Associate Medical Director and Internist, CareMount Medical 

Caroline DeFilippo, MD, MPH, FACP

 One of the effects of social isolation resulting from pandemic response protocols that has caused great concern is the potential for exacerbation of mental health issues, particularly the risk of self-harm and suicide in at-risk populations.

Thankfully, two recent papers published in JAMA Open in the last few weeks of January indicate that these fears may have not come to fruition.

Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic in the US

", John W. Ayers et. al. replicated the methods of a previous cross-sectional study to examine Google search rates per 10 million searches for the term 'suicide'. The authors found that these searches deceased during the early stages of the pandemic, between March and July of 2020.

Though counter to their expectations, the authors report that their findings are supported by extant literature. They also suggest that the search rates may change and even increase, warranting continued monitoring.

In a second paper published in January, "

Suicide Deaths During COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020

" Jeremy Samuel Faust, MD, MS, et. al., assembled suicide death data for persons aged 10 years and older form the Massachusetts Department of Health Registry of Vital Records and Statistics from January 2015 to May 2020. Here, suicide deaths remained at levels previous recorded in recent years, indicating that the early pandemic did not necessarily have a resultant increase on suicide.

However, the authors note that as the pandemic continues, these rates may change, especially as more cases are completed by a medical examiner.

, though we won't be discussing the pandemic's effects on suicide rates, you will hear from Dr. Anisha Abraham, author of the book "Raising Global Teens: A Practical Handbook for Parenting in the 21st Century," about addressing suicide risks in your patients.

Though her book focuses on parenting in general, her insights into addressing suicide risks in pediatric and adult patients remain crucial for all caregivers treating these populations.

In stark contrast to the studies mentioned earlier, the CDC still holds that death by suicide is the second leading cause of death among adolescents between 10 and 24 years of age. The prevalence of suicidal tendencies among teens presents an interesting conundrum for physicians who want to help prevent the worst possible outcome: how and when can you intervene, and what does care look like when one of your patients presents suicidal warning signs?

 Well, there are a number of warning signs that providers need to be thinking about when they're working with young people that can include: someone talking about death, or writing about death, feeling increasingly depressed or anxious. Other signs might be feeling increasingly irritable, having a change in sleeping or eating patterns, and giving away their belongings. These are all things that providers should be aware of when they're working with young people.

 Beyond these behavioral warning signs, Dr. Abraham says that there are also common physical signs and risk factors for physicians to watch out for.

 Other physical facts that I think are really important to look out for are, if there are signs when or certainly in the interview, that they're not giving you good eye contact, if they clearly seem that they're withdrawn, if there are any recent changes in terms of what's happening in their own home environment or in terms of their own physical health.

There are certainly a number of risk factors that we need to consider as well. Young people that have had a history of suicide in the past are at an increased risk for having a suicidal ideation in the future. And many times, people that have actually attempted suicide have come in to see a health provider in the last six months to a year. So being aware of that I think is really important.

Certainly, other risk factors include having a history of depression or anxiety; having a family History of suicide also increases their likelihood. Use of alcohol or drugs or an increasing use of alcohol or drugs puts younger people at higher risk as well. What we do know is if there's been any history of bullying, or particularly cyber bullying, there's been a higher risk of suicide. If young people identify as being LGBTQ—they could also be at increased risk. There's a host of different issues that we as providers need to be aware of.

 If you suspect that one of your patients might be at risk of suicidal tendencies, Dr. Abraham suggestions asking very direct questions when your patient comes in for an appointment.

 I would certainly say that if you are concerned about a patient that might be suicidal, asking very specifically about how they're feeling, have there been any issues in terms of depression, and have there been times that they felt sad or down or life was not worth living, asking about other self-harm related issues as well. So certainly, has there been any history of them trying to cut before—we certainly know that that might increase your likelihood of suicidal ideations as well.

I just want to reiterate that by specifically asking, you're more likely to get information, not to put them at higher risk for suicide, but getting direct information and providing the opportunity to get them support. The questionnaire that I would recommend using and certainly in our academy of pediatrics also encourages the use of questionnaires, would be one called the patient health questionnaire nine, which is a validated survey, but there are many validated surveys that, again, providers can use in their clinical setting.

