients came to mind when I was early in the epidemic.
• 4:28
  SPEAKER_02: We had a patient I was working on the cancer palliative care service.
• 4:32
  SPEAKER_02: So it wasn't even a patient who, you know, had COVID or anything along those lines.
• 4:37
  SPEAKER_02: But because appropriately in this time of such concern and public health crisis, there was sort of a complete crackdown.
• 4:45
  SPEAKER_02: So this 37-year-old guy who was dying of cancer could not have any visitors.
• 4:51
  SPEAKER_02: He had two young children.
• 4:53
  SPEAKER_02: And the policy at that time, there was one exception, which was when a patient was comfort measures only.
• 4:59
  SPEAKER_02: At that point, they could have some small number of visitors.
• 5:03
  SPEAKER_02: But what really broke my heart was here was this man who I was seeing every day.
• 5:08
  SPEAKER_02: I was seeing him, but his own children couldn't see him.
• 5:11
  SPEAKER_02: And as is not uncommon near the end of life, by the point at which that decision was made to move to full comfort, he was he was delirious.
• 5:22
  SPEAKER_02: And the decision then became, you know, do we have his children come in to say that final goodbye?
• 5:27
  SPEAKER_02: So it was just sort of heart-wrenching in these stories, you know, I think doctors across the board, whether you're in palliative care or not in palliative care, there there are these stories.
• 5:35
  SPEAKER_02: One other that comes to mind, just one more to share, was a patient who in this case actually was in the intensive care unit on a ventilator in renal failure with COVID.
• 5:44
  SPEAKER_02: And what really struck me about that was in having that family discussion, family meeting around goals of care, obviously was fully remote.
• 5:53
  SPEAKER_02: It actually was in Spanish, so there was an added layer of complexity with interpreter services.
• 5:58
  SPEAKER_02: But our policy at that point, and this is again early in the pandemic, was that I had never met the patient face to face.
• 6:04
  SPEAKER_02: So we didn't go into rooms.
• 6:06
  SPEAKER_02: And so I was having this family meeting where we're making huge decisions and to not even be able to tell the family that I had ever seen their loved one, you know, beyond on a video was heart-wrenching.
• 6:18
  SPEAKER_01: Yeah, that sounds really difficult.
• 6:19
  SPEAKER_01: And I think, you know, those two different stories well highlight the impact on all the different stakeholders we've talked about, the the patient themselves, but also their loved ones and even the healthcare workers.
• 6:29
  SPEAKER_01: So I think given you know the difficulties and the negative consequences you you both have highlighted, are there ways in which you might adapt your approach to precautions or visitor policies at end of life, perhaps different enforcement for healthcare worker versus visitors?
• 6:44
  SPEAKER_01: Um and Rupak, I'll start with your thoughts on that.
• 6:47
  SPEAKER_00: Yeah, so I think uh adapting infection control precautions, you know, at the end of life requires a really nuanced approach that, you know, in which we balance the need for preventing transmission with the provision of compassionate care.
• 6:58
  SPEAKER_00: I think we all recognize as clinicians there's a profound importance of patient and family needs during the sensitive time.
• 7:05
  SPEAKER_00: And I think there are some approaches that we can apply here that might make dental life care more meaningful for all parties involved.
• 7:11
  SPEAKER_00: I think the first is, you know, risk assessment, kind of developing a personalized risk assessment, you know, the specific infectious agent, the mode of transmission, uh the vulnerability of contacts within the healthcare setting and things of that nature.
• 7:25
  SPEAKER_00: So for maybe less contagious, less severe infections, we might um relax certain precautions to facilitate family um interactions.
• 7:34
  SPEAKER_00: We already talked about modifying or adapting visitor policies.
• 7:37
  SPEAKER_00: Uh, so there are situations where visor restrictions might be necessary, but maybe exceptions can be made during end-of-life care.
• 7:43
  SPEAKER_00: And that can be with respect to you know the duration of contact, so you know, the amount of time involved and so forth.
• 7:50
  SPEAKER_00: PPE, we talked about earlier.
• 7:52
  SPEAKER_00: I think that might require some education and you know, maybe facilitating more closer interactions.
• 7:58
  SPEAKER_00: We can have designated areas for visitation.
• 8:00
  SPEAKER_00: And I think through the COVID pandemic, we've also learned about the many opportunities available through technology, through telehealth or other things, virtual care.
• 8:09
  SPEAKER_00: You know, of course, there's pros and cons with these new technologies, but this can be an option when absolutely necessary.
• 8:16
  SPEAKER_00: And finally, if we do apply some of these tailored or adapted approaches, we can also have post-exposure protocols if there is a concern for a potential exposure.
