Selected Podcast
Care for the Critically Ill
Vice President of Medical Affairs and Chief Medical Officer at Dignity Health, Scott Neeley, MD, discusses caring for critically ill patients and Dignity's new 24-hour intensivist program.
Featured Speaker:
Scott Neeley, MD
Scott Neeley, M.D., is Vice President of Medical Affairs (VPMA). Dr. Neeley works closely with the medical staff to advance clinical and patient safety strategies. He serves as St. Joseph's liaison to the medical staff, and is responsible for oversight of the facilities medical directors and medical staff office. Transcription:
Care for the Critically Ill
Bill Klaproth (Host): It is estimated that 80% of all Americans will experience critical care services as a patient, family member, or friend of a patient during their lifetime. Here to talk with us about care for the critically ill is Dr. Scott Neeley, Vice President and Chief Medical Officer at Dignity Health, Saint Joseph’s Medical Center, in Stockton California. Dr. Neeley is also a Board Certified Pulmonary and Critical Care Physician and is himself, an Intensivist. Dr. Neeley, thank you so much for you time today. Let’s jump right in to this. When it comes to critical ill patients, can you tell us about your new, 24-hour intensivist program, which is the only one of its kind in the area?
Dr. Scott Neeley (Guest): Sure, I’d be happy to. We are really ecstatic to be able to offer these kinds of services to the people who live in San Joaquin County. A 24/7 Intensivist program essentially means that we have one or more Board Certified Intensivists — people who have trained in Critical Care Medicine — working in-house in the hospital 24-hours-a-day. We have four Intensive Care Units here at Saint Joseph’s Medical Center, with a total of 39 critical care beds, in addition to our Post-Anesthesia Recovery Unit and Emergency Department, which also are often thought of as critical care beds.
We have a very busy hospital with a very acute patient population. We have a lot of serious illnesses here, and we take care of some very sick people. Implementing this intensivist program really enhances our capacity to deliver exceptional care to these people no matter what time of day a problem occurs. We have two Intensivists present in the hospital during the day time, and one Intensivist here all night. This group of physicians works as a team. They actively hand-off problems from one physician to the next physician as they come in. They’re able to number one, take care of emergencies immediately when they occur, and number two, provide very good, continuous care to our most ill patients here in the hospital. Day or night, they’re in-house and able to deal with issues as they come up.
Bill: Dr. Neeley, an Intensivist is someone who is trained in critical care. How does an Intensivist-led ICU differ from a traditional ICU?
Dr. Neeley: Well, the type of staffing seen in Intensive Care Units across the country runs the gamut — runs the spectrum. Very traditionally, community hospitals at times did not have Board Certified or formally trained Intensivists responsible for all the patients in the ICU. Traditionally, physicians with many different types of training would care for their own patients in the ICU. The advantage of that is having your own doctor take care of you — the continuity of care that that entails. The disadvantage of that is the physician is not in-house all the time, and that physician may not be specifically trained to handle certain types of critical conditions or emergencies. Having the Intensivist available significantly improves the quality of care and consistency of care delivered in the Intensive Care Unit.
Bill: That brings up a question. How does the Intensivist work in collaboration with other healthcare professionals and potentially, the patient’s family care physician?
Dr. Neeley: Great question. And again, there are a fairly wide spectrum of solutions or answers to that question. Some ICUs actually function on what’s called a closed model. When the patient goes to the Intensive Care Unit, the Intensivist actually becomes the attending physician for that patient, and the attending would then collaborate with other sub-specialists as needed, to provide care during the patients’ ICU stay and then transfer the care of the patient to the care of another physician when the patient leaves the ICU. There are some advantages to that system. There are some disadvantages as well.
We run what you would call a hybrid model. In our Intensivist program at our site, the primary care physician continues to be the primary care physician of record when a patient goes to our ICU, but the terminology we use is co-management. We consider the patient who is in one of our ICUs be co-managed by the Intensivist with the degree of involvement by the Intensivist determined in a collaborative way between the primary care physician and the critical care specialist.
Bill: That’s very interesting, Dr. Neeley, how all of that works. And since we’re talking about critical care, for those patients with a chronic or serious illness can you talk about your palliative care program?
Dr. Neeley: Certainly, I’d be happy to. We have an inpatient palliative care service here at Saint Joe’s. We’re very fortunate to have a physician who has a great deal of experience in caring for patients who are very complicated, extremely ill, perhaps, in some instances who may be in an active state of dying. He’s a great communicator as well as a very skilled and compassionate physician. He works with two palliative care nurse specialists who assist him in checking on the patients, assessing their needs, having conversations with the patients’ families and primary care services. These providers work in a consultative manner, so if a physician has a patient who is extremely ill, who they are concerned may have a very poor prognosis, who they are concerned may not have a really appropriate plan of care, particularly one that may assist them in getting them out of the hospital, they will consult our palliative care providers to have a conversation with the patient and the family about appropriate goals of care and what we can do to actually achieve those goals.
