Kristofer Smith, MD, MPP is the Chief Medical Officer of Landmark Heath, where he oversees efforts to establish a high-quality and clinically effective home-based medical care model for patients with serious illness.
We sat down with Dr. Smith to discuss his experience caring for patients with serious illness and developing programs to provide health care at home, among other topics. The following interview has been edited and condensed. Read More
By Nikol Nesterenko, Jonathan Chernoguz, and Sarah Hooper
Advance care planning — the process by which an individual documents their wishes for health care in the event that they become incapacitated — has become particularly urgent during the COVID-19 pandemic.
However, individuals that wish to engage in advance care planning, and specifically to document their plans in a written form (i.e., advance directives), have faced significant hurdles due to legal execution requirements. State advance directive law often requires or presumes live, in-person witnessing or notarization, actions which were prohibited by social distancing orders or simply unsafe during the pandemic.
In this piece, we summarize the state of remote execution requirements for advance directives before and during the COVID-19 pandemic. Broadly speaking, while many states took some action in this regard, most did not enact comprehensive changes, and therefore failed to meaningfully facilitate remote execution of advance directives.
By Jess Ma
He passed away on the 107th day. After I got home in the evening, I wrote down everything I could remember about him in my journal. For many days after his death, I often dreamed I was standing in that fluorescently bright ICU room. In the dreams, I would be watching him, and then he would wake up and start speaking to me, with those bright blue eyes glittering with animation and life. I always awoke feeling a little unsettled, not by his death, but rather by the fact that I knew so intimately the ways in which he was kept alive, and yet nothing about the life he lived until just hours before his final breath.
He was an existing patient on the unit when I joined the surgical ICU team, and for 10 days I followed him, tracking how every organ system was doing each day. Everyone on the team knew there was only one way this would end; his quality of life had deteriorated so rapidly since the early summer, after a bout of necrotizing pancreatitis and multiple tragic complications; he was barely able to interact with his own body, much less his environment, and his life was propped up precariously by every possible machine that could perform the function of a vital organ. For him, no medical intervention would add more significant chapters to his story. It was just a matter of when his daughter would be ready to close the book.
Because of the pandemic, visitors were only allowed after 12pm each day. When his adult daughter came to visit each afternoon, I was told to avoid intruding on their cherished private time together. I only ever really saw her shadow behind the drawn curtain as I walked past the room; and I knew that one of the surgeons on the service (a group of surgeons rotated between trauma, acute care, and surgical ICU) would routinely give her calls or meet up with her to discuss how her father was doing, even on days he had off. Surgeons are not generally thought off as doctors who can spend a lot of time just talking to patients – after all, in the time he spent on one of those daily conversations, he could complete an appendectomy. Though neither he, nor the rest of the team, could offer a magic solution, what he offered was crucial – his time.
By John C. Messinger
On March 17, 2020, in the first days of the COVID-19 pandemic in the United States, the Association of American Medical Colleges (AAMC) released a statement strongly urging medical schools to pause all clinical rotations and patient-facing activities.
While there was a clear necessity to limit student participation as a means of reserving PPE and creating a safe environment for patients and health care providers, restricting medical students from clinical settings has drastically changed their education.
As a first-year medical student removed from training at the time of this announcement, my greatest fear has been that these changes will alter my approach to care for patients.
By Marian Grant
Those living with serious illness — a life-threatening or life-limiting illness, such as metastatic cancer, dementia, or heart failure — are at higher risk for complications from COVID-19.
Their increased vulnerability has posed additional challenges for the health workers who care for them.
By Samyukta Mullangi, Johnetta Blakeley, and Stephen Schleicher
The COVID-19 pandemic has brought many challenges to oncology care; an area of medicine that typically involves frequent, in-person patient visits to complete a course of treatment.
In many ways, COVID-19 has served as a stress test for the specialty, and has catalyzed adaptive changes that we hope will make the oncology care, and the health care system in general, more resilient going forward.
By Elizabeth Clayborne
I was a little less than six months pregnant when the COVID-19 pandemic hit in 2020. As an Emergency Physician, I am well aware of additional risks that my job often exposes me to on a daily basis. We frequently face physical and emotional strife from unstable psychiatric patients, critically ill nursing home residents, sexual assault victims, and newly diagnosed cancer patients.
People who work in an emergency department tend to understand what comes with the territory: a lot of hard work, unexpected outcomes, and daily traverses of the human experience, from the best emotions you can imagine, to lowest depths of human despair. This is what accompanies caring for every ailment for people from all walks of life. I actually love this part about my job! I never know what I’m going to see when I walk through the doors.
That said, being a frontline physician during COVID-19 has provided me with a profoundly different lens on the pressures surrounding health care workers. And experiencing this while pregnant was pretty terrifying.
Inequities in end-of-life care have been exacerbated by the COVID-19 pandemic, but have yet to receive the same level of attention as some other health disparities brought to the fore recently.
Quality end-of-life care is focused on reducing human suffering and aiding patients in receiving support during the dying process.
Traditionally, poor quality end-of-life care involves the overtreatment of patients, as in the case of continuing to treat incurable cancer aggressively. However, COVID-19 has introduced new challenges in achieving quality care at the end of life. Specifically, it is now more challenging to reduce human suffering at the end of life because of limitations in providing access to two critical resources: (1) medical care that can relieve physical suffering in the dying process and (2) support, such as loved ones, as well as needed psychological, spiritual, and physical support to cope with the existential threat of dying. COVID-19 has made access to both of these a greater challenge for underrepresented minorities.
By Stephanie Anderson and Carole Montgomery
A deep divide exists in the American health care system between patients’ values and the care they receive.
Let’s start with a story – Marcus was in his mid-40’s when he underwent high-risk heart surgery during which he suffered a brain injury. Afterward, the surgeons at first reassured his family that the surgery itself was successful (his heart was working fine) in spite of his brain injury.
Unfortunately, after many days in the ICU he remained unconscious and was not able to get off the ventilator. Specialists told the family that his brain injury was severe, and he would likely not be able to carry on a meaningful conversation or live independently ever again.
By Shoshana Ungerleider
It was the end of a 24 hour shift in the ICU when the 85-year-old woman I had just admitted with end stage heart failure began having trouble breathing. While I knew she did not desire “aggressive measures” taken to prolong her life, I wondered what that meant in the context of this moment. Even though I was a young medical resident, I knew without swift intervention, she would not be able to survive the night. I ran into the waiting room to search for her son, her medical decision maker, but he had gone home for the night.
I returned to the bedside to see that my patient was tiring as her breathing was becoming shallow and fast. She was awake and I sat down to explain why she was feeling breathless. I explained that her condition had rapidly worsened and asked if she had ever considered a scenario where she may need a breathing tube. She had not. As her oxygen levels dropped, it quickly became clear that we had to act. What wasn’t clear to me was whether this frail woman would actually survive this hospital stay, and if she truly understood what intubation and mechanical ventilation were and whether this would cause her to suffer.