But in addition to that, asking very specific questions about depression and suicide are also very helpful. Those questions will include things like have you been feeling down or sad or depressed? Have you felt that life was not worth living? Do you have a specific plan? And is there a way that you would act on this? These are all questions I think are very important to consider. If you are concerned about a patient being depressed or suicidal.

 Once you have identified that r patient may be suicidal, the next step, Dr. Abraham says, is to get psychiatrists or psychologists involved.

: I believe it's very important for physicians to ensure that they get a psychiatrist or a psychologist involved as soon as possible.

If a patient is actively suicidal, then certainly making sure they go into the nearest emergency room or they are screened by a psychiatrist would be very important. If they are not actively suicidal, that certainly have some ideations there are some risks in terms of them being suicidal in the future. Certainly, assessing whether or not there may be any way for them to act on it. Also, ensuring that there are not any firearms or other methods in which they could actually attempt suicide, giving an information about suicide hotlines, and ensuring that they will be able to see a provider counselor as soon as possible are all very important.

It's challenging in a clinical setting, but I think it's again, very important to make sure you have a good connection with mental health providers and providing those referrals as quickly as possible.

Jeremy Samuel Faust, M. (2021, January 21). Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts. Retrieved January 21, 2021, from 

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775359?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=012121

John W. Ayers, P. (2021, January 21). Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic. Retrieved January 21, 2021, from 

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775358?resultClick=3

Podcasts

Physicians Practice® spoke with Dr. Anisha Abraham, author of the book "Raising Global Teens: A Practical Handbook for Parenting in the 21st Century", about signs that a patient may be at risk of suicide and self-harm as well as interventions and communication methods physicians can employ in the clinical setting.

Addressing patient suicide risks in your practice

 One of the most important conversations that a provider can have with a patient regards end-of-life plans. As you'll hear from today's guest, Dr. Caroline DeFilippo, most providers—most people in general—are reasonably not prepared for these conversations.

To begin to have more effective end-of-life conversations, it will help to have a better understanding of how these conversations differ form those you routinely have with patients.

 So I think the big differences with end of life conversations are that they're not necessarily a conversation where the physician is in the driver's seat in terms of prescribing or sharing information about a patient's illness, as much as it's actually the opposite. In that the physician is asking guiding questions, and trying to understand how the patient feels learning about his or her wishes. But really, we're doing more of the listening than the talking. And that's a big shift for us, physicians and providers who are used to a very fast paced and sort of having a certain amount of control and rhythm to how those visits go. And that's one of the many things that makes these conversations hard to do and a natural barrier for us to wanting to start them.

 Though most may be unfamiliar or even uncomfortable with such conversations, Dr. DeFilippo says these conversations are some of her most rewarding.

 I think what's really different, unlike the traditional medicine, we're talking about in terms of us prescribing how to manage an illness or treat hypertension, or a broken bone, for example, is that we're learning from the patients. And it's some of the most challenging circumstances you could ever be faced with in terms of the patients are scared, they're vulnerable, they're nearing the end of their lives. And here you are serving as a guide, and a partner with them. And if I think about why most people I know who are in medicine chose to go into medicine, it was to be there to help patients. And this is one of the most tangible ways in which you can feel that you're helping a patient, it's the most satisfying, raw exposure of emotions. And I would argue in many ways, so obviously, we're doing this for the patient's benefit, but it also is for the providers benefit. It, you know, renews our faith and why we do our jobs, it restores sort of that heart of medicine and the art, both the heart and art of medicine, which many times can feel a little bit lost in the day to day grind, that we're often practicing with it.

: So now that you know how these conversations differ, what exactly does end-of-life planning look like?

