RCT of PC in ED: Corita Grudzen, Fernanda Bellolio, & Tammie Quest

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GeriPal - A Geriatrics and Palliative Medicine Podcast 50 min 3 speakers 8 chapters transcribed 9 hours ago

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What motivated the original palliative‑care study in the emergency department?

Eric Widera 0:00

This episode of the JerryPal Podcast is CME eligible.

Alex Smith 0:04

To claim credit, please go to the CME tab on jerrypal.org.

Eric Widera 0:09

Welcome to the Jerry Powell Podcast. This is Eric Madera.

Alex Smith 0:12

This is Alex Smith. And Alex, who do we have with us today? We are delighted to welcome back Corita Grudsen, who is an emergency medicine physician, researcher, and head of the division of supportive and acute care services at Memorial Sloan Kettering Cancer Center. Karita, welcome back to the Jerry Powell podcast.

Corita Grudzen 0:30

Thank you.

Alex Smith 0:31

And we're delighted to welcome Fernanda Belloglio, who is an emergency medicine physician and professor of emergency medicine at the Mayo Clinic. Fernanda, welcome to the Jerry PAL podcast.

Fernanda Bellolio 0:43

Thank you for having me.

Alex Smith 0:44

And we're delighted to welcome Tammy Quest, long overdue. So delighted to have you, emergency medicine physician and palliative medicine physician and professor and director of the Emory Palliative Care Center. Tammy, welcome to Jerry Pell.

Unknown 0:57

Thanks, friends.

Eric Widera 0:59

So we got a lot to talk about. We're gonna jump into a trial of a primary palette of care in the ED that interestingly enough did not show a difference in the outcomes that they were looking at. But before we jump into that, I think somebody has a song request for Alex.

Fernanda Bellolio 1:16

I do have a song request. It's another one Bites a Dust by Queen.

Eric Widera 1:20

Why did you pick this song?

Fernanda Bellolio 1:23

It's I like that the tempo that it has is around hundred and ten beats per minute. And this is the range of recommended chest compressions during cardiopulmonary resuscitation or CPR. So that's why we asked for this song.

Eric Widera 1:35

Okay. So it was not the fact that uh this was a another primary part of care out. That bit

Alex Smith 1:41

the dust,

Eric Widera 1:42

another primary mentioned.

Corita Grudzen 1:44

No reflection on the trial.

Illia Polosukhin 1:48

Well we'll get to the trial. Alex

Unknown 1:50

You can tell where the the emergency physicians' minds were exactly with Fernanda and we see where you're

Alex Smith 1:59

All right. Uh um for the pre-recorded version I uh set a metronome to hundred and ten. So I'm pretty sure I did okay there. We'll see how I do live here. Let's hear. Let's see.

2:20

Way down low. Ain't no sound but the sound of his feet Machine guns ready to go Are you ready? Are you ready for this? Are you hanging on the edge of your seat? Out the doorway full it's rich. To the sound of the bee. One bites a dust. Another one bites of dust, and another one gone, and another one gone, another one bites of dust.

Alex Smith 2:49

Mm-hmm. That was great. Did the patient survive the CPR or is it too slow?

Unknown 2:56

It usually doesn't work, no matter what

Corita Grudzen 2:58

you do. Especially in this population with a gagne of greater than

Unknown 3:02

six. Depends on how long they were pre hospital. We will

Eric Widera 3:09

Okay, I'm gonna start off with you, Karita. Back, I think back in what May 2016, you published a randomized controlled trial, first author, Palliative Care in the ED, randomized study, cancer patients. Primary outcome was quality of life, and you improved quality of life. Why did you do another study of palliative care in the ED?

Corita Grudzen 3:33

Yeah, great question. Um, so that study was focused on patients admitted to the hospital. And as we know, you know, palliative care. Um For the most part, is available Monday through Friday, nine to five. You know, luckily at MSK we have palliative care twenty-four seven, which is very unique, but So if someone got admitted, palliative care could see them the next day. Um, I think that study was really important, especially I think the message that I give people is you can do something as simple as calling a consult and improve quality of life months later. So that's great. But what do we do about the majority of our patients who get discharged home? You know, most in most ERs admit, you know, far fewer than 50% of their patients.

