When Doctors and Patients Talk About Death Over Zoom

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For doctors who see patients in their homes, tele-health allows them to see many more patients. “One of the challenges is your ‘windshield time’”—all the time you spend in a car, says Bethany Snider, chief medical officer at Hosparus Health, a nonprofit that delivers in-home palliative and hospice care to patients in Indiana and Kentucky. Hosparus had already piloted a tele-health system before the pandemic hit, but Snider says coronvirus pushed the organization to speed up adoption. Their group now treats 1,500 people a day virtually.

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Michael Fratkin, who has practiced tele-palliative and hospice care for five years in rural Northern California, also says virtual visits are more efficient. Seeing a doctor over the computer frames visits in a more focused, purposeful way. It’s easier, he says, “to dive into the work itself.” After all, in-person visits can introduce asymmetrical power dynamics that make people uncomfortable. Patients have to clean their house to prepare for a home visit, and it can be awkward for the doctor to find a natural, polite time to leave. Fratkin finds virtual visits go much more smoothly. “You can actually accomplish much more with less time, with totally adequate intimacy,” he says.

And in some ways, Fratkin believes that separation is important for care providers too. He compares palliative care doctors to the capacitors in circuits. The more surface area and the closer the two plates of a capacitor are, the more energy they’re able to store. Similarly, the more of themselves doctors bring to their patients, and the closer they get, the better their relationship and the care they provide will be. But if the plates of a capacitor touch, the magic is gone. Suddenly it’s just a circuit. The same is true of doctors: Getting too close to patients can ruin that relationship. “The trick is to manage the amount of yourself you bring to the encounter,” he says. Tele-health platforms give doctors an invitation to connect and create intimate relationships with people thousands of miles away. But they can also help maintain that necessary separation.

While tele-health adds a lot to their practices, neither Snider nor Silveira are ready to give up in-person visits just yet. It’s harder for doctors to tell what’s happening if they can’t physically examine a patient. And the technology can sometimes be a real problem. Silveira has battled glitchy platforms and struggled to help patients install the necessary software on their home devices. Plus, not everyone has a great internet connection. “There is a portion of Kentucky that has limited access to high-quality high-speed internet, and that does create a barrier,” says Snider. That hasn’t affected a huge percentage of Hosparus’ patients yet, but it’s a concern as tele-health starts to expand.

But Fratkin is ready to go all-in. “I’m not going back,” he says. His practice, ResolutionCare, normally mixes virtual and home visits, but during the pandemic he went 100 percent virtual to reduce the risk of spreading the virus. “Our patients, the people we care for, didn’t notice,” he says. And he doesn’t worry about connectivity. If patients don’t have good internet, he’ll arrange the installation of a better connection, hook up a satellite dish, or loan out devices to those who need them. Those initial costs might seem high, but they end up having big payouts. “If we avoid one emergency department visit by managing a set of symptoms early and at home, we’re killing it on the numbers game,” he says.

At its best, doctors say tele-health can help bring more family members into conversations and create supportive, loving environments for people struggling with hard questions about prognosis, treatment, and mortality. “Virtual touch and interaction still adds love and support and gratitude and joy,” says Snider. “It’s just a matter of us leaning into that.”


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