Welcome everyone. Thanks for joining. We'll get started in just a minute. Hi everyone, thanks for joining today. My name is Gina Parisi and I serve on staff with HMDCB. We appreciate you all being here for our March Coffee Chat. Before I hand it over to today's facilitator, Dr. Andy Arwari, I just want to share a couple quick HMDCB updates with everyone. So the first thing is that we are partnering with Weatherbee Resources to help promote their GIP intensive that will take place on April 5th. So if you're interested in attending this, I think we sent out an email this morning with more information about the session and you can receive a 10% discount by using the code that's listed here on the screen. And then in April, we are going to co-host a webinar with AHPM on pediatric hospice care that will take place April 18th at noon central. We're going to send out the registration, it will open next week. There will be a small fee to attend this webinar because we'll be providing CME with it, but keep a lookout in your inbox for an email for that or you can visit hmdcb.org slash webinars to learn more. And then in May, we'll host a coffee chat on May 9th at 1pm central and that session will of course be an open format where we encourage you to come with your hospice related questions and we'll also use some of that time to serve as a follow up to the April webinar. Another reminder, just to anyone who expires, your credential expires this year in 2024, you're eligible to renew through our new annual longitudinal assessment. You can learn more about that process and how to register at hmdcb.org slash CCP. Just complete that process by October 31st. And then just want to remind everyone too that we do have a new learning management system so you can create a free account at learn.hmdcb.org and then once you have your account, you can access all up for free all of our webinar and coffee chat recordings, as well as an online discussion board. So I want to introduce today's facilitator, Dr. Andy Arwari. He is a hospice and palliative medicine board certified physician with 20 years of experience in the field. He's completed a master of science in palliative care from the University of Maryland, Baltimore, and is presently working on a PhD in palliative care. Dr. Arwari serves as a faculty member for hospice and palliative medicine fellowship programs for the University of Miami and Larkin Community Hospitals and is the hospice medical director for VITAS where he oversees hospice and palliative care in Miami-Dade and Monroe counties. So Dr. Arwari, thank you so much for facilitating today's coffee chat. And I just want to remind everyone to please stay on mute unless you are speaking and feel free to come off mute to ask questions, provide peer support, or you're also welcome to interact with each other in the chat box. Dr. Arwari. So good afternoon, everyone. Thanks for having me. I hope to have a lively conversation with all of you. And I wanted to start off because this is the first coffee chat that we're having after the annual assembly, the American Academy of Hospice and Palliative Care. I was curious if any of you who have attended the annual meeting have any important takeaways that you'd like to share, especially in regards to hospice and hospice care in the United States. So good morning, everyone. I'm trying to get through here. I wanted to bring up what happened in the hospice homeroom. It got really heated. I'm going to have to put myself on mute in a sec because I am driving, but I'm at a light for a moment. But it got very emotional about medical aid and dying. And I know things are changing rapidly in the United States. And so I think there was some talk. A lady was upset, thinking that we are now making that a part of the hospice benefit. And also, you know, other people were saying, no, that's not our stance. And so I was just wondering if we could talk about, you know, what we're doing or what we're seeing in our communities to protect those hospice agencies that may not want to be involved or just kind of talk about our stance. Because since it's end of life, I don't think we can be silent on it. So that's something that really stood out from there. I'm hoping we can talk about today. But other than that, the annual assembly was wonderful in Phoenix, and it was good to see everyone. So thank you. I actually think this is a very important topic because we tend to struggle with this perception, right? Families and caregivers always have this misconception. And I just wanted to comment something that I'm sure this is common knowledge to everyone. We actually have the ASFRA federal regulation from 1997, which basically states that the federal government will not participate in anything that has to do with assisted suicide. And in 2021, there was a cautionary memo sent by CMS to all the hospice agencies, reminding them that Medicare certified hospices, right, have to be very careful to not give that impression that we are somehow participating in assisted suicide. That's where I stand. I make it abundantly clear to family members as I interact with them and their families that that's not what we do. We do not participate in medical assisted dying. The intent of interventions that we're going to provide are to alleviate suffering and distressing symptoms at end of life, and that we are supporting the natural process. We're not going to expedite it. We're not going to delay it. But we are not providing medical assistance in dying. That's my stance. But I always want to give you the background that there is actually a federal law that people know about this. Is that