Scott Webb (Host): Palliative care is perhaps most commonly associated with cancer patients, but palliative care is also available to cardiac patients as well. And here today to tell us more about cardiopalliative care is Dr. Alicia Topoll. She's a Board Certified Cardiologist at Franciscan Health, subspecializing in hospice and palliative medicine.

 This is the Franciscan Health Doc Pod. I'm Scott Webb.

Doctor, it's nice to have you here today. We're essentially going to talk about cardiology and palliative medicine and what that means and how those two things go together at Franciscan Health. So let's start there. What is cardiopalliative care?

Alicia Topoll, MD, MS: So I think that's a great question, but first I think it's actually helpful to discuss what is palliative care in general. Because not a lot of people have a great understanding of what is palliative care. I look at palliative care as supportive care, and it's for people who are facing serious illness.

Oftentimes I think we think about palliative care in people facing things like cancer, but it really extends to people facing any kind of serious or life limiting illness. Things like heart failure or severe coronary artery disease, lots of chronic illnesses, even like advancing kidney disease, COPD, neurologic disorders.

So palliative care can extend to many different things, cancer care and chronic illness. Cardiology palliative care, I think, is really specifies the needs of people who are undergoing treatment and evaluation for things like heart failure, valvular disease, and other advanced cardiac diagnoses.

We try and really focus on what the disease is, how it affects people's lives. Symptoms that we can manage and having really good conversations about what it means for the people and their life as they kind of journey through these diagnoses. I think one of the other benefits about palliative care is it also involves a multidisciplinary team.

So people like physical therapists, mental health professionals, chaplains, social workers, who can also address a lot of the symptoms and a lot of the other aspects of a disease. I usually use heart failure as one of the most common things that I see and also talk about because so many people actually have heart failure.

And it comes with a lot of different symptoms. People might notice fatigue or pain. They might have nausea, shortness of breath, anxiety, low mood. And so using a multidisciplinary team with palliative care, we can really address a lot of the different symptoms that affect people and also their families as they venture through this diagnosis.

I also think, in cardiopalliative care, you're able to dive a little bit deeper about what it means to live with these conditions, because people can live with things like heart failure for many, many years, and how do we help them live well? We can talk about expectations, from what this disease means for both the patients and their families.

 And we can also talk about different things like advanced care planning, which a lot of people really want to talk about, but often don't talk about with their family because sometimes it feels a little bit uncomfortable. One of the other benefits of having someone who's specialized in both cardiology and palliative care, whenever there are some tough decisions to make, or if someone's critically ill or seriously ill in the hospital, then we can have those conversations, especially if we know the patient, and make sure that we're providing good care that's consistent with what the patients and the families would want.

Host: Yeah. And you mentioned there, the multidisciplinary approach. I know that's so hot in medicine these days, you know, teams of experts working together, trying to help folks to live with, as you say, and manage in this case, heart disease, heart issues. So who might benefit from this type of care and at what point in their treatment should it be considered?

Alicia Topoll, MD, MS: So anyone with a serious illness, or if they have an advancing cardiac diagnosis, say they've not been feeling well, or their symptoms are, have been really hard to manage; those are great times to start thinking about cardiology and palliative care. Especially if there are some decisions they have to make about maybe surgery, or if they're talking with their electrophysiology doctor, and they're unsure what to do about those devices called defibrillators. Cardiology and Palliative Care, we can help kind of dive deeper into those topics and see what makes sense for the patient.

Your family might mention it, your doctor might mention it, and you know, I think what they're trying to do is say, Hey, there are some symptoms that you're having or some things that we'd like to talk about that maybe pulling in someone else who can really spend a lot of time with you, make sure that we're managing your medications and answering all your questions that we can definitely help with.

And sometimes it's just so that you can have an open conversation about what it means for advanced care planning. What are the things that you're willing to do in the future? What are the things that you say, Ooh, I'm not sure that that's something that I'd be interested in. And it gives you an open space that you can talk with someone. And then we can start diving into those different topics.

