{'fraction_non_alphanumeric': 0.020355731225296443, 'fraction_numerical': 0.0033596837944664033, 'mean_word_length': 5.07563025210084, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
CommentReflections on a Real‐Time Advance Care Planning Discussion During Our First Virtual Teaching Rounds in Post‐Acute Care

To the Editor: It was our first virtual post-acute care teaching rounds, necessitated for our third year of medical school Geriatrics/Palliative Care rotation by the COVID-19 pandemic. We had an amazing and serendipitous learning experience that we would like to share. We were able to witness an evolving real-time advance care planning discussion involving a patient whose clinical situation was deteriorating rapidly, and her two children. This experience reinforced what we teach and learn about advance care planning, advance directives, and end-of-life care during the first 3 years of medical school. Students learn about these issues during multiple sessions during the first and second years in curricular threads in ethics and geriatrics, have a required simulation activity on end-of-life care, and the required sessions on geriatrics and palliative care during their third year. The session was planned so that the students virtually attended a meeting held in the skilled nursing facility (SNF) conference room with the faculty physician (JO), a nurse practitioner (SD), and two internal medicine residents. Clinical details were discussed on each patient, and the students were shown relevant sections of the electronic health record. The session was going smoothly when the director of nursing knocked on the door and requested that the nurse practitioner help evaluate a patient who we had just discussed. Less than 5 minutes later, the director of nursing returned and asked the faculty physician, who also serves as a medical director for the facility, to help evaluate the patient. The patient was an 87 year-old woman who had been living independently, but then had four hospitalizations over the course of 3 months. These admissions were for new onset atrial fibrillation associated with hyperthyroidism during which she had an A-V nodal ablation and pacemaker insertion, a pericardial effusion large enough to require a pericardial window, and decompensated heart failure and COVID-19 pneumonia. She was transferred to our facility after two negative viral tests and had one additional hospitalization for a urinary tract infection due to ESBL Klebsiella. When the faculty physician got to the patient’s room, he was told that the patient’s systolic blood pressure was 84 mmHg and that her oxygen saturation was 82% on room air, which had increased to 88% on 4 liters of nasal oxygen. The patient was not alert, but when her name was called, she yelled “Help me, help me”. The attending re-checked the systolic blood pressure and performed a focused physical exam that was consistent with decompensated heart failure. He then obtained the contact information for the patient’s health care proxy decision maker and returned to the conference room where the residents were discussing another patient with the students. We called the patient’s health care proxy—her son, an emergency medicine physician living in another state—and with his permission conducted the phone call on speaker phone with the two residents and nurse practitioner in the room and the four students participating virtually. Although this was a spontaneous, real-time evolving situation, and we did not have time to plan the conversation, we were able to incorporate several of the steps recommended in an excellent recently published article family meetings on behalf of patients with serious illness. These included introducing all present; an “ask-ask” approach to review the patient’s status and prognosis; clarification of the goals of care; discussion of treatment options, and a summary and next steps. The fact that the son was an experienced physician facilitates an effective virtual meeting. We discussed his mother’s recent downward trajectory and her limited prognosis. The son acknowledged that he had been thinking about this and asked if he could conference his sister into the call. Once she was on the line, we all listened as they discussed what they thought was best for their mother based on her goals and values, and asked the faculty physician about the possibility of maintaining their mother in the facility with the goal of focusing on her comfort. After a few minutes of deliberation they decided not to send her back to the hospital for what they recognized would be non-beneficial and burdensome care. We validated their decision and the faculty physician, a geriatrician skilled in end-of-life care, immediately wrote the appropriate documentation and orders. Participating in this brief, spontaneous, but fruitful goals of care discussion was an experience we will not forget students had several insightful reflections about the experience (see the Table 1). This first virtual postacute care teaching session was a great learning experience for all of us and taught us important lessons about both the virtues and challenges of this new approach to clinical education in a critical aspect of geriatric care.