Datica Podcast

April 2, 2019

Pigs, Pain Management & Palliative Care

In this episode of 4x4 Health, we talk with Krista Dobbie M.D., a palliative medicine physician for the Taussig Cancer Institute- Palliative Medicine Program at the Cleveland Clinic.  Dr. Dobbie is a longtime leader in the field of palliative care and, at the Cleveland Clinic, has been on the cutting edge of integrating palliative medicine into other medical specialties.  Her humor, empathy, and desire to educate are all present in this exceptional episode.  If you were as impressed with Dr. Dobbie as we were, we highly recommend you check out her award winning essay “Zumi the Palliative Pig”. Check out some pictures of Zumi below!


Dr. Dave Levin: Welcome to 4 x 4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I’m your host Dr. Dave Levin. Today I’m talking with Krista Dobbie, a palliative medicine physician with the Taussig Cancer Institute, had a medicine program at the Cleveland Clinic. Dr. Dobbie has been a leader in palliative medicine for many years. In addition to providing exceptional care for patients and families facing serious or life-threating illness, she is a bridge builder and educator. Consider her work at Cleveland Clinic. She co-chaired the End-of-life committee leading culture change for better End-of-life care for patients and their families. She founded the first outpatient palliative heart failure clinic and participates in the integration of palliative medicine with other medical specialties. Her contributions to education were recognized by the palliative medicine fellows when they chose her as the 2016-2017 Teacher of the year. Prior to joining Cleveland Clinic, Dr. Dobbie was instrumental in establishing and overseeing an integrated system of clinical palliative medicine throughout Southeastern Virginia. In 2008, that program received a Citation of Merit, Circle of Life award from the American Hospital Association. When Dr. Dobbie isn’t seeing patients, she can be found at home with her various pets including her pet pigs. She’s also a writer. I highly recommend her essays, Patients, Providers and Pets, One Health for All and my favorite, Zoomy the Palliative Pig. We will be sure to provide links to those on our website. I’m proud to call Krista a friend and colleague. She is one of my healthcare heroes and by the end of this podcast, I fully expect she’ll be one of yours as well. Krista, welcome to 4 x 4 health.

Dr. Krista Dobbie: Thank you.

Dr. Dave Levin: I’m gonna ask you a series of four questions today and you have up to about four minutes to answer each one. Let’s start by having you tell us a bit more about yourself and your organization.

Krista: Well, I originally started out pursuing a career in Oncology and after one year of doing an Oncology Fellowship, I realized that I was probably better at helping patients have conversations about what their goals were and how they wanted their care to be directed and I actually pursued a career in palliative care. I started out as a Hospice Medical Director. Back then in those days it was volunteer work 17 years ago. So, I volunteered part-time as a Hospice Medical Director and participated in outpatient home visits and then have the opportunity to help, begin and start an inpatient palliative care unit back in 2005 and that was such a tremendous opportunity to be part of that moment that was changing healthcare and during those days I remember, half the time we had to explain what palliative care was and how it wasn’t just hospice care but it’s been so important in my life to continue that work.

Dr. Dave Levin: So, I wanna go deeper on this question and part of my motive and asking you to come on the show today was to help spread the word about what palliative care is and one of the things that you taught me very early on and our work together is that while it certainly has a major role to play in End-of-life care out of medicine offers much, much more that it’s really for anyone who is facing a serious or life-threatening illness. Can you talk a little bit more about that, about those concepts and how you’ve seen it play out in real life with patients and families?

Krista: Sure. Palliative care is really an all-encompassing field, in that you wanna look at the patient as the total patient and you look at what that patient is going through and what does that mean, I mean, palliative care is care for seriously ill or patients dealing with life-threating illness but what is it on a day-to-day basis, it’s talking to patients, talking to families, addressing their symptoms and attempting to improve their quality of life while they are living with that illness and that maybe pain management for some, that maybe spiritual support as they struggle with why they are dealing with the illness, that maybe support to the care giver, to the family who’s frustrated or feeling burned out and that’s why true palliative care requires a multidisciplinary team, it requires physicians, it requires nurses or extended care providers like, physician’s assistants or nurse practitioners and also social work and we often times neglect to uplift and support our social workers in healthcare but they are the folks that can really meet with these families and offer counseling. So, palliative care is not just End-of-life care, it’s important care and I teach my fellow that sometimes it’s just walking through the door and saying, hey, how are you, I’m Dr. Dobbie, let me know how things are going and I tell them to get comfortable with the hi, how are you consult because when you sit down and when you really start to listen to what the patient is going through, you really start to find out what’s important to that patient and oftentimes what we as physicians worry about may not be what the patient is worried about and especially today medicine has become so technical, so many different physician teams are required to deliver good care and sometimes you need just that one person that can sit down and say, how are things going.