Host: Yeah. I know with the heart, and I'm sort of simplifying this, of course, but I've spoken to other experts and it's like sometimes there are electrical issues. Sometimes there are plumbing issues, if you will. Just want to have you talk about some of the symptoms that cardiopalliative care addresses.

Alicia Topoll, MD, MS: So any symptom that a patient is having, we can talk to them, we can, you know, ask questions for them about what some of the other team members may think can benefit. A lot of the common symptoms that I might see or talk to people about would be fatigue, which is probably the most common symptom that people may have just feeling tired or run down.

Shortness of breath is another common one, especially with heart failure and valve problems. Really any kind of symptom that people may have, I like to talk to them about, you know, what can we do to make their life a little bit better so that they can do the things they want to do. But just to list off a few, you know, fatigue, shortness of breath, people will have nausea, lightheadedness, maybe some anxiety, low mood, feeling nervous.

 And so my approach to these symptoms is really listen to the person and see, you know, how we can best help. And part of that involves talking with those multidisciplinary team members. So if there's maybe a therapist who would be helpful, a physical therapist who can help with strength training and help with some of the fatigue.

One of my favorite things to use is aromatherapy. People find great benefit in using some aromatherapy to help with sleep or help with anxiety. So I really talk to the people, my patients about what they want to try. And then we form a stepwise plan of how we can make them feel better.

 I group things into two buckets. So we either have medications, and we've got all the non pharmacologic things to treat people with. And so I can talk to them about what they're willing to do, especially since a lot of our patients with cardiac diseases, are already taking so many medications and they want to feel better, but they may not want to add, you know, one more pill or one more thing.

So really trying to individualize a treatment plan for people.

Host: Yeah, I'm sure that's a comfort both to patients and to family members, and that's what I wanted to ask you about next, the family members and sort of their role in this, you know, especially with a loved one who's seeking this type of care.

Alicia Topoll, MD, MS: I think family members are some of the most important, if not the most important, part of a care team. And I really look at it as a team because the family members often are accompanying the patients to their visits. They're asking questions that a patient might forget, especially if they're in the hot seat.

And we're talking about a lot of medications. They write things down. They advocate for their family members to get the kind of care that they want. And so they may also recognize new or changing symptoms. They might say, Hey, mom or dad, or my spouse, they're starting to get really run down, they're sleeping a lot more and identify things that we can really look at and try and figure out a way to help, you know, either normalize what's going on with their body or help come up with a plan of what to do, in order for them to achieve their goals.

The family members, you know, they support their loved ones. They're walking the journey and it's a similar, but a very different journey than what the patients are going through. Caretaking is really hard and I think we probably don't talk about caretakers and the caretaker burden and fatigue that can sometimes happen.

And so, palliative care is also there for the family. We're able to support the family members. We're able to talk them through some of the things, how to manage when to call the doctors. I think also when we see patients in the hospital, family members are at the bedside, making sure their family members are getting the care, asking the questions, especially when family members, you know, the patients don't really feel great.

So they can't really advocate or ask the questions that might be difficult. Sometimes even in serious situations where patients may not be able to participate in the conversations with the doctors, family members are there making sure that they are their voice.

Host: Yeah. That's really interesting. Sometimes in these podcasts, Doctor, we like to debunk, myths or misconceptions. Are there some misconceptions about cardiopalliative care?

Alicia Topoll, MD, MS: There are, and I think a lot of those probably transcend to the palliative care in general of what is a misconception. The number one misconception people have about palliative care is that it's equal to hospice. And while there's a spectrum of what palliative care is, palliative care does not mean you are changing anything.

It doesn't mean that you are stopping care. What palliative care is, is really making sure that your goals are heard and in agreement and or concordant with what the doctors are recommending. So, palliative care is not hospice. For palliative care, it's for anyone with serious illness, whereas hospice is for people who usually have a prognosis of about six months.

We think about, you know, what is a difference in, for instance, in patients who are having cancer treatment. Hospice would mean that they would be stopping that cancer treatment. Whereas palliative care, you can continue cancer treatment. So just like in cardiology, we're continuing all the treatment for your heart failure because that treatment will make you feel good.