enforced? Is it fully communicated? I leave that open to everyone else's opinions and discussions about how they feel about this and what they share with their families and patients. That's amazing. Someone put those links in the chat because I was not aware of that. And I would love to amplify that in my community and also in the online community because, you know, it needs to be readily available. And I don't think people know about that, honestly. And unfortunately, you know, this is something that medical assistance in dying, you have a lot of advocates. So I really feel strongly about this. I find it very interesting, at least in my experience, what I've read. Usually the people that write about medical assistance in dying are not physicians. A lot of letters behind their names. Unfortunately, they're not the ones that have to actually provide intervention to end someone's life. So I think that's a little bit of a problem, right? Because this is not coming from within our group that we say, well, I advocate, I believe in this. And so I'm going to advocate about this. I have a big problem, and I'll share what my concerns are with the group and you guys tell me what you think. We do a horrendous job at screening patients for depression. I challenge anyone, and in my experience, I've never seen consistently patients screened for depression or anxiety, especially during hospitalizations or physician visits. How do you know the patient's not depressed? What do we try? And why is the patient asking for medical assistance in dying? And what I'm mostly concerned about is, are these patients that know the difference? Do they have access to hospice and palliative care? Are they doing it out of desperation because no one is addressing their suffering? And so it just becomes a movement, and I think we are obligated to speak about it. I'm not judging, right? I'm not saying everyone may have a reason for it, but I don't think we should just buy into it and just say, yep, we're going to support this, or sure. Again, I'm absolutely happy to email you, Dr. G, the reference to the federal regulation. Hi, this is Dr. Chalad Rajaram. I'm a little confused about where you stand, Dr. Anwari. Are you saying that you're against this? One of the things in California, I'm in California, so is that with this End of Life Options Act, is there are two physicians that need to be screened for depression? And there is a recommendation for the person to come on hospice. The reason being is that if there was poor symptom management during the time that, again, this is a patient initiated, and they have to be able to take the medicine themselves. While there are two physicians who do the consultation independently and also prescribe whatever the medication they need to take. So, what I'm on, and if they have to come on hospice is because there have been some instances where things were not very good, and therefore, that there is an agency that's available. Now, within VITAS hospice, and I'm retired from VITAS, I'm not an active physician, I'm the senior medical director for 15 years, is that there are people who come on this with the End of Life Options Act. Ahead of time, everybody knows this is why they are coming on to the hospice program. Many a time, the medicines remain on the shelves. They're never used. The team is doing a great job in bringing the interdisciplinary care, the one that you're talking about, the communication and all of those aspects of why are you wanting to do this. Not judging, but being there for providing emotional, spiritual, medical, all supports that we all know about in hospice. But I'm a little bit concerned about where you said you stand. Again, as a community, we are hospice medical director certified physicians. We are a community as well. Are we going to have empathetic, nonjudgmental aspect of this where the states have come up with this is the way for this is allowed in the state of Washington, Oregon, California? I don't know every state that does this, but I want you to be clear and understanding. Because I'm feeling the tension already within this conversation. Absolutely. And thanks, Dr. Shah. I really appreciate it because I, so I want to separate my personal views and from my professional views. Right. And can you, can you do that really? Are they, are they, is that an easy thing to do? I don't think so, but I do think we should, as a community, HPM community, you know, be aware of the federal regulation. How enforced is that federal regulation? That's the question that maybe hangs on all of us. I don't know if that's really enforced, but there is a federal regulation out there. The ask for a law from 1997 that basically states that the federal government will not support and actually threatens to take funds away from agencies that they're funding to provide end of life care. And you would say, well, how current is that? Again, there was a cautionary memo in 2021, went out from CMS to all the hospices in the United States saying federal government will not support this. So I just want everyone to be aware of that and not get caught off guard and saying, well, I wasn't aware that there was a federal law that actually said that, you know, this is not to be funded. I also think that if you start reading the articles about this, there's a lot of confusion out there. Right. I just read something from three ethicists that were saying that there was a distinction between medical assistance and dying in euthanasia. I honestly don't see the difference, right? Because what's the intent? The intent is to end someone's life. And we are providing the intervention. We