• 8:26
  SPEAKER_00: So I think lots of institutions have, you know, adapted uh some of these precautions through COVID.
• 8:31
  SPEAKER_00: And we've we can apply some of those lessons today.
• 8:34
  SPEAKER_01: Thanks, Rupak.
• 8:35
  SPEAKER_01: And well, I'm curious, you know, do you have any any different thoughts about how to adapt precautions at the end of life?
• 8:40
  SPEAKER_01: And in particular, are there differences in how you might adapt those for you know the healthcare worker entering the room versus visitors or family members who are coming?
• 8:50
  SPEAKER_02: To the point Rupak made, obviously thinking about PPE and healthcare workers is important, but I think that just sort of in the lived experience, I think that we can be tighter on PPE.
• 9:02
  SPEAKER_02: It's people just want to be able to see their family and be able to see their family at a time that they can interact with their family.
• 9:09
  SPEAKER_02: So I think that waiting until a patient is sort of right at the end, sort of realizing that at that point in time, usually people aren't interactive and talking to their family anymore.
• 9:20
  SPEAKER_02: And so I think we can be stricter on the healthcare worker side and really try to move things towards trying to make it possible for patients to have as much access to family as is as is feasible.
• 9:34
  SPEAKER_02: I will say with regard to the telehealth piece, there are definitely video conferences.
• 9:39
  SPEAKER_02: It's it's not the same, but it really has been a major improvement.
• 9:43
  SPEAKER_02: And just to note, sort of aside from the infectious disease side, with the increase in video conferencing, we actually are able to involve a lot more family members in family meetings than typically was possible.
• 9:55
  SPEAKER_02: So I think that we definitely can learn lessons from the pandemic.
• 9:59
  SPEAKER_02: But I think when time is short, being able to have at least a small amount of time with your family is so critical.
• 10:05
  SPEAKER_01: Thanks, Melissa.
• 10:06
  SPEAKER_01: And I think that's an important point you bring up about sort of when in the timeline of the illness these adjustments are made.
• 10:12
  SPEAKER_01: Because I think a lot of policies do sort of wait until the patient is actively dying.
• 10:16
  SPEAKER_01: And to your point, that may be too late for the patient to be able to have those meaningful interactions with the family.
• 10:21
  SPEAKER_01: So that's a good point.
• 10:22
  SPEAKER_01: Rupak, you touched a little bit about this already, but I wanted to get more of your thoughts.
• 10:26
  SPEAKER_01: Um, given your particular background in infectious diseases, if there are certain situations under which you would try to maintain isolation precautions or not adapt policy, you'd even at end of life.
• 10:36
  SPEAKER_01: So are there certain organisms that make you particularly nervous or certain types of precautions for which you'd be more or less inclined to adapt your approach at end of life?
• 10:45
  SPEAKER_00: You know, I guess for for those with a background in infectious diseases and hostile epidemiology, I think a primary goal might be to balance the need for infection prevention with compassionate end-of-life care.
• 10:56
  SPEAKER_00: And I think there are specific scenarios where there should be kind of heightened precautions.
• 11:02
  SPEAKER_00: So I might group these into um a few categories.
• 11:06
  SPEAKER_00: The first, I think most evident might be highly contagious or lethal pathogens.
• 11:10
  SPEAKER_00: So for example, Ebola virus, we don't hopefully see that often, but certainly for something of that nature, or you know, novel strains.
• 11:18
  SPEAKER_00: Perhaps there might be a new and you know, upcoming circulating influenza strain that's highly pathogenic, or perhaps more prevalent um multidrug-resistant organisms, Candidaoris perhaps might warrant things where you might um have a bit more hesitation about relaxing some of these protocols.
• 11:36
  SPEAKER_00: I think the mode of transmission might also be um relevant.
• 11:40
  SPEAKER_00: So for pathogens in which airborne transmission is a concern, I think that might give some hospital epidemiologists pause.
• 11:47
  SPEAKER_00: We might think about multi-druggers and tuberculosis or things like that.
• 11:51
  SPEAKER_00: And finally, I would also be more cautious in settings where there's a high prevalence of immunocompromised persons.
• 11:59
  SPEAKER_00: So, you know, certainly end-of-life hospice that often involves patients who are immunocompromised.
• 12:04
  SPEAKER_00: But to the extent when there's concern for transmission to others, perhaps in oncology wards, transplant units, solid organ transplants, we might have greater concern about uh relaxing some of these.
• 12:16
  SPEAKER_00: So it's important to balance these, but those would kind of be three buckets that I'd I'd consider.
• 12:21
  SPEAKER_01: Thanks, Rapak.
• 12:22
  SPEAKER_01: And I think your last point actually segues really nicely into my last question, which acknowledges that not all hospitals have the same layout or distribution of where their end-of-life patients are located.
