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Seeing Palliative Care through an Equity Lens

Dr. Ramona Mahtani

Council Award Recipient: Dr. Ramona Mahtani

During a period of so much chaos, when COVID-19 targeted the most vulnerable and raged through hospitals and nursing homes, Dr. Ramona Mahtani was a constant, reassuring presence. At the height of the pandemic, she worked tirelessly to alleviate patients’ symptoms, engage with their families and support other health-care providers.

“There is absolutely no doubt that her work changed lives,” said Jessica Bell, MPP for the riding of University Rosedale, where Dr. Mahtani’s hospital, Mount Sinai, is located.

At its meeting in December, CPSO Council recognized Dr. Mahtani’s extraordinary service with the presentation of its Council Award.

Dr. Mahtani is lead palliative care physician for the hospital-based program at Mount Sinai. In April 2020, during the first wave of the outbreak, she and other hospital physicians were sent as a lifeline to a neighbouring long-term care home devastated by an outbreak. During the first two weeks of the pandemic, 12 residents had died and 89 more had become infected. Creating further chaos, staff members were also falling ill. Forty-seven health-care providers became infected, leaving them unable to care for the residents who were not infected.

As co-lead physician supporting the long-term care home, Dr. Mahtani helped evacuate 15 residents to her hospital’s emergency department in the first 48 hours. At the hospital, she worked with a dedicated palliative care team to alleviate patients’ symptoms, and provide intensive comfort and support for both the patients and their families. Meanwhile, she was still doing virtual rounds on every single resident at the nursing home, often twice daily. In partnership with the home’s nursing leaders, Dr. Mahtani and her colleagues continued to evacuate residents to the hospital when more intense medical and palliative care was needed.

Ms. Bell says she was impressed by the phenomenal empathy and support that Dr. Mahtani provided to the staff at the long-term care home as she helped build their clinical capacity and skills, while setting the tone for this critical partnership. “She made herself available 24/7 to everyone at the long-term care home during the outbreak and beyond,” she said.

Her dedication to service was all the more impressive because both her parents were seriously ill, in two different hospitals across town.

During Ontario’s third wave, Dr. Mahtani and her team cared for many critically ill young or pregnant patients, largely from disadvantaged socioeconomic backgrounds. As COVID-19 cases surged, the Hospital for Sick Children, in collaboration with Mount Sinai, created a new ICU for these young adult patients and Dr. Mahtani crossed the street to care for these patients as well.

The experience of supporting so many racialized patients in multiple ICUs during the pandemic only reinforced Dr. Mahtani’s resolve to effect change. She is currently focusing her efforts on improving access to high quality palliative care for communities that experience poor care due to racial and ethnic marginalization. She says restoring human connection in care work is the building block needed to face the legitimate mistrust patients and families feel. She is committed to ensuring lessons learned during COVID-19 become part of future work and advocacy.

Below we speak to Dr. Mahtani. We also have a video of her remarks 🎥 when she accepted the award at the December meeting of Council at the end of the article.

Can you describe the role of palliative care in your team’s response to COVID-19?
We recognized the importance of our purpose — to care for the most vulnerable. For our team, the mechanism to achieve that care was intensive listening and understanding of their individual stories with the aim of alleviating suffering through honest connection and humility. Fundamental to our team’s response was amplification of support to frontline staff, in particular bedside nurses and allied health, as they, too, were juggling so many different demands on their lives due to systemic societal inequities. It was a messy, chaotic time that required me as a leader to come face-to-face with the hard truths about systemic biases.

Sinai also specifically recognized the role of palliative care leadership and clinical support during the pandemic. They saw us as specialists in caring during very complex, uncertain times. So, I know I’m very fortunate because many institutions did not make that connection.

Can you discuss the significance of viewing palliative care through an equity lens?
The ugly truth is that systemic biases exist even when people are dying. We have many studies now highlighting disparities in palliative care for racialized communities. But expansion of palliative care specialists and palliative care beds alone is not a solution. We need a major upgrade in our content and delivery if we are going to be accessible to diverse populations.

The initial step in this process is to name structural racism as a root cause of health inequities experienced by ethnic and racialized communities. Naming it upfront unburdens the responsibility of patients and families to navigate the worst time of their lives alone. Naming it allows us to show up differently — to be proactive rather than silent in our response.

How do you incorporate cultural sensitivity or cultural humility into this approach to care?
We know that each and every human wants high quality care for themselves and their loved ones — even though the components of that care may vary depending on their values. We should not be asking for patients and families to adapt to an accultured version of care. This process of acculturation is often hidden in policies and processes: “This family is not the right fit based on their customs,” “She has to be DNR to get PCU level care,” “He cannot be hydrated or tube fed to be referred to my palliative care program.”

I’m not minimizing the importance of having a vision for limited resources like PCU beds, but I am asking who are we serving with current palliative care criteria? Do patients and families need to erase themselves, cut the tethers to their cultural identity by giving up fundamental beliefs to receive palliative care at end of life?

In your personal history, you experienced racism. Can you describe your lived experience?
Yes. I experienced humiliating, oppressive racism as a young child in a British school in Asia and then the marginalizing, polite version when I immigrated here as a teenager.

What did that do to you?
I was a very tough kid growing up. Opinionated, loud, messy and confident. Over time, the message of “your clothes, your family, your food, your accent, your looks, your entire brand are not remotely cool” got to me. I went through some very dark teenage years.

In their understated way, my parents pulled me up by conveying their belief and trust in me.

Your life is so busy. When you do have the opportunity to relax, what do you do?
The most important lesson I’ve learned along the way is my inner voice needs to be trusted and honoured. There were times when I worked almost all the time during the pandemic, but I did so with a strong sense of purpose, not pressure. There were other times, when my three daughters returned to school, that I felt an urgency to be there every day at pick up, so I did that too. You can’t be everywhere at all times, but you can certainly remain one person with many purposeful roles — so you make choices and you accept them as yours.

Video from Council