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Transcript

Merging Best Practices with Infectious Diseases and the Palliative Care with CAPC · The SHEA Podcast

• 0:11
  SPEAKER_00: Welcome to the We're All in This Together COVID-19 Allies and Infection Prevention podcast series as part of the Society for Healthcare Epidemiology of America Rapid Response Program.
• 0:23
  SPEAKER_00: I am Dr.
• 0:24
  SPEAKER_00: Manisha Jutani, infectious diseases physician and associate professor at Yale School of Medicine, and I will serve as your Shea moderator and speaker today.
• 0:33
  SPEAKER_00: I'm also happy to welcome Dr.
• 0:34
  SPEAKER_00: Diane Meyer, Director of the Center to Advance Palliative Care, or CAFSE.
• 0:40
  SPEAKER_00: CAFSE is a national organization dedicated to increasing the availability of quality health care for people living with a serious illness.
• 0:48
  SPEAKER_00: As the nation's leading resource in its field, CAFSE provides healthcare professionals and organizations with the training, tools, and technical assistance necessary to meet this need.
• 1:00
  SPEAKER_00: Discussion on the podcast does not reflect Shay's or CAFSE's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 1:12
  SPEAKER_00: Today's episode will focus on collaborations between healthcare epidemiology and palliative care and how we as a team can work together to address the most important questions surrounding the COVID-19 outbreak.
• 1:27
  SPEAKER_00: Dr.
• 1:27
  SPEAKER_00: Meyer, welcome.
• 1:29
  SPEAKER_00: I've had a long-standing interest in merging best practices of infectious disease management and palliative medicine.
• 1:35
  SPEAKER_00: The COVID-19 pandemic has highlighted why it is so important to keep major principles from each of our disciplines in mind.
• 1:43
  SPEAKER_00: What's been your experience with this pandemic so far?
• 1:47
  SPEAKER_01: Well, the experience has been overwhelming, exhausting, and instructive, as I think it has been for every health professional working in a community that's been affected by this virus.
• 2:01
  SPEAKER_01: At the Center to Advanced Palliative Care, we are in New York City, and therefore we were at the epicenter of the city that had the first surge or the first wave of infection.
• 2:15
  SPEAKER_01: So many of our colleagues were communicating with us multiple times a day, and we very rapidly saw the need to develop essentially a toolkit that would help support not only palliative care teams trying to work alongside their colleagues, relieving suffering and communicating with patients and families and other clinicians about what was most important for this patient at this moment in their life, but also developing resources that would help all frontline clinicians, whether they be infectious disease doctors or emergency department doctors and nurses or critical care clinicians who, in many cases, didn't have access to palliative care colleagues, either because there weren't any or because those colleagues were completely overextended given the level of the demand.
• 3:09
  SPEAKER_01: So we very rapidly put together a toolkit that included things like pocket cards for the management of shortness of breath.
• 3:16
  SPEAKER_01: How do you do it?
• 3:17
  SPEAKER_01: What's the starting dose?
• 3:18
  SPEAKER_01: When do you escalate?
• 3:20
  SPEAKER_01: How do you manage side effects?
• 3:22
  SPEAKER_01: And pocket cards that included helpful prompts and scripts, for example, an emergency department clinician with a patient who looked like they might need to be intubated pretty soon who also had end-stage dementia and had come in from the nursing home, where it isn't entirely clear what the best course of action would be in that situation, and where very immediate and urgent conversations needed to occur with healthcare proxies, surrogate decision makers, family members, clinicians at the sending facility.
• 4:01
  SPEAKER_01: Imagine having these conversations under normal circumstances.
• 4:05
  SPEAKER_01: They're stressful, they're challenging, they require a lot of emotional intelligence and stability on the part of the clinician initiating the conversation.
• 4:15
  SPEAKER_01: And now dump this into the context of this incredible emergency, public health crisis.
• 4:23
  SPEAKER_01: In our emergency department, there were ambulances and stretchers lined up outside the ED because there was no room for them inside.
