Palliative care and the importance of holding space [PODCAST]

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“Holding space means being physically, mentally, and emotionally present for someone. It means putting your focus on someone to support them as they feel their feelings. An important aspect of holding space is managing judgment while you are present.

Like when you tell a patient that they have stage IV pancreatic cancer and that it is nonsurgical and even with the best treatments, their time is very short. Then you hold space.

You say nothing. You sit there and provide support by sitting there-next to their emotions. You don’t run to offer false hope. You don’t run to talk about 5 percent of the patients that respond to the newest therapy. You don’t try to look at the bright side. Change the subject. Or worse, run out the room.

You hold space. Sometimes, you sit for 2 minutes. Sometimes 10 minutes. While saying nothing. It feels like an impossibly long time, but I wish I could tell you how you are bearing the weight of that news by just sitting there. Holding space.”

Faryal Michaud is a palliative care physician and can be reached at Write Your Last Chapter.

She shares her story and discusses her KevinMD article, “The importance of holding space.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Faryal Michaud. She is a palliative care physician, and she wrote the KevinMD article “The importance of holding space.” Faryal, welcome to the show.

Faryal Michaud: So happy to be here, Kevin. It’s lovely to meet you in person like this.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Faryal Michaud: Oh, I’d be glad to. So I started by being an internal medicine-trained physician. Initially, I was an academic hospitalist, but then I was working as a private hospitalist for 10 years. During those years of practicing as an inpatient hospitalist, I just realized that there’s a huge empty space about having important conversations with inpatient clients that would come and go, and I started getting really interested in palliative care.

By the time I had finished my internal medicine training, the palliative care subspecialty did not exist, so I had to go back and do extra training afterwards. Then there was a period of time that I did palliative care and then hospital medicine, and then when we got really busy, I shifted entirely to inpatient palliative care, which is what I’ve been doing for the past six years now.

Kevin Pho: Now, tell me how the pandemic has affected your work as a palliative care physician.

Faryal Michaud: You know, that’s a great question, and I’m so glad you bring this up. I think that obviously the pandemic has affected every aspect of medicine, but I personally think that our service line has been overwhelmed, because there’s a huge need for having early goals-of-care conversations with patients when we can see that they may have that direction, and maybe families, and patients themselves, do not want to have that prolonged, protracted course.

But what’s been hardest for me is that it’s all virtual. We have no visitation policy on this, there is absolute end of life, so when someone’s actively dying. So all of these conversations that before would happen with the patient and family at the bedside, where they would really rely on family support to make big decisions, are all being done via Zoom. It’s not really Zoom; it’s kind of Teams meetings. Families are really struggling because their loved ones are alone in the hospital, and patients are struggling because there’s no family support, and these people are in a hospital for a very long time. So that’s becoming very difficult, and patients are dying alone. They have no resource.

And also, in the beginning, because we were trying to limit our PPE use, we would only go in if we had to. Our team is multidisciplinary, Kevin, so there’s a physician, there’s a chaplain, there’s a social worker, and a nurse. Usually we would all go in together with our own chair, sit around, and talk. Now there’s only one person that goes in, and the rest of the group is actually in a separate room, so we can’t read the patients. So I think our practice has changed. We are busier, but we’re really practicing in silos, and I really don’t think that patients are getting the best care. But that’s the reality of our time right now.

Kevin Pho: Now, when you talk to patients and their families about palliative care issues in a virtual setting, what are some tips to maintain that connection as best you can?

Faryal Michaud: That’s wonderful. So one thing that we actually do: For example, I could be present at the bedside if the patient is symptomatic or has issues that need to be addressed, or a social worker could be. So what we do is describe the patient to the family, if the family cannot have a visual way of looking at their loved one, because not everyone, you know, we have a different, very multicultural area in Hawaii, and not everyone can manage audiovisuals. So we describe the patient. If we say something and the patient smiles, we tell the family, “OK, he’s smiling right now,” or, “He was very touched, and he’s happy right now.” Or if he’s sad and he’s crying, we’ll say, “He’s crying right now.” I think painting a picture would allow the family to be there.

And then we also check in with people when they’re quiet. So we will call on the son, who may say nothing at all, because obviously they may be on mute, but also they may be crying. You don’t know what’s happening. So we are actively calling in and inviting them, with the invitation saying, “John, you heard what we said. What do you think about all that?” So we are constantly bringing everybody in, doing the best that we can, and describing the patient to their loved ones so they feel like they’re there. It’s very powerful.

Kevin Pho: So let’s transition into your KevinMD article, “The importance of holding space.” Now, for those who haven’t read the article, can you walk my audience through it and share the story of why you decided to write it?

Faryal Michaud: Yeah, thank you so much. I just loved, I felt so inspired to share this. I’ve been reading your articles for many, many years, yes. So I wanted to say, one thing that we do in palliative care, and I’ve heard people reference it, and I don’t really think people understand it very well, is the whole idea of, again, holding space. You hear people say, “We’re going to hold space for them.” It’s almost like non-action.

I actively meditate, and that’s something that I really love, and I started thinking about the actual act of holding space, where you really are nonjudgmentally sitting there for the patient and trying to take whatever comes to you, whether it could be sadness, madness, anger, denial, and just really hold that space for them, and really understand the therapeutic value of that. The term “attending,” the physician being an attending, really means attending to the patient, and not necessarily to do lab draws and give medication and this and that. Sometimes our job is that therapeutic presence. And I just realized, the more residents I had, the more people that would come and rotate with me, new physicians, I just realized this is not very well taught. So I thought, what if I put it in words?