Bill: Let’s talk about that conversation a little bit more. In a palliative care situation — this is a difficult time for many families, when a loved one is facing this, and requires a sensitive talk with family members about their intentions to care for their loved one versus what they might actually be doing in prolonging futile care — how do you manage that delicate conversation?
Dr. Neeley: Again, terrific question. The real answer to that is a very long one. In my view at least, I’ve been working in the palliative care field for over ten years and actually ran a palliative care program in my Intensive Care Unit in a prior role. I think that there are a number of key elements in that conversation. It certainly helps for the person who is facilitating the conversation to not only have a tremendous amount of clinical expertise, but to also have a great deal of compassion and insight about people, and also to be an effective communicator because oftentimes, people are in an emotional state during these times that impede their ability to both think clearly about what effective goals for a person might be, and also, how to get to those goals.
I think that number one, being able to listen and to gain insight into what the patient wanted for their life, how they would want to be cared for under these circumstances, what kind of goals do they have, things that they might want to accomplish with the rest of their life — just being able to listen and get to know what was important to that person is a great starting place. After going to where they are and listening to what’s important to them, being able to honestly talk about the medical problem, to be able to honestly talk about the prognosis, and to also be able to talk about what the burdens of care might actually look like if the person continues, for example, to receive aggressive life-sustaining treatment — for example, if a patient tells you “What I’d really like is to go home,” that goal is not compatible in some instances with the type of treatment necessary to prolong life, such as mechanical ventilation, which is using a machine to support breathing. In some cases, dialysis; in some cases, complex medical treatment that can only be given in an inpatient setting. Lining up the person’s goals — what’s important to them — with a treatment plan that actually makes sense, is a really important part of that conversation.
And then, being able to explain what the burdens to that care might look like. When you talk about futile care, that’s a very broad generalization, but what does it mean — for example, to a seriously ill patient who is really not going to be able to return to what most of us would view as a functional life — to spend the rest of their life in a bed in a medical facility, perhaps with a tracheostomy, being supported by mechanical ventilation? What does that feel like? What does that look like? What are the discomforts and the risks inherent in that type of care? What happens to people who receive that type of care during the end of their life? Being able to explain those things in plain language that really makes sense to people is an important part of the conversation.
Bill: So, there’s a lot of information that goes into that conversation. I think you touched on it though. Compassion is really so important when you’re in those situations, and then listening to the family about the goals, and then talking about the different care options. I think that’s really important, but I love how you said that compassion is the first thing that you have to deal with in those very delicate conversations.
Dr. Neeley, thank you so much for you time today and talking with us about the Intensivist program and palliative care. For more information, please visit SaintJosephsCares.org, that’s SaintJosephsCares.org. This is Hello Healthy, a Dignity Health Podcast. I’m Bill Klaproth. Thanks for listening.
Care for the Critically Ill
Bill Klaproth (Host): It is estimated that 80% of all Americans will experience critical care services as a patient, family member, or friend of a patient during their lifetime. Here to talk with us about care for the critically ill is Dr. Scott Neeley, Vice President and Chief Medical Officer at Dignity Health, Saint Joseph’s Medical Center, in Stockton California. Dr. Neeley is also a Board Certified Pulmonary and Critical Care Physician and is himself, an Intensivist. Dr. Neeley, thank you so much for you time today. Let’s jump right in to this. When it comes to critical ill patients, can you tell us about your new, 24-hour intensivist program, which is the only one of its kind in the area?
Dr. Scott Neeley (Guest): Sure, I’d be happy to. We are really ecstatic to be able to offer these kinds of services to the people who live in San Joaquin County. A 24/7 Intensivist program essentially means that we have one or more Board Certified Intensivists — people who have trained in Critical Care Medicine — working in-house in the hospital 24-hours-a-day. We have four Intensive Care Units here at Saint Joseph’s Medical Center, with a total of 39 critical care beds, in addition to our Post-Anesthesia Recovery Unit and Emergency Department, which also are often thought of as critical care beds.
We have a very busy hospital with a very acute patient population. We have a lot of serious illnesses here, and we take care of some very sick people. Implementing this intensivist program really enhances our capacity to deliver exceptional care to these people no matter what time of day a problem occurs. We have two Intensivists present in the hospital during the day time, and one Intensivist here all night. This group of physicians works as a team. They actively hand-off problems from one physician to the next physician as they come in. They’re able to number one, take care of emergencies immediately when they occur, and number two, provide very good, continuous care to our most ill patients here in the hospital. Day or night, they’re in-house and able to deal with issues as they come up.
Bill: Dr. Neeley, an Intensivist is someone who is trained in critical care. How does an Intensivist-led ICU differ from a traditional ICU?
Dr. Neeley: Well, the type of staffing seen in Intensive Care Units across the country runs the gamut — runs the spectrum. Very traditionally, community hospitals at times did not have Board Certified or formally trained Intensivists responsible for all the patients in the ICU. Traditionally, physicians with many different types of training would care for their own patients in the ICU. The advantage of that is having your own doctor take care of you — the continuity of care that that entails. The disadvantage of that is the physician is not in-house all the time, and that physician may not be specifically trained to handle certain types of critical conditions or emergencies. Having the Intensivist available significantly improves the quality of care and consistency of care delivered in the Intensive Care Unit.