Dr. Dave Levin: There’s a lot in what you just said. I’d like to drill a little deeper on two ideas here. The first is this notion of in healthcare, we can’t cure everybody but we can heal everybody and as you point to there are many things that go into healing people, that go beyond the purely technical pathophysiology of their disease are the treatment plans and a part of what I have found so inspiring about this and frankly also helpful to me in my own journey through life is this idea is there’s always something that we can be doing to help and comfort and to heal those who are sick even if a cure, an outright cure is not possible but this is critically important and it often aligns better with what patients want than what we might be thinking about from a purely medical standpoint. The other thing that I learned from working with you and others in palliative medicine is that very often the first thing to do is to treat the symptoms just as you alluded to and that there’s two benefits to that. There’s the obvious benefit of it’s part of the healing process, it makes people feel better and alleviate suffering but the other is that very often these patients are facing really critical difficult decisions about their care, about their lives, about their families and a part of the purpose in treating the symptoms is to get them into a state where they can more readily and easily deal with those. If you’re suffering great pain or nausea or in great distress, you’re not in any condition really to deal with these more challenging kinds of questions. So, I apologize, I know I got up there, just gave a speech about all this.

Krista: Ha, ha [Laughing], I love it.

Dr. Dave Levin: So, correct me where you need to but also if you could share some examples from your own work that kind of illustrate this, I think it would be helpful.

Krista: Well, I totally agree. I think you need to control pain, you need to control very distressing symptoms like, shortness of breath, nausea vomiting because you can’t have meaningful conversations if the patient can’t participate because of those distressing symptoms but I’ll give you a recent example that I love. I had a lady who had advanced Metastatic Pancreatic Cancer and she had been ill for quite some time and I sat at her bedside, this was after her pain was controlled and we started to begin to discuss where she was with the dying process and we had started to talk about the fact that she knew that her disease was not being able to be cured and that she was tired and that she was at the end of her treatment options and I said, what is the most pressing thing right now, what are you fearful of most about dying? Are you worried you’re gonna be in pain, are you worried about your daughters and her answer surprised me and it reminded me that it’s always so important because each patient is different. She said, Dr. Dobbie, I’m worried about my two little dogs and where are they going to go when I die. I think a good example of palliative care as we talked about that, we worked out a plan so that her family was aware of that fear and her family joined together and we ended up placing the dogs and she went home and I know she was at such peace and her anxiety was gone and had I just given her Ativan, that wasn’t gonna fix her anxiety but addressing what she was really fearful of and it’s different for every patient. I had a recent patient with Pulmonary Fibrosis, very short of breath and he asked me, he said, I need to know how I’m gonna die because I am scared each day, my oxygen requirements are going up and we had a really good conversation about how we could alleviate his shortness of breath. Sometimes what patients think is distressful, it’s different for each one of them and I think good palliative care gets to the root of that issue. Taking a time to listen and formulate a care plan that’s individual. Often times I’ve had several young mothers that want to go home to be with their children but they don’t want to die in the home that their kids are gonna grow up in. So, we address that and as they get more ill, we may move them to an inpatient hospice facility. So, those are some examples that I can think of that are different for each patient but meaningful to each patient.

Dr. Dave Levin: Alright, now I’ll promise myself I was not gonna get tearful during this podcast. You are challenging me Krista. I want to go, before we leave this, part of what I’ve learned from studying this area from working with great physicians like, you. Again, is this issue of, it’s not just for patients that are facing death. I wanna press you a little more on this. The story that I remember from my working with you was a gentleman who had suffered a pretty severe leg injury and it was not gonna kill him but it was dramatically altering his life and the future. Do you recall the patient I’m talking about and would you mind sharing a little bit of that story?