• 4:31
  SPEAKER_01: The sense of pressure and the time pressure was really unprecedented.
• 4:38
  SPEAKER_01: So what we did was make it much easier for people to make those calls and have those conversations and get a clear care plan designed.
• 4:48
  SPEAKER_01: So for some of those people with dementia from nursing homes, it was very clear that the patient, when they were able to speak and the family, wanted to live as long as possible.
• 4:58
  SPEAKER_01: And those patients were intubated and sent upstairs.
• 5:02
  SPEAKER_01: And there were others who didn't even know that their loved one had been transferred to the hospital, who said, Oh, he never wanted to go back to the hospital.
• 5:12
  SPEAKER_01: He never wanted to be in a hospital again, and no, he would not want to be intubated.
• 5:16
  SPEAKER_01: And that was very helpful because it helped get the right care to the right patient at the right time in a timely manner.
• 5:24
  SPEAKER_01: Since we launched this toolkit, which is available for free on our website at capc.org, there have been hundreds of thousands of downloads of these tools, as well as a number of our training courses, which are free in the environment of the public health emergency.
• 5:45
  SPEAKER_01: So, what's been instructive about that to me is that our fellow clinicians really want to feel confident in handling problems like this and realize that they are not confident, mostly because we didn't get much training on this stuff during medical school and residency and fellowship, shockingly.
• 6:05
  SPEAKER_01: And the need for it could not be averted or avoided.
• 6:09
  SPEAKER_01: It's obvious to everyone that these are core skills that everyone needs to have.
• 6:14
  SPEAKER_01: And it became much more obvious in the context of the COVID emergency.
• 6:19
  SPEAKER_01: And as COVID is spreading across the country, so for example, in North and South Dakota, it's escalating rapidly.
• 6:26
  SPEAKER_01: In states like Connecticut, which were the best performing states in the country a week ago, it's now rising again.
• 6:35
  SPEAKER_01: So it's a series of waves, and what we've been trying to do is target health systems, clinicians, palliative care teams in those areas that are facing a surge with communication about these resources.
• 6:50
  SPEAKER_01: So adjust-in-time communication so that we can be as helpful as humanly possible.
• 6:57
  SPEAKER_00: I think the work you've done is amazing.
• 7:00
  SPEAKER_00: And I think as infectious disease physicians and healthcare epidemiologists, we recognize how utilizing resources at the right time and providing patients with the appropriate care based on their goals of care, is so important.
• 7:19
  SPEAKER_00: And I have experienced this through my own work as a nursing home investigator where I did a cranberry capsule trial, a pneumonia prevention study, both clinical trials where interventions in older adults, particularly those most debilitated in the nursing home setting, interventions often are difficult to actually work to prevent infection.
• 7:46
  SPEAKER_00: And so many of them are at such high risk of many infections, and COVID just added on top of that.
• 7:54
  SPEAKER_00: You know, I think in healthcare epidemiology, antimicrobial stewardship is such an important aspect of what happens at the interface of infectious diseases, and particularly in palliative care.
• 8:06
  SPEAKER_00: What is the goal of an antibiotic?
• 8:09
  SPEAKER_00: You know, antibiotics are supposed to be curative.
• 8:12
  SPEAKER_00: And yet in some patients, that really might not be a consistent goal of care.
• 8:17
  SPEAKER_00: So having these tools, CAPSI is provided, I think can be incredibly instructive to infectious disease doctors as well, along with all the other frontline workers that have been working as emergency room physicians or other frontline internists taking care of particularly older adults, but all patients with COVID.
• 8:40
  SPEAKER_01: I think that's a really important point.
• 8:42
  SPEAKER_01: And antibiotics are the exemplar of a treatment that on the surface seems like why wouldn't you give it?
• 8:49
  SPEAKER_01: Benign, low risk, theoretically.
• 8:53
  SPEAKER_01: And if it helps treat the infection, it should A prolong life and B reduce symptom burden.
• 9:00
  SPEAKER_01: And that is probably true for the majority, but for some patients that is not true.