 End-of-life planning can take on many, many different definitions. And I think that's one of the key things I want to bring up today. It's not just about shelling out a health care proxy, it's not about completing a Do Not Resuscitate order. I think a bit more broadly, it's about planning for what's ahead. And it may include many different things. It's an umbrella of options. So it's first introducing the concept to the patient and meeting them where they are, and then navigating with them over the course of ideally, many conversations over many years with them the various needs that they will have. And so it may just be saying, you know, as you're getting older, you're a very high functioning older individual. But we know at some point, you may not be able to meet your care needs, living independently as you aren't, for example, 95 years old, let's talk about what that might look like what options we have in place for you. Or God forbid, you did have a fall on you needed to be in a hospital for a period of time, how would we manage that? So sometimes it's this very hypothetical, 'what if' conversation, and other times it's incredibly grounded with we know you have a diagnosis, and we know there's a timeframe of progression. And we know these are issues that are going to arise such as frequent rehospitalizations. For a patient with advanced lung disease, let's talk about what would be the reason she would feel comfortable going to the hospital. And when there might be situations where you'd say, I no longer wish to go to the hospital. But unless we really present the patient with very specific scenarios, I think it's hard for most people to bring that up on their own. That's not a natural proclivity, we have to say, let's talk about my mortality and talk about how that might look and feel no, people aren't raising their hand begging to talk about it. So we as the physicians owe it to the patients to say, we've seen this enough times to know how this might go. And I want to have a plan. In case it goes this way. And I want to have a plan in case it goes the other way.

: The best time to starting engaging with end-of-life conversations with patients, Dr. DeFilippo says is early! Early, early, early...

 Early, early, early. I can't say that enough. I was just reading an article where someone was actually sort of lamenting this move towards primary palliative care and saying, "Are we supposed to start talking to people at birth about their end of life plan?" No. Okay. So when I say early, I don't mean that early. But what I mean is the earlier the better. So we've got 90 million Americans living with some sort of chronic serious illness. Every one of those 90 million Americans should be having some conversation about what might be coming. So even if it's that they have diabetes, that's been difficult to control. We know that leads to complications and some of those complications can really shorten their lifespan. That's the time to just start talking about that. And what are your thoughts? How do you feel? What are your supports? Do you have any documents in place? Do you want to learn about them? You don't want to start these conversations after the crisis has occurred. And unfortunately, that's the way we tend to structure this in our healthcare system. We wait till they're in the hospital, we wait till the critical event has occurred. And suddenly someone, oftentimes the patient, says, "This is not what I want, how did I get here? How did we go from treatment to treatment to treatment, and I don't want this for my life." And I will tell you, it's a very hard ball, if you will, if you're thinking about this as a momentum with a rolling ball, it's a hardball to stop. So once you've kind of committed to a certain treatment course, it can be very difficult to back off and say, "Actually, that's not really what I want at this time."  It almost takes more work to stop it, once it started. So I would argue the earlier you start at least introducing the idea gently probing inquiring making it a safe space to talk about these concepts, the better you and your patients are served. So as events occur, you can put them into the right context based on what the patient has shared with you.

: Up next, Dr. DeFilippo shares some personal examples of end-of-life conversations and planning she has engaged in with a couple of her patients.

 Absolutely, yeah. So pre COVID, we had actually started an initiative at CareMount, where I work in trying to get patients to chat more about their end of life wishes long before a crisis had occurred. And through our trainings, we had a series of guided questionnaires, we would take our patients through just understanding what their wishes and their goals are. 

One patient comes to mind who was an older gentleman who had multiple medical problems, but nothing urgent or pressing. But he had clearly expressed that should he become ill he did not want any advanced medical therapies applied to them, it was really important to him that he died in peace with his family without machines and interventions. The COVID pandemic arrived a couple of weeks later, in our area in New York, and unfortunately, this patient became ill with COVID. And he found himself in the hospital, in a situation where mechanical ventilation was being offered to him. And both he and his wife were able to draw on this conversation that had occurred in an outpatient setting during a calm, non crisis moment to say this is not consistent with his wishes. And it was difficult for the family members who were not present during that conversation to understand how he came to that conclusion, why it was reached. And their feeling was, of course, we'll do more and we want to, you know, give him as much as we can. But it was because they had that conversation that they can draw on this and had clarity to say, No, the easy thing sometimes is to do more and to keep escalating care. And it often is harder to stop and just maintain care or de-escalate, even if that's so clearly what the patient wanted. So you know, that conversation really resonated with our care team to say, you got to talk before the crisis arrives. And it sometimes makes it much easier to manage the crisis. 