Bill: That brings up a question. How does the Intensivist work in collaboration with other healthcare professionals and potentially, the patient’s family care physician?
Dr. Neeley: Great question. And again, there are a fairly wide spectrum of solutions or answers to that question. Some ICUs actually function on what’s called a closed model. When the patient goes to the Intensive Care Unit, the Intensivist actually becomes the attending physician for that patient, and the attending would then collaborate with other sub-specialists as needed, to provide care during the patients’ ICU stay and then transfer the care of the patient to the care of another physician when the patient leaves the ICU. There are some advantages to that system. There are some disadvantages as well.
We run what you would call a hybrid model. In our Intensivist program at our site, the primary care physician continues to be the primary care physician of record when a patient goes to our ICU, but the terminology we use is co-management. We consider the patient who is in one of our ICUs be co-managed by the Intensivist with the degree of involvement by the Intensivist determined in a collaborative way between the primary care physician and the critical care specialist.
Bill: That’s very interesting, Dr. Neeley, how all of that works. And since we’re talking about critical care, for those patients with a chronic or serious illness can you talk about your palliative care program?
Dr. Neeley: Certainly, I’d be happy to. We have an inpatient palliative care service here at Saint Joe’s. We’re very fortunate to have a physician who has a great deal of experience in caring for patients who are very complicated, extremely ill, perhaps, in some instances who may be in an active state of dying. He’s a great communicator as well as a very skilled and compassionate physician. He works with two palliative care nurse specialists who assist him in checking on the patients, assessing their needs, having conversations with the patients’ families and primary care services. These providers work in a consultative manner, so if a physician has a patient who is extremely ill, who they are concerned may have a very poor prognosis, who they are concerned may not have a really appropriate plan of care, particularly one that may assist them in getting them out of the hospital, they will consult our palliative care providers to have a conversation with the patient and the family about appropriate goals of care and what we can do to actually achieve those goals.
Bill: Let’s talk about that conversation a little bit more. In a palliative care situation — this is a difficult time for many families, when a loved one is facing this, and requires a sensitive talk with family members about their intentions to care for their loved one versus what they might actually be doing in prolonging futile care — how do you manage that delicate conversation?
Dr. Neeley: Again, terrific question. The real answer to that is a very long one. In my view at least, I’ve been working in the palliative care field for over ten years and actually ran a palliative care program in my Intensive Care Unit in a prior role. I think that there are a number of key elements in that conversation. It certainly helps for the person who is facilitating the conversation to not only have a tremendous amount of clinical expertise, but to also have a great deal of compassion and insight about people, and also to be an effective communicator because oftentimes, people are in an emotional state during these times that impede their ability to both think clearly about what effective goals for a person might be, and also, how to get to those goals.
I think that number one, being able to listen and to gain insight into what the patient wanted for their life, how they would want to be cared for under these circumstances, what kind of goals do they have, things that they might want to accomplish with the rest of their life — just being able to listen and get to know what was important to that person is a great starting place. After going to where they are and listening to what’s important to them, being able to honestly talk about the medical problem, to be able to honestly talk about the prognosis, and to also be able to talk about what the burdens of care might actually look like if the person continues, for example, to receive aggressive life-sustaining treatment — for example, if a patient tells you “What I’d really like is to go home,” that goal is not compatible in some instances with the type of treatment necessary to prolong life, such as mechanical ventilation, which is using a machine to support breathing. In some cases, dialysis; in some cases, complex medical treatment that can only be given in an inpatient setting. Lining up the person’s goals — what’s important to them — with a treatment plan that actually makes sense, is a really important part of that conversation.
And then, being able to explain what the burdens to that care might look like. When you talk about futile care, that’s a very broad generalization, but what does it mean — for example, to a seriously ill patient who is really not going to be able to return to what most of us would view as a functional life — to spend the rest of their life in a bed in a medical facility, perhaps with a tracheostomy, being supported by mechanical ventilation? What does that feel like? What does that look like? What are the discomforts and the risks inherent in that type of care? What happens to people who receive that type of care during the end of their life? Being able to explain those things in plain language that really makes sense to people is an important part of the conversation.
Bill: So, there’s a lot of information that goes into that conversation. I think you touched on it though. Compassion is really so important when you’re in those situations, and then listening to the family about the goals, and then talking about the different care options. I think that’s really important, but I love how you said that compassion is the first thing that you have to deal with in those very delicate conversations.
Dr. Neeley, thank you so much for you time today and talking with us about the Intensivist program and palliative care. For more information, please visit SaintJosephsCares.org, that’s SaintJosephsCares.org. This is Hello Healthy, a Dignity Health Podcast. I’m Bill Klaproth. Thanks for listening.