the physicians are the ones that are writing scripts for those medicines. I have a hard time seeing that there really is a distinction between the two. But I just want to be sure that as practicing hospice physicians, we are at least aware that there is that federal regulation in that is still vigilant and that is still in play. Right now. Are we being educated at our different hospices about this? I don't know. That's a question that I was hoping, you know, all of you would participate in and share your experiences of what you what your hospice agencies are are sharing with you or if they're reminding you of this or if this has ever been brought to anyone's attention. I live in Tennessee where it's not allowed to do medical assisted aid in dying. I also graduated with a master's from the University of Maryland program in palliative care. So I know that we discussed this in some of the coursework that we did in one of the courses there. But the difference between euthanasia and medically assisted dying was characterized by whether the patient gives the medication to themselves, it's self-administered or it's administered by a physician. The difference being that the ultimate choice ends up being the patients like Dr. Rajaram was saying that sometimes the medicine sits on the shelf and, you know, they don't ever use it. But I do remember from one of the slides at AHPM, you know, last week that there was something about Huntington's disease and then and I remember that because I had a patient with Huntington's and her way of trying to die faster after having watched several relatives die was voluntary stopping of eating and drinking. So that was her method of suicide, if you will. And it was a really, really difficult course within our hospice agency because at times she would want to eat and so we would support her in whatever she wanted to do. But then she was so miserable being alive, she didn't want to be alive. So that was a difficult case that I know would have qualified for that medically assisted aid in dying according to whatever slide that was and I apologize, I can't remember what session it was that I was in where they were talking about that. Everything kind of blurts together when you first get back from the conference, but that's how we would handle it as an agency because we're in a state that does not allow it in Tennessee. Just a little commentary I want to make, there's an excellent book by Dr. Timothy Quill and I forgot his co-author's name right now. He's another palliative hospice and palliative medicine physician and they actually had a presentation at a previous AHPM. I want to say a year before or two years ago and it's a really great book because it really affects the ethics behind voluntary stop eating and drinking and what Dr. Quill says, right, is that it's not considered medical assistance in dying because it's the patient's choice and we're just respecting their autonomy. So I just wanted to bring that up, right? So if someone were to come in, for example, and tell me I'm not going to eat and drink anymore, would I consider that I'm helping them or I'm eating in their dying? And the answer is no, I'm respecting their autonomy and it would, what is dissected in that book, right, this is not considered medical assistance in dying. I do find it a little bit difficult, right, if I am as a physician writing for an intervention to cause the patient intent, cause the finality of that patient. I am, even though I am not the one administering that medicine, right, I am providing that intervention to that patient. Yes, it is the patient's choice. I have facilitated the vehicle to terminate that patient's life. And to follow up on what Dr. Shalott had said, right, about, I had clarified was what I was saying is, again, I'm not judging, you know, we can't, because this is not going to, it's not, it's not a, I'm saying don't do this, that's, we're not, we have to respect the bioethical principles of autonomy, right? What I am saying though, is I would like to see a little bit more due diligence as far as screening patients to understand the why. Are we doing a good job at screening patients for depression? Are we intervening in depression, right? So we know that depression is not, it, so we know that the World Health Organization identified 300 million people as having depression. We know that the medicines that we use to treat depression, we haven't had really any new medication since the 1970s, right? The SSRIs came out in the 1970s, then in the 1950s, we worked on the, on the monoamine oxidases of the 1970s. So yes, now we have, for example, we have ketamine, and ketamine, by the way, is a phenomenal drug. I use it a lot. However, I am not seeing patients actually get screened for depression. And I mean, I'm talking about our population, right, the patients with chronic progressive terminal diseases. If you look at their records, how often do you find that they've actually been screened for depression, that we have an objective screening tool that we say, yep, you know, we looked at depression, we looked at anxiety, we tried interventions, we know that this patient is making a choice, not because they're depressed. So my, so I want to clarify what Dr. Rajam had asked me, right? What I'm saying is, at least, let's make sure that we screen these patients first, appropriately, to exclude the possibility that they're coming from a place of a, they're suffering because we have not helped them or intervened on their depression or anxiety. I want to add to that, and I want to move away from this to another topic I want to add. One is, again, these are