Corita Grudzen 4:18

And so how do we think about palliative care in those patients that go to observation and go home or just get discharged straight from the ER?

Eric Widera 4:26

So that two thousand sixteen study w was in the E D, but it was getting specialty palliative care to see 'em when they were hospitalized. Is that right? Yep.

Corita Grudzen 4:33

They could have seen them in the E D or the next day upstairs. Yeah.

Eric Widera 4:36

Okay. But that was uh a specialty palliative care study.

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Chapters

8 chapters

1 What motivated the original palliative‑care study in the emergency department? 0:00–6:02 2 How did the 2016 randomized trial differ from the new JAMA cluster‑stepped‑wedge trial? 6:02–12:50 3 What was the design of the cluster stepped‑wedge randomized trial and why was it chosen? 12:50–18:28 4 What components made up the intervention (training, decision support, feedback)? 18:28–24:52 5 Why did the trial show no difference in hospitalization, hospice use, and other outcomes? 24:52–31:19 6 How did clinicians perceive the training and decision‑support tools despite the negative primary outcomes? 31:19–38:14 7 What lessons do the researchers draw about primary palliative‑care interventions in the ED? 38:14–44:46 8 What recommendations do the guests have for designing the next primary palliative‑care study? 44:46–50:32

Speakers

3 identified

Eric Widera 8 min Alex Smith 4 min Illia Polosukhin

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Topics in this episode

Alex 1 Alex Smith 2 NYU 1 Eric Widera 1 Mayo Clinic 1 JAMA 1 Chris Jones 1 Ed Martin 1 Elizabeth Chung 1 Harry Hahn 1 Susan Nelson 1 Emory University 1

Source

Recorded10 Apr 2025

Publisherrss.libsyn.com ↗

Transcriptspeaker-named · 100+ languages

Handlerec:20524513

Show notes

Early in my research career, I was fascinated by the (then) frontier area of palliative care in the emergency department. I asked emergency medicine clinicians what they thought when a patient who is seriously ill and DNR comes to the ED, and some responded, (paraphrasing), what are they doing here? This is not why I went into emergency medicine. I went into emergency medicine to act. I can't do the primary thing I've been trained to do: ABC, ABC, ABCs. Most emergency providers wanted to do the right thing for seriously ill patients, but they didn't have the knowledge, skills, or experience to do it. Today we focus on an intervention, published in JAMA, that gave emergency clinicians basic palliative care knowledge, training, and skills. We talk with Corita Grudzen and Fernanda Bellolio about their cluster stepped wedge randomized trial of a palliative care intervention directed at emergency clinicians. They got training in Vital Talk and ELNEC. They got a decision support tool that identified hospice patients or those who might benefit from a goals of care discussion. They got feedback. So did it matter? Hmmm….it depends. We are fortunate to have Tammie Quest, emergency and palliative trained and long a leader in this space, to help us unpack and contextualize these findings. Today we discuss: Why the study was negative for the primary (hospitalization) and all secondary outcome (e.g. hospice use). Why to emergency clinicians, this study was a wild success because they had the skills they wanted/needed to feel like they could do the right thing (during the onset of Covid no less). Why this study was a success due to the sheer size (nearly 100,000 patients in about 30 EDs) of the study, and the fact that, as far as the investigators know, all study sites continue to employ the clinical decision support tool. What is a cluster stepped wedge randomized trial? Were they surprised by the negative findings? How do we situate this study in the context of other negative primary palliative care interventions, outside the ED? E.g. Yael Shenker's negative study of primary palliative care for cancer, Randy Curtis's negative study of a Vital Talk-ish intervention, Lieve Van den Block's negative study of primary PC in nursing homes. Why do so many (most, all??) primary palliative care interventions seem to fail, whereas specialized palliative care interventions have a relatively robust track record of success. Should we give up on primary palliative care? What's next for primary palliative care interventions in the ED? And if your Basic Life Support training certification is due, you can practice the correct chest compression rate of 110 beats per minute to Another One Bites the Dust. -Alex Smith

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