• 9:04
  SPEAKER_01: If you have a person, for example, who has overwhelming sepsis, multi system organ failure, respiratory failure, and it's pretty clear they're not going to make it, adding an antibiotic is A of no benefit and B carries some burden and risk.
• 9:20
  SPEAKER_01: In the nursing home, in particular, where the final common pathway of advanced cognitive impairment is difficulty handling secretions and difficulty moving, and recurrent aspiration pneumonia, recurrent urinary tract infection, recurrent pressure ulcers and cellulitis are due to the underlying disease.
• 9:46
  SPEAKER_01: That is the body's loss of ability to move, the body's loss of ability to protect the airway, the loss of ability to provide oneself with hygiene.
• 9:57
  SPEAKER_01: And antibiotics don't fix that.
• 9:59
  SPEAKER_01: They don't fix that underlying vulnerability.
• 10:02
  SPEAKER_01: And then the question is is the burden of that antibiotic, so for example, if we give somebody C diff, are we helping them?
• 10:11
  SPEAKER_01: Or are we making their last days and weeks totally miserable?
• 10:16
  SPEAKER_01: I think part of our training throughout medicine, and antibiotics are no exception, has to be a weighing of benefits and burdens for everything that we do.
• 10:26
  SPEAKER_01: What are we trying to accomplish here?
• 10:27
  SPEAKER_01: What is accomplishable in this patient population?
• 10:31
  SPEAKER_01: And given what may or may not be achievable, then how do we decide what the goals are?
• 10:40
  SPEAKER_01: But we often say things like to a family, do you want us to do everything?
• 10:44
  SPEAKER_01: Well, what family is gonna say no, don't do everything.
• 10:47
  SPEAKER_01: Put my mom on the street.
• 10:49
  SPEAKER_01: We ask the wrong question.
• 10:51
  SPEAKER_01: Do you want us to start your mom on antibiotics?
• 10:53
  SPEAKER_01: Who's gonna say no?
• 10:55
  SPEAKER_01: Right?
• 10:56
  SPEAKER_01: So what we have to do is frame the question to make sure that we're all on the same page about the reality of the situation.
• 11:04
  SPEAKER_01: And if the patient is dying, regardless of what we do, we need to say that.
• 11:08
  SPEAKER_01: Because how's the family member supposed to know?
• 11:11
  SPEAKER_01: We know, and then we say, Do you want us to do everything?
• 11:14
  SPEAKER_01: They don't know.
• 11:15
  SPEAKER_01: They assume we're asking that question because we think doing everything, whatever that is, will help.
• 11:21
  SPEAKER_01: Otherwise, why would we ask?
• 11:22
  SPEAKER_01: Why would we offer something that we believe is of no benefit?
• 11:27
  SPEAKER_01: And the family is right, we shouldn't be offering something we think is of no benefit, and yet we do it all the time.
• 11:33
  SPEAKER_01: And it's very sloppy, in my view, and unprofessional.
• 11:38
  SPEAKER_01: And palliative care is about helping not only ourselves, our colleagues, our families, and our patients understand what is and is not achievable, what is and is not beneficial, so that decisions are based in reality and not in fantasy.
• 11:57
  SPEAKER_00: As you've pointed out, infections in many ways are a common pathway towards an end for many of these patients.
• 12:05
  SPEAKER_00: And COVID has just highlighted the utmost of viral infections right now, where antibiotics don't help anyway.
• 12:12
  SPEAKER_00: What we've seen as an ID community is that a lot of patients get antibiotics when they have COVID because people are unclear what this febrile illness necessarily is, number one.
• 12:23
  SPEAKER_00: Number two, my research group has done two different surveys, one with subspecialists of all different types of critical care, infectious diseases, and many agreed that antibiotics would be considered escalation of care.
• 12:39
  SPEAKER_00: But who owns that discussion and who actually brings that discussion forward with a family or patient is more challenging.
• 12:49
  SPEAKER_00: And that's where people don't know exactly how to address that.