things that come fast. Patients have made their decision, and we as a hospice get the call that one of the reasons for them to come on is they have made this decision. They've already had two doctors who already have evaluated them. Many of them have the prescriptions, but in California, since there's a hospice agency that needs to now kind of be involved with an admission, even for a choice that they have made. Now, after we admit them, we can have these conversations. But let me now segue into what I enjoyed at the conference. And mine is more to do with spirituality, is a good way to move from this topic to spirituality. I took part in the I-SPEC, which was from Dr. Pachowski and her team from George Washington University on improving spiritual care practice. And I'm planning to join, along with the UCI spiritual care team, maybe a couple of days of training in July, which they're offering to improve. We have medical students now doing two weeks of spiritual care rotation for third and fourth years, and I'm enjoying that for the last two years. So that is one good thing that I took back, and I'm going to work with the faculty at UCI palliative care. The other one was on existential distress and within family and caregivers. And of course, they need more randomized control studies and more diversity in samples. I heard that many times during this meeting, is that the sampling has not been very good and we haven't been very diverse in the sampling methods used. And I hope in the future that the academy, as well as our HMDC, will be looking that. The embodiment of caregivers, again, integrative methodologies for cultivating self-care. That was another one that I'm very interested in the self-care with students and with fellows. We are asking them always, what are you doing for self-care? And if we don't do it ourselves, how do we know what to ask them? So I think that I came away with. And then there were three physicians who also did divinity. So they are chaplains as well. So I attended that one to hear their perspectives, even though I didn't learn too much. I was hoping for a lot, but I think with that little time that is given to each person, you don't really get to see the journey very much. But there was an interesting combination of three palliative physicians who are also have done their divinity courses and are chaplains as well, bringing their perspective. So those were what my takeaways were, mostly from the psychosocial, spiritual, and self-care perspectives. Thank you for the opportunity. Thank you for sharing that. Does anyone else have anything that they took away from the meeting that you found useful or meaningful? Andy, just to circle back really quick to the main conversation, I'll share a link in the chat to the federal regulation you were referring to, but feel free to correct it if that's not the most up-to-date version from CMS. And I can also send you the link later, Gina, so maybe you can email it to anyone who might be interested. Yeah, we can include it in the follow-up. Absolutely. Again, I just want people to be aware of it, and they can perhaps share with their own hospice agencies and discuss how they are handling that. And again, I'm not in any way, shape, or form saying that it's wrong. Of course, I practice in a state where maid is not possible, it's not legal. That also is part of my views on it, but I do think that we have a little bit more work to do. There is a webinar coming, I'm sorry, a coffee chat about this, so I'm sure there'll be more discussions around this. I do perhaps have another thing that I wanted to ask about the assembly to see what we think. In my experience, in the past assemblies, I was not able to attend this year because of work obligations. My perception has been that there's perhaps a little bit more leaning towards palliative care than there is about hospice. And so I'm wondering what others may think about it, and if they think that perhaps we should advocate for the academy to have a little bit more offerings on topics related to hospice. Most importantly, not only on hospice, but integrating palliative care and hospice, which I think is an important issue. One of the things that I personally struggle with is always when we have these discussions about palliative care is not hospice and hospice, and I'm not palliative care, and I'm hospice but not palliative care, when in reality, possibly care is the same, it's just the moment in which the patient is going to access different care. Just wanted to see what others may think about how we can potentially advocate for more hospice offerings for the academy. This is Tom Browning. I've practiced hospice medicine for 35 years in Massachusetts, and I heard myself referred to as a vendor. I was floored, speechless. So yes, I'm all over it. I felt like a stranger in my home. So I didn't really know what to do with that. So I would like to hear what we can do, because I don't see, I'm going to try to retire, and I don't see anybody who's interested in doing what I do. I don't, you know, I'm in touch with all the fellowship programs in Boston. They're all interested in academics and palliative care and working within the acute care setting. And don't perceive what I do as really practicing medicine. That's where it came up. It's a vendor, as opposed to a team-based medical care service that provides therapeutic benefit to our patients. I just today had a long talk with a man who is coming home with hospice services that hopefully will extend his life with bad cardiovascular disease. So yes, I'd love to see more specific offerings for hospice. We've birthed the