2018 Nominees Section
Position: Chief Medical Officer
Organization: Hospice of The East Bay
What role does your nominee have in senior care and senior care issues?
Russ Granich graduated from Boston University School of Medical and did his residency in SF at California Pacific Medical Center. He started a private practice and decided to become a reservist in the US Army out of his desire to help our country. A few years later he was called up for Desert Storm where he was awarded the Army Commendation Medal. About that time, he transitioned to Kaiser Permanente as a primary care provider and a few years later he became a hospitalist and subsequently chief of that department. After seeing many of our elder citizens suffering at the end of their lives, he started one of the first Palliative Care programs at Kaiser Permanente, even before the organization recognized the need. He was a powerful force in the development of a regionwide program, bringing many innovative ideas to the table.
For example, he developed an order set in EPIC for patients at the end of life who are on comfort measures only, including algorithms never used before. In 2006 he decided to leave hospital medicine and focus more on the care of our seniors through nursing home care, Home Health and Hospice. He headed all three departments as well as Palliative Care and Geriatrics at South San Francisco Kaiser Permanente. One program that was started by two excellent nurses a few years earlier was a home palliative care program. He helped build and expand that program, expanding to a daily census of about 400 patients, and the program won the California Coalition of Compassionate Care Leadership Award this past April.
A few years ago, he was asked to become the physician leader for nursing home care, home health and elder care for all of Northern California Kaiser Permanente, which he did in addition to his other responsibilities. His goal is always the best quality of care for seniors and the frail elderly. He was once again innovative and was well respected among senior leadership. He developed the first of its kind educational conference for nursing home physicians in order to improve care. Because of his expertise, he served as an informal consultant to National Kaiser Permanente Hospice compliance. He was asked to become a delegate to the California Medical Association to represent KP as their expert on Medicare, Palliative Care, Pain Management and issues pertaining to seniors. Despite all of his responsibilities, he also felt the need to help the seniors in San Mateo County and became active in the county medical association, eventually becoming president and being awarded special recognition in the state senate and the US House of Representatives.
After working for Kaiser for over 28 years, Russ was offered the opportunity to be the Chief Medical Officer of Hospice of the East Bay, the same organization that cared for Russ's mother at the end of her life several years earlier. He felt it was time to give back to the community where he lived and decided to join Hospice of the East Bay, one of the best rated and well-respected agencies in the area. He has been working at that organization for the past few months and has been improving the infrastructure of the medical staff and the care provided to those who need it.
Why should this person be nominated
This is just one of many stories that illustrate the kind of wonderful doctor Dr. Granich is. After what happened, he developed a protocol for the hospital that would allow other patients to get their final wishes met.
Mary (not her real name) was 82 when she got sick and was admitted to the hospital. The doctors were able to treat her but she ended up in the intensive care unit (ICU) on a breathing machine called a ventilator. After three weeks on the machine, the doctors told her that they were unable to help her breathe on her own and she would spend the rest of her life with a breathing tube, hooked up to this machine. Mary was quite awake, alert and mentally very sharp. The idea of living the rest of her life on a machine was horrifying for her. That’s when the doctors called Dr. Granich to figure out what to do next. He met with her and one of her sons, Ron, who was very devoted and visited every day.
She was alert and understood her predicament. She and Dr. Granich talked as best they could, her writing things, the son filling in info, answering yes and no questions. Her husband of 57 years had died about 10 years before. She lived in her own house, but it was divided up so her other son could live there. He paid rent, enabling her to keep her home.
Mary had only two options: to continue the current treatment and stay in the ICU on the ventilator or to have the doctors take her off and let her illness progress the way nature intended, which most likely would result in her dying, but she would be free of machines. This is an accepted process for patients, like Mary, for whom life on a machine is unacceptable. She had lengthy discussions with Dr. Granich, who helped her understand what her options really meant. Mary had no desire to live on a ventilator. She had a full and meaningful life. Her son agreed and was willing to honor her wishes to have the breathing tube removed (called terminal extubation). However, she had one wish: To die at home. Usually patients who want their ventilator turned off do so in the hospital. However, Dr. Granich felt that he needed to make that wish come true. The intensivist did not think she would make it home if she was taken off the machine in the ICU. There was only one solution—send her home on the ventilator and remove her breathing tube there.
When faced with this decision, there is always the fear of what kind of suffering the person would go through. If they can’t breathe, won’t they feel like they are suffocating or drowning? It would be a horrible way to die. Dr. Granich assured Mary that he would make sure she did not feel that way. There are medicines he can use to ease her breathing and act like a numbing agent for her lungs, so she would never feel like she can’t breathe. Dr. Granich assured her that he would be there with her and be certain she was comfortable.
Dr. Granich had never done a home extubation before but knew that if it was possible, he would make it happen. This had been done before, elsewhere, never at his hospital, but it took an extraordinary amount of time and effort. It is not simply sending the patient home and “unplugging” them. There needs to be the right type of equipment to transport her home, the best critical care transport team, having a hospice nurse at home, making sure that there is still IV access for medications and a whole host of different medicines to assure a comfortable transition. And of course, someone needed to be in charge, a doctor who could accomplish this herculean task. The hospice manager listed many objections and concerns. The discharge planners didn’t think it could be done. The pharmacy objected to sending home IV medications. Dr. Granich worked with his colleague, a skilled palliative care nurse specialist, as well as the nurse manager of the ICU, and they dealt with each concern.
Three days later the team was ready. The patient was picked up by critical care transport (CCT) at 9 am while Dr. Granich waited at her house. She arrived, on a portable ventilator, but her medicine had not arrived and the hospice nurse was not there. There were issues with pharmacy about dispensing IV medicine that had already been addressed, but this was unusual and a real concern. Dr. Granich quickly called the team. The ICU manager showed up with the medications 30 minutes later. He called up the hospice manager and had the nurse come immediately. While they waited, the team got her settled in her bed. The CCT nurse stayed and helped. The team put her favorite movie on her TV. Her son held her hand. The hospice nurse arrived and started doing her evaluation. Dr. Granich looked around her home. Why was it important for her to be there? It was obvious. Her home was filled with love and memories. He could tell that everything had some meaning. When her medicine arrived, Dr. Granich removed her tube and gave her IV medication while he held her hand, constantly reassuring both her and her son. She was awake and could talk a little. She tasted food for the first time in three weeks. She enjoyed her movie. Dr. Granich stayed for a couple of hours to make sure she was stable. While he sat and waited, he was looking around, observing everything he saw. One item was a Salvador Dali-style melting clock.
She died later that night, comfortable, at home with her family. The next day Dr. Granich bought the same clock online. He never learned what that meant to her, but it sits over his desk and every day he looks at it and thinks of her.