• 12:53
  SPEAKER_00: And then the third is among stewardship groups, we did a survey where we asked if you actually do stewardship on patients who are at the end of life, where you potentially address this issue of although the harm may be somewhat limited, C diff, people may think of it as quote unquote benign, although most ID people don't.
• 13:16
  SPEAKER_00: But what is the benefit?
• 13:18
  SPEAKER_00: What is the good that we're trying to provide?
• 13:21
  SPEAKER_00: And I think that stewardship teams often try to do this, but again, are not equipped necessarily with the resources, whether it be manpower or even the script or even the direct contact with the patient to be able to have that dialogue.
• 13:35
  SPEAKER_00: And this is where I think resources like your center can provide are incredibly helpful for people also providing stewardship because this is where we can work with primary teams to help advance that discussion.
• 13:50
  SPEAKER_00: Where it's not do you want antibiotics or not?
• 13:52
  SPEAKER_00: What is the goal of care at this point?
• 13:54
  SPEAKER_00: What is the realistic expectation of how your family member is going to do with the current illness in front of them?
• 14:01
  SPEAKER_00: And then what are the appropriate treatments to offer and suggest based on what the reality of their care is at that moment in time?
• 14:11
  SPEAKER_01: Precisely.
• 14:12
  SPEAKER_01: And what you're saying is making me think that we ought to develop some antibiotic stewardship script, because we don't have anything that's specific about that.
• 14:21
  SPEAKER_01: And I think that would be really wise because, as we both have said, antibiotic decisions are viewed as kind of trivial, as standard of care, regardless of the context.
• 14:33
  SPEAKER_01: We both know that that has adverse consequences, both for the individual patient as well as for the utility of antibiotics as a group for the whole population, as if they are overused and used in circumstances where they can't help.
• 14:49
  SPEAKER_01: One thing they certainly will do is breed antibiotic-resistant bacteria, which then spread to other people.
• 14:56
  SPEAKER_01: So they do a lot of harm when they're used incorrectly.
• 15:00
  SPEAKER_01: I think we should work together on developing sample conversation guides.
• 15:07
  SPEAKER_00: I think it's a great idea.
• 15:08
  SPEAKER_00: I think a lot of stewardship providers are struggling more with interfacing with the primary doctors, where maybe they do a chart review and then they leave a note in the chart saying all the reasons why they should stop certain antibiotics.
• 15:23
  SPEAKER_00: But then that primary provider is left with the patient and family member.
• 15:28
  SPEAKER_00: And so, in some ways, there are two sets of scripts, one for other providers.
• 15:32
  SPEAKER_00: How do you communicate with other providers on why we are doing certain things?
• 15:38
  SPEAKER_00: And then the second is with that provider and with the patient andor surrogate, which maybe a lot of that you've already done in some of the scripts that you've identified.
• 15:49
  SPEAKER_00: But I think that there is an opportunity to advance the dialogue among providers because I think that there's a lot of discrepancy in terms of even what providers think.
• 15:59
  SPEAKER_00: Some providers feel strongly that how could you not offer antibiotics?
• 16:03
  SPEAKER_00: That is something in the medical field that I think we struggle with.
• 16:06
  SPEAKER_00: ID people have drank the Kool-Aid and know why we do stewardship.
• 16:10
  SPEAKER_00: That is where equipping people who are in infectious diseases and doing antimicrobial stewardship to be able to frame that dialogue in a way that can make sense can help them as well in making those recommendations.
• 16:24
  SPEAKER_01: I think we need to work on both how does a primary care physician, a pediatrician, a geriatrician, a nursing home clinician explain to a patient or a mother or a family member why antibiotics will do more harm than good in this situation and are not recommended.
• 16:44
  SPEAKER_01: And to then be able to say, and what I do recommend is so you're not saying we're doing nothing.
• 16:50
  SPEAKER_01: You're saying in my medical judgment or in my clinical judgment, here's what I believe would be the best thing to do for your child, yourself, your mother, so that we're not sending a message of pulling away human caring and human support, which inadvertently is sometimes how we do it.