palliative care program. So anyway, thank you. Hello, I'm Ron Van Buskirk, and I stand 100% with what you've just said. I get aggravated every time I hear somebody from CAHPSI say that palliative care has nothing to do with hospice care, that, you know, we've, especially some of us who are older, I'm, I've been doing this since 92, and hospice gave birth to palliative care. I mean, Dr. Balfour, when he coined the term palliative care, I don't think he ever dreamed where it was going to be a for-profit national movement. No, and thanks for, you know, that's an important, let's remember that Dr. Balfour was a fellow under Dr. Saunders, right? So the philosophy of care that he learned was holistic interdisciplinary care. And that's what we all advocate for. I don't think any of us here would say that we're different. But unfortunately, we have this dichotomy of hospice and palliative care, when in reality, it's a continuum of care and it's the philosophy of care, which is the same. It does not change. But somehow we seem to be, you know, at odds with each other at times, or there are people that want to, and I think that really, it should be more of a, how do we show that this is a continuum? And absolutely, it's the philosophy of care that has value to patients and families. So I think we just confuse more, right, when we start saying, well, palliative care is not hospice, or you're in hospice, and this is no longer palliative care. And, you know, that just is not really what I think the way we should be going. And we need to start somehow working towards normalizing that, more education for our communities. And unless we do that, you know, these things are going to be perpetuated. I work in fellowships where the majority of the time that the fellows spend are in palliative care, right? And they themselves sometimes say, but I don't understand, you're doing exactly the same thing that I'm learning in the hospital. Yes, interventions are the same. It's just the moment of time when I'm delivering these interventions, that's going to make the distinguishment between palliative care and hospice care. They themselves don't spend a lot of time in the actual part of hospice, right? Which I think is also the service. So we need to also help everyone understand that that also has value for our future physicians and team members who are going to be working in the hospice field primarily. My capsule summary is that hospice care is really palliative care for people who are dying. That perhaps becomes a question that is almost never discussed, and that is, when does somebody become dying? Right now, the federal government says it's six months, and I think many of us think that's the point that we need to start talking about to try to change. And we all know that that was a financial decision. Of course. Right? That came from the office, the Congressional Budget Office, that it landed on six months, but there really wasn't anything clinical behind that. I just think that we have to start working towards how do we integrate palliative care into just any type of care, and how do we integrate palliative care into just any type palliative care into just any type of care, but it just normalizes palliative care. And actually, I really do think that we should be talking about care, not palliative care. I mean, if you think about it, the things that are done in palliative care are just care, good clinical care. As we need to start getting that integrated upstream sooner so that then it becomes easier for people to accept and transition into hospice when it's appropriate. I'm a big proponent of educating patients and families and sharing with them that we are the only country in the world that has a fully funded end-of-life service. Hospice is under Medicare Part A, so when patients do elect their hospice Medicare benefit, Medicare Part A becomes hospice, right? A lot of people don't even know this. They're like, what? What are you talking about? And we need to stop medicalizing hospice as there's nothing left for us to do, so we're going to recommend hospice. Because that's the perception that a lot of patients and families have. It's we are the ones that are making people hospice. And the reality is, no, we're just alerting you that it's time that you can access your benefit if you so choose. But people don't realize it's a benefit. And they just think that we are the ones that are pushing them in that direction. That's how we get linked to medically-assisted dying, right? With what you just said. Absolutely. Very good observation. I wanted to add to that. I haven't been in hospice forever. I've been in it since 2017. I did outpatient internal medicine before that for eight years. And what I found is, in dealing with patients, sometimes even asking for a palliative care consult, like with my mother, who was hospitalized a couple of years ago. And we asked for a palliative care consult. And the hospitalist said, well, she's not dying. She's not dying. And my sister, who I've educated so thoroughly about all of this, thankfully, as part of the master's program in palliative care, we went over lots and lots of different information about goals of care and what really broke my father's heart, that article by, I think it's Katie Johnson, which is really, really excellent, about having a pacemaker put in. Her father had dementia and was kept alive long after his mind had quit. And this was a cardiac issue with my mom. And so when she talked to the hospitalist, she said, no, palliative care is an umbrella. And within that umbrella is the six months that someone, once somebody has a prognosis of six