• 12:33
  SPEAKER_01: And so a one-size-fits-all approach to infection prevention at end of life may not be feasible.
• 12:38
  SPEAKER_01: Given this, should infection prevention policies be different in facilities that have dedicated hospice units compared to facilities where hospice beds might be on regular acute care units or IC units or oncology units?
• 12:49
  SPEAKER_01: I want to get both of your thoughts on this, but I'll start with Melissa.
• 12:53
  SPEAKER_02: So I do.
• 12:54
  SPEAKER_02: I think that dedicated hospice units do present a real opportunity, especially if they're located outside of an acute care hospital.
• 13:03
  SPEAKER_02: You know, it really, if you're choosing to go to a dedicated hospice unit, you're making choices.
• 13:09
  SPEAKER_02: And I think that most patients and families would more than be willing to take risks associated with loose requirements around infection control in order to have time together.
• 13:20
  SPEAKER_02: I think that patients and families, all the time we're talking about weighing benefits and risks and what's focusing on what's most important to them.
• 13:29
  SPEAKER_02: The challenge becomes when we're talking about something that has such public health implications.
• 13:35
  SPEAKER_02: So patients and families make decisions like going to go ahead and eat, even though they have terrible swallowing and could develop a pneumonia other times, even things related to infectious disease, like how you're going to manage endocarditis when being in the hospital or going to a facility to get IV antibiotics, that's what the correct answer is on the boards.
• 13:58
  SPEAKER_02: But when time at home is what's most important, if it isn't going to be possible, taking oral antibiotics for something like that is an approach that we would definitely endorse in line with patients' goals.
• 14:09
  SPEAKER_02: The challenge is when we're talking about a public health situation by looking at a place, thinking about a dedicated hospice unit, patients are making a choice to go there.
• 14:19
  SPEAKER_02: And with that choice, they can prioritize being able to have their families and know that other patients will too.
• 14:26
  SPEAKER_02: And that yes, that increases the risks of infection.
• 14:29
  SPEAKER_02: Having lived through the pandemic and continuing on, most patients are willing to take that.
• 14:34
  SPEAKER_01: Yeah, those are some great points you bring up, Melissa.
• 14:36
  SPEAKER_01: Thank you.
• 14:37
  SPEAKER_01: Rupak, what are your thoughts about differences in approach depending on the setting?
• 14:41
  SPEAKER_00: Yeah, no, I think this uh this distinction is pretty important.
• 14:44
  SPEAKER_00: Um, just like we have different approaches for infection prevention that vary by healthcare setting, you know, acute long-term care versus primary care.
• 14:51
  SPEAKER_00: I think we can also think about no one size fits all in in this context as well.
• 14:56
  SPEAKER_00: So I think in hospice units, you might have the opportunity to consider the environments and how that might support infection prevention precautions.
• 15:06
  SPEAKER_00: So there might be private rooms with, you know, additional facilities or additional suites where visitors can can gather and reduce the risk of transmission.
• 15:16
  SPEAKER_00: Um, it might be more feasible to have more lax visitor policies and so forth.
• 15:21
  SPEAKER_00: Whereas I think in acute care units, in hospice beds and acute care units, we really need to be cognizant of the wide range of patients that are managed in these settings, as we said, particularly immunocompromised patients.
• 15:33
  SPEAKER_00: And so infection prevention policies might need to be more stringent in this setting.
• 15:37
  SPEAKER_00: And I think it it does involve more coordination with hospice beds and acute care units, you know, where to have them, you know, what healthcare providers are assigned to these units, and how can we kind of juggle these dual priorities of infection control and providing compassionate care.
• 15:51
  SPEAKER_00: So I think there needs to be more planning, whereas in hospice units, perhaps there might be more flexibility and kind of structural or other ways to support more compassionate infection prevention policies.
• 16:01
  SPEAKER_01: Great.
• 16:02
  SPEAKER_01: Yeah, I know it's it's a good point and sort of the planning piece that we need to go into allowing for those different policies depending on the patient type is important.
• 16:10
  SPEAKER_01: Well, I really appreciate you both joining, and thank you both for such a fantastic conversation.
• 16:15
  SPEAKER_01: Um, and thanks for being here with us today.
• 16:17
  SPEAKER_02: Thank you.
• 16:18
  SPEAKER_00: Thank you so much.
• 16:19
  SPEAKER_00: Really happy to be here.
• 16:20
  SPEAKER_01: You can find more educational content like this podcast on Shay's online education center, Learning CE, at www.learningce.shay-online.org.
• 16:31
  SPEAKER_01: This concludes today's episode of the infection prevention and antibiotic stewardship at End of Life series.
• 16:36
  SPEAKER_01: Thank you for tuning in.