• 17:11
  SPEAKER_01: We say things like withdraw care.
• 17:14
  SPEAKER_01: Think about how that sounds.
• 17:16
  SPEAKER_01: We're going to withdraw care from your mother.
• 17:19
  SPEAKER_01: I always say if it's care, it's not futile, and if it's futile, it's not care.
• 17:24
  SPEAKER_01: We should expunge that phrase, withdraw care, from our vocabularies.
• 17:29
  SPEAKER_01: We never withdraw care.
• 17:31
  SPEAKER_01: We always provide care.
• 17:33
  SPEAKER_01: The nature of that care has to be adjusted based on the patient's situations.
• 17:39
  SPEAKER_01: I think we sometimes don't realize the power of our words and the implications that we've somehow decided that this patient is no longer worthy, which comes across in our language and is not what we intend, but understandably is very distressing for the person hearing it, whether it's a family member or a patient.
• 17:59
  SPEAKER_00: It comes off in our actions too.
• 18:02
  SPEAKER_00: So somebody with critical illness has 10 consultants coming and going, potentially talking with family members.
• 18:10
  SPEAKER_00: Now, you know, obviously in the COVID situation, many family members were not at the bedside, but I've found so many family members who really looked forward to conversations as they processed how to make these decisions and what to proceed with and what not to proceed with.
• 18:26
  SPEAKER_00: And then all of a sudden, everybody disappearing.
• 18:30
  SPEAKER_00: And it's not that we aren't providing care, but there's now a more limited number of people providing that care.
• 18:36
  SPEAKER_00: And so that's a challenge.
• 18:38
  SPEAKER_00: What do we replace that with?
• 18:39
  SPEAKER_00: What do we, we want to still provide care, and yet there's only so many people who maybe might be entering a room anymore.
• 18:47
  SPEAKER_00: And I think family members feel that, they see that.
• 18:50
  SPEAKER_00: And I totally agree that it's not that we're removing care.
• 18:55
  SPEAKER_00: This is where I think as infectious disease physicians, we can really learn from what palliative medicine has done, which is that we are providing care, even in explaining to people and talking to people, particularly about how infection is a common way to die after you've had a serious illness, that in fact it can be a peaceful way to go.
• 19:19
  SPEAKER_00: And that once we recognize that retaining meaningful life and quality of life is not something potentially consistent with what this person wanted at this stage of their life, then people can feel at peace with decisions that they're making thereafter.
• 19:36
  SPEAKER_00: So I think as infectious disease doctors, we can learn to incorporate that within our practice, particularly in dealing with this COVID pandemic.
• 19:45
  SPEAKER_01: I would urge caution on assuming that inappropriate care is unwanted care.
• 19:52
  SPEAKER_01: Because it is very often the case that because people really didn't go to medical school, they didn't do residency and fellowship, they don't know what the benefits and burdens of various treatments are.
• 20:03
  SPEAKER_01: And most people, quite naturally, evolution determines this, want to live as long as possible.
• 20:10
  SPEAKER_01: They believe that if we are discussing a treatment, it is because we think it will help them.
• 20:16
  SPEAKER_01: Otherwise, why would we bring it up?
• 20:18
  SPEAKER_01: Sometimes it's a matter of determining wishes, you know, when there's a real choice to be made.
• 20:24
  SPEAKER_01: When there is no real choice to be made, we have to say that.
• 20:27
  SPEAKER_01: We have to be willing to say, at this point, antibiotics, pressors, ventilator therapy, dialysis will not help your mother live longer or regain any meaningful quality of life.
• 20:40
  SPEAKER_01: What I recommend we do at this point is ensure her comfort by doing the following.
• 20:47
  SPEAKER_01: And then you stop talking.
• 20:49
  SPEAKER_01: But you make a professional recommendation that indicates that you are far from abandoning the patient, you are moving closer to the patient and helping the patient.
• 21:00
  SPEAKER_01: It's the abandonment implication that is so distressing for families.