months or less, then their hospice appropriate. We don't think she's dying. My sister and I were taking shifts, so I wasn't there at the time. And I gave her massive kudos and pats on the back for such a great conversation. But there's also a conversation, Dr. Goudry, I hope I'm not messing up your name, but in the comment, she said, upstream is a problem when many specialists say things like, it's not time for palliative care. And I thought, I so need to add that comment because I've seen it myself with my own family. And now that I do hospice, a lot of times people will, you know, have a big church family, big extended family. People will ask me things and they'll say, well, I know this isn't really your field. Well, I'm a doctor first, you know, and internal medicine, we're trained to take care of everything. I had a very big practice with a wide variety of clinical problems. I didn't quit being a doctor when I started to focus on end of life care. And so, and of course, having done the master's in palliative care, I feel very comfortable with the palliative, but even to be able to take some of the jobs that are available that are hospital based with palliative, I have to have the fellowship. It's not sufficient that I have the master's in palliative care and I have my hospice medical director certification. So, and that's a credentialing thing coming down from on high, you know, so there's a lot there that's trying to separate us as two different entities and we're not, it's a continuum. Sure. Absolutely, Dr. Mercer. And, you know, as a fellow alumni, right, I will tell you that when Dr. McPherson, who was the program director for the master's, for those who may not know, she's a big proponent of primary, secondary, and tertiary palliative care. And so I was like, yeah, I don't know. And so as you go through the program, you kind of say, yeah, that's absolutely correct. I think that every physician in the United States should have primary palliative care skills. They need to, right? That's absolutely a must. And then we can start talking about secondary and tertiary, but that's the problem. This is, you know, not advocated, there's not enough resources or it's not integrated and that has to change. The other thing that I think is important is that if you look at the physician workforce in the United States today, 70% of the physicians in the United States are specialists and only 30 are considered the primary pediatrics, family practice, and internal medicine. So unless we start integrating palliative care skills, at least primary palliative care skills in fellowships and subspecialty training, we're never going to meet the expectation of integrating palliative care into the healthcare system. I don't think, and I hope this is, you know, so we know that about 80% of hospitals in the United States have a palliative medicine service. What we don't know is who really constitutes that service. Is it an interdisciplinary care? I know of hospitals that you have a nurse practitioner or you have a chaplain and a physician, or you may not necessarily have the core interdisciplinary team members for that palliative care. Whereas in hospice, that's regulated under the Code of Federal Regulations, you have to have the core services, right? There's no way around it. So, again, there's a lot of confusion, a lot of misunderstandings, and as you pointed out, to this day, there are people, when you mention that word, palliative care, it's like, oh, yeah, no, my patient, my loved one, whoever they may be, they're not dying. They don't need that, right? It's unfortunate. So, we still have a lot of work to do to educate not only the community, our fellow physicians and clinicians. There were a lot of kind of poster sessions from various fellows and others that I went through, and I enjoyed the app that we all had on the phones on the academy meeting, because the posters were all in it, and a couple of days before the meeting started, I was able to read a lot of the posters from the app itself, and it was able to give my faves and likes and whatnots. And when I actually walked around, there was a lot about primary palliative care that you're talking about, Tanvari, on the ways that they have integrated this and brought this further up. So, I was happy about that, yeah. But how do we bring more hospice conversations? I think each one of us has a role, and that's the only way to do it. If you think of the whole HPM, we can bang our heads on the wall and feel the unhappiness, but let's just do one person at a time that we are dealing with in our communities, with both palliative and hospice teams, and then making the difference, making that call. Yes, the word vendor, I've been teaching at the palliative department for 13 years, and yet I'm referred to sometimes as a vendor, but that is, I feel their loss, or their own perception. I don't want to lose my energy trying to change it. I'll continue to go forward. One thing I was going to say, and I thank Gina for mentioning the October webinar about spirituality, is that VITAS actually honored me, even though it's been three years I retired from them. I'm still a mentor to the two medical directors at my program, who are my palliative fellows and medical residents at UCI. I promoted, I brought them, I trained them, I mentored them, and now they're running the ship. Now, I am still there as teaching spirituality, teaching some of the didactics for fellowship, but VITAS brought 30 copies of my book at the academy meeting, had me sign this for anyone that walked into the booth, which was a great honor. HMDC already did that, but the academy, when