Then, as I was doing that, I sort of felt like it’s very similar to meditation as well, where you are holding space for different thoughts, right? You could be angry and just realize, “OK, I’m angry, and I’m just going to let this slide.” I think that same interaction comes into focus when you’re dealing with patients.

So I actually have, Kevin, a support group for physicians, and I had initially written a version of this particular holding space article for that group. It was very, very positive; people were having so much response, saying, “This is wonderful.” Then someone shared, “It would be wonderful if you could share it with a larger audience.” And I can’t think of a larger audience than your audience, so there it is. Thank you.

Kevin Pho: Wonderful. And it clearly resonated, because that article got 2,000 shares on social media, so I think it clearly struck a chord. Now, we in primary care, of course, talk about palliative care issues as well, and you’re right, we don’t have a lot of training in this. So when you teach your residents and your clinicians about holding space, how do you go about teaching that to us?

Faryal Michaud: An analogy I always use is similar to a palliative care consultation. That is, if I was going to a palliative care consultation, and my job was going to be to share a difficult decision or a poor diagnosis, just bad news, the way we approach that is that we imagine that we go into the patient’s room and we open that door. We open the door to the patient’s room, and then we share what we have to share, whatever that is, and I teach extensively how to do that.

But after you share that communication, and the example you used was telling someone they have stage IV metastatic pancreatic cancer, that there’s no treatment available, it’s nonsurgical, when you share that information, as physicians, we’re such fixers. There’s such an urgency, as soon as we see someone crying, to say, “Oh, but there are new studies that came out,” or, “Oh, there’s new,” you know. We want to rescue patients. But I think what I want to say is, holding space would be to open that door and then just wait for what’s coming to you.

It may very well be that patients may run to you, because they would say, “I knew something was up,” and you just kind of respond to where they’re at. And where they’re at may be to slam that door in your face, and it’s important not to take it personally, and again, not to rescue. If they need to shut you down, that’s their job. You’re holding space for a whole array of emotions.

Sometimes, you know, my husband is a radiation oncologist, so I actually teach this to him as well, and he says, “How long do you wait, or what’s the pause?” I always say you stop after you share whatever you have to share, and then you let them say something. So if you don’t know how long, it feels ridiculously long when you haven’t done this many times. Even two minutes sounds like an eternity. But you just tell yourself, “I’m going to wait to see what they have to say.” And then whatever they say, whether it’s anger, whether it’s frustration and denial, you hold space for that too, meaning, “I see that.” You attend to whatever feeling that is. You don’t have to do anything, and even by not doing anything, you’re doing plenty, a lot.

Kevin Pho: That’s wonderful advice. We’re talking to Faryal Michaud. She’s a palliative care physician. She wrote the KevinMD article “The importance of holding space.” Faryal, in primary care, we’re overwhelmed with a zillion checklists that we have to do, and we’re all pressed for time, yet we know that discussing advance directives and palliative care issues is certainly critical for every patient. Now, can you share your approach on how to bring up these issues in a typical primary care visit?

Faryal Michaud: Yeah. So I think what’s very important is that a lot of times physicians feel awkward, because they feel like if they go that route, they’re taking the hope away, and it’s going to be a difficult conversation. I think if you come from a place of worry, so say your patient has congestive heart failure and has been in and out of the hospital 15 times in the past year, how do you, as a primary care physician, have a conversation in a well setting that doesn’t take an hour of your time?

This is what I will say. Here’s how the conversation would go, for example: “Hey, Marie, I heard that you were in the hospital and you were very sick. Tell me about that.” So let them give you a little bit, and you can listen for what they have to say. Then you start by saying, “I really wish that whatever’s going on with you,” say congestive heart failure, “was going to miraculously go away, but I worry that at this stage, nothing we do is going to actually change the trajectory of your disease, and I wonder if we should talk about what we would do if this happens again.”

This sentence: wish, worry, wonder. I teach this to my residents, and I actually have an episode like that: How do you use that to talk to patients? It’s going to get you out of any difficult conversation, and it’s going to be a quick way to wrap your mind around a difficult thing. You align yourself with the patient, and when you worry, they worry. When you wonder, you’re sharing your prognosis and recommendation.

Kevin Pho: My final question: What is your take-home message that you want to leave with the KevinMD audience?

Faryal Michaud: I want to ask everybody that if you feel like a patient is being struck by a serious illness, and you do have a palliative care service in your hospital or in your institution, please use us. In a way, palliative care does not mean giving up hope. I would like us to be involved upstream. I want patients to make decisions knowing what their options are, and we empower patients. We don’t take the hope away. So I just want to encourage everyone to look at us as a glimmer of hope, not somebody who comes in and takes patients’ hope away.

Kevin Pho: I understand you started a podcast earlier this year. Can you talk a little about that and how people can reach you?

Faryal Michaud: Absolutely. So I started a podcast during COVID, because I just felt like there were a lot of physicians struggling with all this, not enough palliative care physicians going around. And I also want people to live their bucket list now. I don’t want you to wait until you get sick to say, “OK, now I have only six months. How can I jam in everything I wanted to?” So living intentionally is what I really strive for myself, and I also try to pass that to people.

So I started a podcast called Write Your Last Chapter, and this podcast is divided into a guest show; I have Palliative Pearls, which I share, which is educational, for physicians and patients alike; as well as, then, I will have what we call Talk Story, which is sharing life stories that you can actually take and somehow allow to be part of your guiding light of how to live your life intentionally, with your bucket list now.

Kevin Pho: Well, thank you again for sharing your insight, and thanks again for being on the show.

Faryal Michaud: Thank you, Kevin.

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