And, it's for people who need a little bit of extra support. Maybe they're having a lot of those symptoms we talked about, or they want to talk about advanced care planning. The purpose of our palliative care is really to ensure that we have important conversations, and that we're treating the patients, the families.

We're making sure that they are having the best quality of life and that we're continuing with all of the aggressive type cares.

Host: Sure. Yeah. I see what you mean. It does seem like hospice and palliative sometimes get used interchangeably and sometimes they do go together. Those two words can go together and then the type of care and treatment can go together. But as you say, palliative is a little bit different and just wondering, you've addressed this a little bit today, but the conversations you have with patients and families, when you start talking about advanced care planning and decision making with them. What's your approach?

Alicia Topoll, MD, MS: Advanced care planning I think is one of the best things that we can do, and I think these conversations should be done early and often. They should be done, you know, before people go into the hospital. And sometimes we have to update those conversations and think a little bit more about them after people are in the hospital.

Usually when I meet people, my first thing is I ask them, have they ever thought about a living will? Have they ever experienced family members, you know, who have been pretty sick or had a diagnosis similar to theirs. What are the conversations that they have? Because really pulling upon those past conversations and experiences oftentimes shape the way that patients think about their future care.

It's sometimes an uncomfortable conversation, and so, I think having it with the doctor is sometimes a little bit easier, so we can talk to them about the different options, trade offs, expectations, and it makes it somewhat easier to talk with their families. The advanced care planning I, often use a website called prepareforyourcare.org, and it has some great videos. It has some great options to walk people through different things that can sometimes happen, in the hospital so that you can be prepared. I think everyone should have an advanced directive. And one of the most important things is also talking to your family member about what is in that advanced directive, because if they don't know what's there, then they're not going to be able to advocate or make sure that the patient's voice is heard whenever the doctors are asking some preferences.

You can do advanced care planning with your physician, you can do it at home. The biggest thing is I think it's just important for everyone to have one and then continually update it because things may change and that's perfectly natural and normal. And share your opinions and thoughts with your doctor too, so that they know.

Host: Right. I think that that's maybe one of those misconceptions is that once you do some of this planning and you put things down on paper and sign things that you can't change your mind, but we're all human beings and we might change our minds or your health may change for the better, for the worse, whatever it might be.

 And nothing is in stone. It can be reversed if you will. Good conversation today, Doctor, just want to finish up and have you share maybe a success story, you know, generically speaking, but just one that makes you smile whenever you think about it.

Alicia Topoll, MD, MS: Sure. I have so many because,

Host: I'm sure. Yeah.

Alicia Topoll, MD, MS: It's wonderful to really help patients, especially when they come to you and they say, Hey, I'm really anxious. So, you know, I worked with someone who had once had a heart transplant and she struggled with a lot of anxiety and there was a lot of anxiety, even about taking some of her medications.

What we adjusted are heart failure medications, changed some pills, to liquids, talked a lot about anxiety and anxiety management strategies. So I had mentioned I, I really enjoy looking at other options, not just medications, to help people treat their symptoms. So, we talked about aromatherapy, things like lavender to help her sleep and help her calm down, a fan to help with the deep breathing activities, meditation, we did a lot of strategies to help manage anxiety because she didn't like taking medication and so she really did not want to add one more thing to her pillbox.

And after a few months of going through these strategies and really working together, then she was able to take her medicine. She was able to feel much better. She was engaging with her family. And she really had a better outlook. She really enjoyed line dancing. So she went back and did line dancing. And so it was really great to see her come with this question that she really didn't know who to talk to about these symptoms. And then we worked together and came up with a plan that was good for her and she did a great, great job.

Host: Well, I always like when I get to the end of these, Doctor, where I have a big old smile on my face, you know, uh, so that definitely brought a smile to my face. Appreciate your time and your expertise today. Thank you so much.

Alicia Topoll, MD, MS: Awesome. Thank you so much. This was wonderful.

Host: And for more information, go to franciscanhealth.org/heartcare. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.