Krista: I believe so. I think this is a gentleman that, if I’m remembering correctly, it may have been someone who had sustained a traumatic injury from a fall that palliative medicine was consulted for to help with his pain management. His quality of life, he was unable to work and actually what he ended up having was a complex regional pain syndrome and had continued swelling even after the leg had healed and we were able to temporize his pain and actually refer him for a spinal cord stimulator for one of our anesthesia team and it changed his life because he was then able to be out of pain and go back to work and in fact, I just saw a gentleman last week in clinic who had survived a very large resection for a spinal cord tumor and fortunately he was not paralyzed but he had some residual nerve damage and was dealing with a lot of significant nerve pain and I think he just anticipated that this would be his new normal and his life and the neurosurgeon referred him to my outpatient palliative care practice and we were able to change his medicines around and they sent me the most wonderful message about how he was actually participating with the family again and living his life in his greatest success was he was able to sleep through the night without waking up in pain and I think those are the patient examples that get me up in the morning and keep me doing this job 17 years later.

Dr. Dave Levin: If I recall correctly, the first gentleman that we were talking about was also a surfer. Maybe I’m conflating.

Krista: Oh yes, yes.

Dr. Dave Levin: And, what I remember about when you shared this story was that he was in two kinds of pain. He was in the pain that you described from his injury but he was also in a kind of psychic pain grieving about surfing and also about how this was gonna affect his relationship with one of his children. Am I recalling this correctly?

Krista: Yes, I had forgotten. That was so long ago. I had forgotten, that was a severe Orthopedic injury and we spent a lot of time with him doing his post-op pain management, counseling him, getting him also some professional, I don’t profess to be a professional counselor but getting him some professional counseling to accept that injury and to be able to recover from that, that was very significant orthopedic injury. That’s a great example of palliative care and it can help so many people and so I tell my colleagues, if you even remotely thought of me, get me involved, it won’t hurt, maybe more than likely we can help.

Dr. Dave Levin: Part of why I remember that story is because it made a profound impression on me. If I have not made this blatantly obvious to our listeners today, part of the message here is that palliative medicine applies to a wide range of conditions and I would echo your advice to your colleagues in speaking to just the community to say, if you are a loved one or facing a life-threatening over a very serious injury, you should consider getting palliative medicine involved. These stories illustrate to me the profound impact and I’ll make one last observation about it. I don’t wanna leave people with the impression that palliative medicine is lightweight if you will when it comes to medicine. In fact, as you described, you deal with some very difficult and complex clinical situations, like advanced pain management, complex injuries and the like but you also are looking at, as you said, the whole patient and their other needs and what are their goals. So again, I apologize I know I just gave a speech there, got up on the soapbox but as I am known to do but it should be obvious that this is a passion for something that’s very important.

Krista: One thing I do wanna say, our organization has really transformed in support of palliative care and now any person that is placed on ECMO which is a machine that helps oxygenate the lungs when the lungs are failing, these are usually people that maybe listed for lung transplant. Any patient that is placed on ECMO, automatically gets a palliative care consult and that’s really that hi, how are you consult for the family because oftentimes the patient is sedated but we know that we may have to make some difficult goals and care decisions down the road if the patient doesn’t get a transplant or if they get sicker but it’s so nice to know and tell families, this is automatic. I mean, everybody that gets put on this machine and we’re here to help you and so I think we’ve come a long way in 20 years, that was never happened in the past but it’s much more common now.

Dr. Dave Levin: It goes to another really important issue here and we don’t want to spend too much time on this today but acceptance by other physicians, nurses and other members of the care team has been an important issue as well and it always fascinated me when I was in Cleveland Clinic to watch this interaction because on one hand you’ve got a group of clinicians that are dedicated to providing absolutely cutting-edge medical care and do it exceptionally well and there’s at least the possibility of the temptation to view palliative care is kind of throwing in the towel. Well, we’re done now, there’s nothing else we can do, let’s call a palliative medicine or to view it almost as a kind of professional thread in a way and part of the journey that I’ve seen you and others on in palliative medicine over the years is essentially to deliver the same message we’ve been talking about for the last 15 minutes or so but no, this is actually in support of your goals, this is helpful to you, it can enhance the work that the rest of the team is doing and I’d like to believe that we’ve made good progress on that cultural front. No doubt it’s an ongoing effort though.

Krista: We’ve made incredible progress and one of my very favorite consults, I got called by a thoracic surgeon for a lady who had nausea and they had tried everything and Krista, can your team help us and I thought, this is great! Ha, ha [Laughing].

Dr. Dave Levin: Exactly.

Krista: I’ve arrived!