The second example that comes to mind is actually shows the other side of it. And this was another older gentleman, this gentleman in his late 90s, who was living independently until he had a hip fracture. And he wound up in a rehab facility with a variety of complications that occurred and basically wasn't doing well. And the family was torn with quesitons like  "What do we do? Do we push them back to do more? Do we give him a transfusion? Do we treat his infection?" And ultimately, with a lot of challenging discussions, they wound up bringing the patient home, very happy, who died peacefully a couple of days later. 

In hindsight, the family realized the patient had always been trying to tell them that he didn't want to do anymore. But he didn't feel he had the voice. He didn't want to let them down. He didn't want to disappoint them by saying I'm ready. And if only they could have had those conversations in that non emergent situation, they might have been able to avoid some of those challenging moments that occurred in those last few weeks of his life. And so I think, you know, both of these highlight sort of expected outcomes, things that you say you knew this was going to be hard on the patient hard on the family. But the difference of having had a conversation up front, and having shared it with multiple family members, really changes the trajectory of end of life care for people in a very dramatic way.

: If you're looking to gain more preparatory experience with end-of-life conversations, Dr. DeFilippo shares where to look for resources.

 Yeah, so there are a bunch of resources that are available to support physicians. The first thing I'm going to say though, is this is a skill. Like any other skill we were trained in, in medical school and residency, we need to look at this as a tool we can practice we can get better at. So for some people, this is a tool that's very easy and natural, and they don't need that much help with it; but for others, it can be quite challenging. And so I think the key here is for all of us, regardless of our natural proclivity to seek more engagement, think of it as a CME opportunity. It may be that you go to a variety of websites of which the Center for Advancement of Palliative Care has a number of different resources online, there are many, many podcasts available out there. And you can look at this from a variety of different angles. 

So you can think about this as how do I improve my communication skills? So how do I become more comfortable just with talking about this, you can look at this from what are the local documents and legal restrictions ramifications that are available in my region? So I should know what forms to complete and you're talking more to social workers or case managers to help you. 

Or you could look at this from a symptom management perspective and say, I actually want to become more competent with managing end of life pain, or end of life comfort, and I want to make sure I have the skills to do that. Each one of those domains is a skill set in and of itself. And each one of those domains has many, many resources available. 

So I think the first step here is just acknowledging what it is you want to learn more about, and then investing in those resources that are out there. Some of these are free, some of them are quite small amounts of fees. But what you will find is there's an abundance of information there. A lot of the palliative care providers that exist in the community are aware of the fact that they can only meet the needs of a certain small segment of our population. So I mentioned that 90 million patients, that's going to double in the next 25 years as our baby boomers age. So we know we're looking at 100 and 80 million patients who are going to have palliative needs over the next 25 years. There's no way we have enough providers to meet those needs. So we all need to develop more skills to be able to support them better.

This week on Perspectives, Dr. Caroline DeFilippo, MD, MPH, FACP of CareMount Medical in New York, explains how physicians can grow more comfortable with these conversations and when they should consider having them with their patients.

How physicians can prepare for end of-life conversations with patients

End-of-life conversations include some of the most valuable advice physicians can deliver to patients, yet many physicians still lack comfort and experience with these interactions.

In my own experience as a practicing internist, I have found end-of-life conversations with patients to be one of the most satisfying aspects of my career because they make me feel I’m making a difference in a person’s life. These experiences have also convinced me that, across our profession, we must prioritize and improve our ability to communicate with patients about end-of-life issues, especially as the so-called “

 aging Americans continues to affect the U.S. healthcare system.

The COVID-19 pandemic has brought our collective failure around end-of-life care into sharper focus, as thousands of Americans died in nursing homes or hospitals, unable to spend their last days in the company of loved ones. While some of those who died in hospitals and nursing homes likely were following their end-of-life wishes, it’s a virtual certainty that many more were not. Surveys repeatedly show that the vast majority of Americans prefer to die at home – 71% according to a 2016 

 survey and just 9% in the hospital. Unfortunately, many of those who died from COVID-19 in hospitals might have had the chance to die at home if they had engaged in end-of-life planning with their doctors prior to the pandemic.

