Submitted by Natalie C. Ernecoff, PhD, MPH
2020 AAHPM Research Scholar Recipient
It has been a hard year, and the path forward remains uncertain — but we believe we will find a path. That was the conclusion of Sean Morrison’s welcome to the 2021 NPCRC Foley Retreat. With particular poignance as some emerge from a year of universal isolation, Diane Meier’s opening plenary featured work from Ashwin Kotwal and others on the high prevalence and devastating impacts of social isolation and loneliness. The moving and personal talk emphasized the degree to which she was — and we all were —affected by isolation, even as some of the more well-resourced members of society. Privileged though we may be, the pandemic months were a reminder of how potent social determinants—including isolation—can be, and how among much of the population they are compounded over time and intersect with each other to create adverse effects on quality-of-life and health outcomes. To that end, our work must go beyond traditional health care, incorporating both population health approaches to meet patient needs and meaningful relationships.
Meaningful relationships proved to be an undercurrent throughout the meeting. I presented a poster to groups who were excited to be in a room together to engage with each other and the science. This interpersonal, visual feedback was stimulating — and we were free to interact with our materials and with each other, walking around a room without the constraints of a Zoom window. The sessions were a reminder that while virtual venues can connect us over space and time, communing together allows us to build relationships and ideas in ways that we sorely missed.
As evidence of the advantages of an in-person forum, Dr. Morrison provided a thoughtful, yet controversial, presentation of his and colleagues (Diane Meier, Bob Arnold, James Tulsky) recent high-impact publications on the evidence base for advance care planning (ACP) with ample time for debate and feedback. Dr. Morrison described extensive evidence that ACP does not effectively move outcomes, sparking rare controversy in palliative care.
Although our field understands the importance of language, finding the right degree of nuance in how we define our terms can prove difficult, often imperfect, and sometimes impossible. To that end, defining ACP (and palliative care, for that matter) has remained conflicted and somewhat nebulous within the field, despite deep thought and healthy discussion within the community. Morrison’s talk generated lively discussion, including concern that, outside the palliative care community, ACP is conflated with effective goals-of-care communication and, even more dramatically, palliative care as a discipline. Though agreed-upon definitions are an essential starting-point (which collectively our field has yet to find), the opportunity for ensuing debate makes us all better scientists.
In the spirit of finding shared language, Dr. Zara Cooper made a compelling case for integration of surgery and palliative care. Despite a history of working in distant silos, Cooper emphasized shared goals of the two communities. With a call for interdisciplinary empathy, collaboration, and focus on patient needs, she described the ways in which the population of people receiving surgery is indeed nearly the same population, epidemiologically, as that living with serious illness. Clinicians in surgery and palliative care are caring for the same patients, whether they communicate with each other (and their shared patients) or not. Further, their perspectives (and care for their patients) are more similar than many of those in the palliative care community have long believed. Finding shared language provides an opportunity for finding shared goals of care delivery.
The organizational feat of holding an in-person conference in a state of continued uncertainly was not lost on attendees. We missed our friends and colleagues who made hard decisions to stay home in light of ongoing risk and uncertainty. To engage with one another generates ideas and professional collaboration. But perhaps more importantly, it reminds us that we are all in this work together, that we all have the privilege of serving people during some of their hardest moments, and that we are not alone.