• 21:05
  SPEAKER_01: So similarly, when there were 10 consultants coming in the room, while yes, the families loved to talk to the consultants, it was a disaster, right?
• 21:14
  SPEAKER_01: So the nephrologist would come in and say, Great news, the creatinine went from four to 3.8.
• 21:20
  SPEAKER_01: Now you and I know that is a meaningless statistical variation.
• 21:24
  SPEAKER_01: The family doesn't know that.
• 21:25
  SPEAKER_01: They think this is good news.
• 21:27
  SPEAKER_01: Mom's getting better.
• 21:28
  SPEAKER_01: The nephrologist is just dating the fact as he or she sees it.
• 21:33
  SPEAKER_01: And we all do that all the time.
• 21:35
  SPEAKER_01: We focus on our organ system and our numbers and we communicate that to the family or the patient with no context.
• 21:42
  SPEAKER_01: No wonder families don't trust us.
• 21:44
  SPEAKER_01: We don't get our act together.
• 21:46
  SPEAKER_01: No consultant should go into a room and pontificate without first talking to the primary team.
• 21:52
  SPEAKER_01: What is the plan here?
• 21:54
  SPEAKER_01: What's the big picture?
• 21:56
  SPEAKER_01: And it isn't about these antibiotics are not consistent with the goals.
• 22:00
  SPEAKER_01: Of care, the goals for the patient are to live longer, but they may not be achievable.
• 22:04
  SPEAKER_01: And that's where we have to say, this is not going to be beneficial.
• 22:08
  SPEAKER_01: We're not going to use it.
• 22:10
  SPEAKER_01: It's not a choice.
• 22:11
  SPEAKER_01: What we are going to do is the following.
• 22:14
  SPEAKER_01: Are there people who need to come to visit?
• 22:16
  SPEAKER_01: Are there people who need to say goodbye?
• 22:18
  SPEAKER_01: Are they, you know, if they can't visit, can we set them up on a screen?
• 22:22
  SPEAKER_01: There's so much we can do to make a disastrous situation meaningful and precious and memorable.
• 22:30
  SPEAKER_01: It's the opposite of abandonment.
• 22:32
  SPEAKER_01: But we have to know how to do it.
• 22:33
  SPEAKER_01: We have to be trained to do it.
• 22:35
  SPEAKER_01: And if we didn't get that training when we were in training, we have to get it in mid-career because it's such a core set of principles and practices for any clinician.
• 22:45
  SPEAKER_00: Yes, absolutely.
• 22:47
  SPEAKER_00: I think it's interesting because it's like the person who comes to the emergency department and you're trying to figure out whether to intubate them or not.
• 22:53
  SPEAKER_00: That's one dialogue.
• 22:54
  SPEAKER_00: Does it fit with their goals of care and what do you do in the acute setting, right?
• 22:58
  SPEAKER_00: Then there's a different dialogue when the person's been there a while and now you're trying to figure out.
• 23:04
  SPEAKER_00: I think as infectious disease doctors, though, we've all had these patients where the family just resists.
• 23:12
  SPEAKER_00: Everybody has seen the patient, and we've said this patient has been indubated for 10 months or on a trach or whatever, living in the hospital, unable to leave with one infection after the next.
• 23:26
  SPEAKER_00: That's where I think we struggle with, you know, what is the goal here?
• 23:31
  SPEAKER_00: I think at least my colleagues in palliative medicine struggle with those patients too.
• 23:36
  SPEAKER_00: I'm sure everyone has struggle because to us, that is not a life worth living.
• 23:43
  SPEAKER_01: That's not our life.
• 23:45
  SPEAKER_01: Right.
• 23:45
  SPEAKER_01: That's projection, right?
• 23:47
  SPEAKER_01: We as physicians are more terrified than anybody of disability, of cognitive impairment, of loss of the things that make us doctors.
• 23:56
  SPEAKER_01: And so we project that.
• 23:58
  SPEAKER_01: To some people and families, life in any form is better than death.
• 24:03
  SPEAKER_01: This is particularly true in trauma-informed care in populations that have been traumatized, who have known nothing but bias, racism, denial, exclusion.