Whether due to a lack of training, or cultural and spiritual beliefs, many physicians simply are not comfortable discussing end-of-life planning with patients, resulting in something I liken to a giant game of “hot potato.” Because no one steps up to take responsibility and initiate the process with the patient, the conversation often gets pushed aside and left for someone else until the patient has undergone a medical crisis, which may be too late. By then, a patient may have received treatment they may not have wanted and/or died in a manner and place they would not have chosen.

Balancing medical industry work with a healthy private life

It doesn’t need to be this way. With a little training and preparation, physicians can develop the skills to conduct end-of-life conversations in the same way they learn to take patient histories or perform a physical examination. Here’s some recommendations for how to get started.

To begin educating themselves on end-of-life planning, physicians need little more than access to a web browser. A surplus of materials from training modules, checklists and support documents are available online to help doctors develop familiarity with basic processes and concepts. 

American Academy of Hospice and Palliative Medicine

 are just a few of the many national organizations that offer training and resources. A physician should start familiarizing herself or himself with their state’s paperwork and legal forms, such as Do Not Resuscitate orders, and begin asking patients whether they are aware of their end-of-life options.

To demystify the process and make it seem more manageable to patients, it’s important to view end-of-life conversations not as one-time events but as a series of ongoing discussions. The more comfortable physicians are with these conversations, the more patients will feel at ease. The best approach is to include end-of-life conversations in usual wellness visits, which will encourage patients to view the discussion as a status check. Ask them how they’re feeling and if anything has changed, then move the conversation into the territory of legal documents and end-of-life options. Treating end-of-life discussions as ongoing events enable physicians to devote more time to these conversations; it is also emotionally easier on patients because they are allowed to deal with the process gradually without feeling forced to make quick decisions during a medical crisis.

Don’t undersell yourself or the services you provide. End-of-life discussions are heavy, emotional conversations that require time and care. Familiarize yourself with the relevant billing codes and use them when appropriate. For patients who are homebound or lack reliable transportation, telehealth is a great option for end-of-life discussions. Rather than hosting patients in a sterile, unfamiliar office environment where they may feel vulnerable, let them remain in the comfort of their own homes sitting next to a loved one in their favorite chair with their favorite blanket to ease anxiety around difficult conversations.

Physicians generally feel that we need to know all the background, history and details of a patient’s illness to provide proper counsel and avoid mistakes. For end-of-life planning, though, doctors should adjust their mentality. In more dire situations, we don’t need to know all the background details – we just need to ask patients how they feel and what’s important to them. Let patients know that you’re worried, and because their condition may worsen or time may be limited, the end-of-life discussion needs to happen as soon as they are ready.

No one expects all physicians to become palliative care experts and attempt to organize the entire end-of-life-planning process by themselves. Take a collaborative, comprehensive approach and partner with support staff, social workers, nurses, care coordinators and others. At a minimum, it’s important to have contacts with local hospice and palliative care providers to know where to refer patients. A wider support system exists; it’s just up to physicians to tap into it.

It is important to acknowledge that end-of-life conversations aren’t much easier for physicians than patients, and that feelings of discomfort are acceptable and to-be-expected, especially in the beginning. Nonetheless, physicians should view end-of-life planning as a shared responsibility, regardless of individual specialties or areas of practice. Doing so will make us better doctors and help our patients overcome some of their deepest fears. Our job is to simply start the conversation.

End-of-Life Conversations: How these differ from your other, routine conversations 

Why End-of-Life conversations can be the most satisfying for physicians

What end-of-life planning looks like

The best time to have end-of-life conversations with patients

End-of-life Conversations: What works and what doesn’t

Resources available to gain comfort and confidence with end-of-life conversations

Videos

We must prioritize and improve our ability to discuss end-of-life issues with patients, especially as America’s aging population continues to increase and affect the healthcare system. 

Caroline DeFilippo, MD, MPH, FACP

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