Dr. Dave Levin: If you’ve just joined us, you’re listening to 4 x 4 Health and we’re talking with Dr. Krista Dobbie, palliative medicine physician at the Cleveland Clinic. Krista, I know you’ve got your hands on a lot of different things, so this may be a tough question for you but what’s the most important or interesting thing that you’re working on right now?

Krista: I’ve made it my mission in 2019 to improve palliative medicine for our heart failure population. So, we had started an outpatient palliative medicine heart failure clinic here at the Cleveland Clinic. I think we’re about at least ten years behind dealing with this population. Studies show that they suffer just as much if not more symptoms than Cancer Patients and I really want to focus on improving hospice care for this population and so we’re coming together here at the Cleveland Clinic with multiple teams to say, how can we make the hospice care for our heart failure patients. The best we can, the smoothest transition from the inpatient setting to the outpatient setting and how can we think outside the box to deliver therapies to these patients that help them remain comfortable and spend the remaining days that they have at home enjoying their loved ones and family.

Dr. Dave Levin: So, there’s literally a million different areas that you could focus on, I think palliative medicine. Why did you gravitate to this particular population in a setting?

Krista: I think because palliative medicine is well entrenched now in cancer care and it’s not as entrenched in heart failure care and there’s lots of reasons for that and it’s no one’s fault but this is a neglected patient population that I think heart disease is still the number one killer in our country and a lot of these patients, they need help, they need help with, when do they not wanna come back for more IV Lasix to the hospital, when would they wanna consider an advanced therapy like a left ventricular assist device or potentially a heart transplant or maybe they don’t want those things. How do you help them be comfortable, we still need a lot of research in this area because a lot of the therapeutic interventions we borrow from the cancer population but yet we don’t have good clinical based evidence that using some of these modalities is as beneficial in heart failure.

Dr. Dave Levin: Yeah, I would, as someone who’s also been an administrator and responsible for cost of care, I would add, this is a patient population where not only is there a big opportunity to improve the quality of their care, there’s a cost issue here as well whether it’s the total cost of care or the data that suggests there’s substantial number of unnecessary hospital admissions or readmissions, there’s cost associated with that, there’s actual penalties, let’s save that from some tears and so I don’t mean to play down the clinical or other importance of this but I think it’s one of those happy coincidences where there’s a real opportunity improved care, there’s a group of clinicians that can come together as stakeholders and subject mater experts and there’s a business case that aligns too, that makes this not just feasible but sustainable over time. Is that a fair summary as well?

Krista: Yeah, sure. I think the most important thing for me is you really want to stay home but you want your IV Lasix to try to help get the fluid off, we can do that at home and you can be comfortable, why not and it decreases your chance of hospital acquired infections and it also allows you to be comfortable, so that patients do have quality of life rather than feeling, we would overload it in short a breath.

Dr. Dave Levin: For the next question, I always remind my guests that this show is PG-13. So, with that in mind, we’re family-friendly here but what’s your favorite pet-peeve or rant these days?

Krista: Well, and this happens less and less but I still go a little crazy every time I get the 4:30 consult on Friday for the patient that’s had a 40+ day hospital admission and now all of a sudden, the ICU team wants you to come do goals of care and so I always have to check myself a little bit, like gosh, there’s been so many missed opportunities to discuss goals of care. Did the patient want to be intubated, did the patient want the trach and the feeding tube, does the patient want to be committed to be living in a long-term healthcare facility now and yet maybe all of those things have already occurred but you’re getting called in to have that conversation. So, while we’ve made many advances, unfortunately some of those patients still slipped through the cracks and I get quite passionate about those missed opportunities. So, I have to always remind myself before I call my consultant back not to give them an earful on Friday afternoon and why are you calling me now but sometimes it flips out.

Dr. Dave Levin: Right. Well, it’s certainly a reasonable pet peeve to have. What hopeful signs do you see to address this and improve over time?

Krista: Well, I think we have started more projects with our ICU team to prevent that from happening. So, I do see that happening less and less frequently, also any family members that are listening today, when you’re being faced with difficult decisions for our loved ones, you too, you could always request that the palliative care team meet with you and we certainly had families request that when maybe physicians forgot that they could call our services or didn’t think to place that consult. So, I would encourage family members, you know, you have a voice in this too and you have a right to request that the palliative care team be a part of your care team.

Dr. Dave Levin: Well, I think that’s an extremely important point that patients and their families have every right to expect this kind of care and they should inform themselves and they should advocate for themselves and if you get pushback on that then you should push back as well.

