What did you see at Cook County Hospital when you were an attending physician specializing in patients with HIV and homeless that inspired you to devote your career to Palliative Care?

My interest in caring for patients experiencing homelessness and patients with HIV infection began in the late 1980s when I was a medicine resident and continued when I started working at Cook County in 1990. At that time, many people were first diagnosed with HIV infection when they presented with AIDS related opportunistic infections. In those early years, anti-retroviral therapy was not as effective as it is now. As an attending physician on the AIDS Unit at Cook County Hospital, much of the care was primarily palliative care. Some of those patients were homeless or estranged from family and the care team played a significant role in supporting them through the end of life. Across the country, quite a few physicians and nurses who cared for patients with AIDS in those early years then moved into the field of palliative medicine. However, I was asked a single question by Maurice Lemon, Program Director for Internal Medicine Residency, to create an end of life curriculum for the residents that I learned about the field of palliative medicine. To feel credible in teaching this, I decided I needed to immerse myself more fully into this new field.

You became the hospital’s sole Palliative Care practitioner in 2001. What was that like trying to pioneer a new service and team within a hospital?

The Division of General Internal Medicine at Cook County Health has a long history of supporting providers who saw an unmet need and created opportunities for program development to address that need. Pioneers in primary care established the first HIV clinic for men, women and children (Ron Sable, Renslow Sherer and Mardge Cohen), while others established programs to address the disparities in primary care (Gordon Schiff) and breast and cervical cancer screening and treatment (David Ansell). Still others developed programs in preventive medicine (Arthur Hoffman and David Goldberg) and the creation of the division of hospital medicine (Avery Hart and Brian Lucas). These pioneers modeled and provided mentorship to me in creating the Section of Palliative Medicine. In addition to the encouragement and guidance from the division, the program was also supported by the Department of Medicine leadership (Brendan Reilly and Robert Weinstein) and hospital administration.

How has the Palliative Care Program at Cook County Hospital grown since then?

Although I retired from Cook County Health at the end of 2014, I continue to work part-time covering the inpatient palliative care consultation service. Several physicians who were with the program for many years also retired or moved to other states for family reasons (and all remain active in palliative medicine). Yet, the Palliative Care Program continues to thrive and is now led by Orlanda Mackie, MD, who has been with the program since the early years. Through her leadership, the palliative care program has further expanded outpatient clinics in oncology. Lisa Gobbi, MD, a psychiatrist and a recent fellow graduate, is expanding the reach of the program into outpatient nephrology and cardiology. Ancy Jacob, nurse practitioner, with a background in critical care, has increased our presence in the intensive care unit through automatic triggers. Ruhi Shariff, MD, has enhanced and expanded the educational program with a palliative care elective for medical students and required rotation for internal medicine, family medicine and pediatric residents.

How did you and your team evolve during the COVID pandemic? Are there important takeaways that you can share?

At the beginning of the pandemic, we learned from the experience of our colleagues across the country that were impacted early on, particularly in Washington and New York. As processes and protocols were developed, we offered communication skills education utilizing the resources provided by VitalTalk. Members of our team had to learn and adapt to providing telehealth visits, which can be particularly challenging as 30% of our patients have Limited English Proficiency. Palliative care programs in safety net institutions care for patients from communities of color who are dying due to disparities in access to care. This was further magnified during the pandemic as these communities were disproportionately impacted by COVID.

Some team members were involved with providing support and structure around wellness and resilience for the institution. One important takeaway is that attention to wellness and strategies to foster resilience are core to sustaining us in this work. We have built some activities into our workday to foster resilience and not as an extra activity done “after hours.”

More broadly, how do you think the COVID pandemic has impacted the access and delivery of palliative medicine in general?

The pandemic required all providers to practice primary palliative care skills, including providing empathic communication, communicating prognosis, guiding family meetings and ensuring intensive symptom management in the setting of worsening symptoms of COVID. Our role often involved coaching and guidance when we were not involved in direct care.

Do you think legislation and policy going forward will better support Palliative Care? Do you have thoughts on what that model should look like?

We saw in the pandemic that the United States did not provide the leadership and response at a federal level that occurred in many other countries. And we are the only developed nation that does not have universal healthcare coverage or view healthcare as a human right. Many other countries recognize and support the high value care provided by palliative care and offer these comprehensive services within the context of a universal healthcare plan.

If you could have one conversation with someone making end-of-life decisions whether healthy, just receiving a terminal diagnosis or dying, what would be important for you to convey?

I would encourage the person to talk about what matters most to them and what they value with those who matter most to them. Have those conversations early and often. My parents had talked with me for years about their priorities and wishes and so a foundation was already laid when we came to points of decision making, even as those decisions may change over time. Yet, having multiple conversations can increase the comfort in bringing up difficult topics. My children are all young adults and they have heard me discuss my values and wishes frequently (and more than they really wanted to hear)!

Do you have research or educational projects you are currently working on that you would like to tell us about?

In addition to the clinical work at Cook County, which includes teaching residents and fellows, I am the Education Lead for Palliative Care and Opioid Education at Chicago Medical School-Rosalind Franklin University. It is exciting to create and modify developmentally appropriate curriculum across the four years and have it received so enthusiastically by the learners and wholeheartedly supported by the administration. I received an e-mail from a recent graduate who described how he used the communication skills he learned during medical school with a patient shortly after starting internship. He was appreciative for the training and felt prepared and confident in supporting the patient with difficult news. It is gratifying to be able to influence the next generation of physicians.

If people would like to reach you directly for additional information or assistance, how would they do so?

I am still working part-time at Cook County Health, and I can best be reached by e-mail: cdeamant@cookcountyhhs.org