• 24:17
  SPEAKER_01: In a situation where policy and law says that patients and families are allowed to make these decisions and we are obligated to follow them.
• 24:25
  SPEAKER_01: I think we just have to agree, okay, we're gonna find a vent facility.
• 24:30
  SPEAKER_01: And you know, when we find event facility three months from now, that's where your mom will go.
• 24:34
  SPEAKER_01: It's not like we're arguing with them that their goal is not valuable because we've kept this patient alive for 10 months.
• 24:42
  SPEAKER_01: We've proven that what we do works.
• 24:44
  SPEAKER_01: And to that family, that is valuable.
• 24:48
  SPEAKER_01: It's not our call, really.
• 24:51
  SPEAKER_01: And then I think we need to not have judgment, we need to accept it, we need to honor their love for one another, realize the trauma they're going through, and do what we can within the constraints of the system to honor those wishes without getting tied into a knot about it, because we are not the patient.
• 25:10
  SPEAKER_00: I think that's the struggle though.
• 25:12
  SPEAKER_00: The struggle is do we say this would really not be recommended?
• 25:18
  SPEAKER_00: We would not recommend antibiotics in this situation, as you were suggesting before.
• 25:24
  SPEAKER_00: I think where we usually get caught is where the family is saying, of course we're going to give antibiotics.
• 25:32
  SPEAKER_00: We recognize it's a really resistant bug and it can only be given IV, and there's only one amino glycoside left that's going to treat this resistant bug, but of course we're treating it.
• 25:45
  SPEAKER_00: That's the situation where it's a challenge.
• 25:49
  SPEAKER_01: Yeah.
• 25:49
  SPEAKER_01: So we are not empowered to make futility decisions under the law in this country.
• 25:55
  SPEAKER_01: As I'm sure you are aware of during the crisis standards of care debate early in the COVID pandemic, even deciding who could and who could not get a ventilator, no state would approve a crisis standard of care because it is so controversial and there was so much fear on the part of marginalized and disabled populations that certain people would be more futile than others.
• 26:20
  SPEAKER_01: You know, frankly, they're right to be concerned.
• 26:23
  SPEAKER_01: All the evidence says they're right to be concerned.
• 26:25
  SPEAKER_01: Our history proves that.
• 26:27
  SPEAKER_01: Yes, exactly.
• 26:29
  SPEAKER_01: At some point, we are going to run out of money soon as a healthcare system and as a society.
• 26:36
  SPEAKER_01: It remains to be seen how we will be supported to work under conditions of true scarcity, which are coming.
• 26:43
  SPEAKER_01: And what I worry about is it will be like it is in other parts of the globe where those with money get care and those without don't.
• 26:50
  SPEAKER_01: And we saw a lot of that during the pandemic, sing home abandonment, rural hospital abandonment, public hospital abandonment.
• 26:58
  SPEAKER_01: I think we are already have a dress rehearsal for which way our society is going to go when the money for public supportive health care runs out.
• 27:06
  SPEAKER_01: And all we can do is advocate for our patients as best we can within those constraints and vote and work on policy.
• 27:16
  SPEAKER_00: We've got our job cut out for us.
• 27:18
  SPEAKER_00: Well, Dr.
• 27:19
  SPEAKER_00: Meyer, thank you so much for joining us today and sharing our perspectives and experiences.
• 27:25
  SPEAKER_00: A special thank you from me and from Shay and to all the healthcare personnel.
• 27:30
  SPEAKER_00: Thank you for all you've been doing for responding to the COVID-19 pandemic.
• 27:34
  SPEAKER_00: This podcast can be accessed on Shay's Online Education Center under the Rapid Response Program.
• 27:42
  SPEAKER_00: Thank you again for participating as part of CAPSE and a special thank you from Shay.
• 27:49
  SPEAKER_00: This concludes our episode of the Allies and Infection Prevention podcast series.
• 27:54
  SPEAKER_00: Thanks for tuning in.