Krista: Yeah.

Dr. Dave Levin: So, the other thing that I’ve seen as things like, multidisciplinary rounds in the ICU setting, things like that, that can help kind of broaden the perspective for the care team and sometimes identify opportunities for palliative medicine to get involved sooner. It’s my podcast, so I get to do what I want and even though I’m only supposed to ask you four questions, I’m asking you five today. So, my extra question today is, what’s up with the pigs?

Krista: Ha, ha [Laughing]. I’m so glad you asked. So, I have three pet pigs. I only ever set out to have one. I always say my heart is bigger than my head because I took in two rescues and I got my pet pig six years ago. I think because I was feeling a little burnt out and I needed something that was bringing joy in my life, something that was different. I’ve always had dogs or cats. So, I got Zoomy and what I started to do is make videos of the pigs and I started to share those with my patients. It happened quite by accident. One day I had one of my most favorite patients get a terrible diagnosis and when she wasn’t doing well and I turned to her and I said, I’m not going to let you leave here sad, let me show you my pet pig and we both kind of laughed through our tears and it was such a powerful moment and I realized that this was an incredible tool. It was a virtual pet therapy, I like to call it. I started to send it to patients when they were nervous about chemo, here have this will help you smile and get through your day, you got this. I would use it for fellow colleagues. We’d come out of a family meeting and I’d text, that was really rough, I’m glad we’re in this together, here’s a video of my pig to cheer you up and it taught me that if you share something personal of yourself with your patients, with your colleagues, you know, you no longer this white coat and we ask people when they’re their most vulnerable to have very personal discussions with us and I’m not saying a pig helps that go easier but I think when people feel a connection to you, like you’re a true human being and not just these white coat, those discussions happen more organically and there is more of a trust in having those discussions. So, I always say, my pigs have made me a better physician, haha [Laughing].

Dr. Dave Levin: It’s probably true and what you are describing is something very dear to my heart which is this idea of being an authentic leader and an important part of being an authentic leader is to show your personal side to be willing to be vulnerable in front of others because the truth is we’re all vulnerable, we just tied it to different degrees and the other thing I think that’s, I love this idea of virtual pet therapy and again, this is something I’ve learned from working with folks like you and your colleagues is there’s all kinds of other therapies out there. Again, they may not cure the underlying disease but they heal, they provide comfort and so aromatherapy and massage therapy and pet therapy and all these other things, these are real and have real value and it feels like sometimes we’ve lost some of that in our very westernized scientific approach to medicine and we need to bring some of that back into, to humanize this and what is a very humanistic activity. I love the pigs and the other thing you said today that strikes very deeply with me is this is for you and it’s for your colleagues and to our listeners, I highly recommend that you follow Dr. Dobie on Twitter on a regular basis. She posts something that just makes my day, that just makes me smile and very often, it involves one of the pigs as well, [Laugh]. So, I just love this part of your story for so many different reasons and thank you for sharing all of that. For our last question today, you’ve offered an awful lot of sage advice but I’m gonna ask you to wrap today by offering your most sage advice.

Krista: I think my most sage advice is in healthcare be you. I think there was a time that we talked about professionalism and maintaining boundaries and while I think all of that is important to prevent burnout and moral distress at times, I think remembering to be you, to share something personal with your patients, that makes that connection, it builds those meaningful relationships and I think when you have meaningful patient interactions on a day-to-day basis, that builds resilience and it actually fights against burnout because you feel like, you’ve made a difference in someone’s life and so I think that happens by sharing something of yourself.

Dr. Dave Levin: Well, that’s sage advice not just for practicing medicine, that’s sage advice for leading your life. To me is resonates very deeply for myself and for others when I sort of find myself blue and down and cynical, very often the curious to connect with others to help to give and you feel better and it helps you appreciate what you have. So, that’s truly sage advice indeed. We’ve been talking with Dr. Krista Dobbie, palliative medicine physician and obviously one of my personal heroes from the Cleveland Clinic. Krista, thanks for joining us today.

Krista: Thank you so much for having me.

Dr. Dave Levin: You’ve been listening to 4 x 4 Health, sponsored by Sansoro Health. Sansoro health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I hope you’ll join us next time for another 4 x 4 discussion with healthcare innovators. Until then, I’m your host Dr. Dave Levin, thanks for listening.