I wrote to them, I am a no one. I didn't even get a reply from the academy. You would think that someone who spent 30 years on thinking about a search within, how to kind of bring this knowledge, how to share this, with a palliative organization that talks about spirituality, self-care, there was absolutely, I was a nobody, but am I going to hold it? No, because I have more things to do, and we all have more things to do, and let us continue that. HMDC was amazingly kind of present, and I made sure that because people that came after me in my program are all HMDC certified. We all took a group picture at the HMDC booth, and we published it. We promoted it, because I think we feel the essence of who we are in this organization, and I want to continue to be, that's why I joined today. I wanted to be a part of this that honors you. Let's not worry about others that don't. Thank you. And by the way, congratulations on your book, and thank you, because I think it's so important that, you know, we need more. I see it as an advocacy, right, for what we're doing, and so thank you so much, and I'm actually looking forward to reading your book. Thank you, and actually the CMO, Dr. Joe Shager, he got the Josephine B. Magno Award from the academy, and we had an event for him. I invited HMDC into that event that evening, that reception, and he's in Orange County now, and my physicians had a quarterly physician's dinner, and guess what they did for Doctor's Day, which is actually today, and happy Doctor's Day to all of you that have joined, is that they brought copies of my book for me to sign for every physician at the quarterly physician's dinner for hospice, and Joe Shager attended this. He was here two nights ago, so those are the humbling parts, and those are the ways that we go forward, and I want to share it because it is not my joy. It is all of you that work in this field and work in this beautiful and wonderful thing, and don't feel dismayed. I would continue because we make a difference. Thank you, very beautifully said, and I agree with you. I think that, you know, we're talking about all these things, however, each of us needs to continue to advocate, and that's why it's important to advocate and to help dispel the myths around hospice, and also help everyone understand the difference. It's not an easy task, but I am grateful for the HMDC organization. I really do think it brings a lot of value and I just hope to see it grow as time goes by. Again, I am at least someone who believes that we really should not be making a distinguishment between palliative care and hospice. It's a philosophy of care should not have a dichotomy. It should be a holistic philosophy of care that we believe in and just need to continue to advocate for it. I did want to ask, did you, because you mentioned the posters, how did you find there were posters specifically for hospice-related care that interested you or caught your attention? Yeah, let me kind of, while others are talking, let me just find those specific ones. I'm going to go into my app. Thank you. I'm really humbled by everything that some of you have done, but some of us are in a situation. We have two community hospitals that our hospice is affiliated with. For a while, I did inpatient palliative care at both hospitals, until both hospitals told me they didn't want to have inpatient palliative care because it generated no income. So, I don't do that anymore. And in Texas, anyway, I don't know what the statistics really are, but the last time I looked, only 30% of the hospitals with over 300 beds in Texas had palliative care programs. It's really a shame, specifically because, so for example, for hospitals, when we look at their survey, right, the HCAP scores and the things that they're asking about the experience, I always like to say it's the patient experience, not the patient satisfaction. There's a huge difference between experience and satisfaction, right? Everyone tends to refer to these things as patient satisfaction scores. It's really about the experience. One of the things that I think is an opportunity is measuring their experience. And one of them really is, was the care that was provided coordinated? And who better to do that than an interdisciplinary care team? I still think a lot of care that's being delivered in the United States is siloed. And we need to, that's another thing that needs to happen, or it needs to occur, is the transition to interdisciplinary care as teams. What better service to exemplify that other than hospice? This has been, this is what we do, right? We work as part of a team. We're not siloed. Matter of fact, sometimes, you know, we have to tug at people's ears like, hey, you know, you need to talk to each other and you need to come up with plans together. It's not, you know, the doctor says we're going to do this. It's, what does the team think? And everyone has to have a voice at the table. So that hopefully should permeate throughout the whole entire healthcare system. And that should be the ideal that we should aspire to as delivering healthcare and as receiving healthcare, right? Because we're all going to be on both sides one day or the other. Going back to the hospice, if you, if you go to the app and you look at the posters and they have arranged them according to hospice, and there are about, there's about 20. I just took screenshots of them along with the numbers and the topic, and I emailed it to Gina. So Gina should have the screenshots of, and it's like hospice at home, historical perspectives. It's like, a specialized program for hospice patients living with end stage heart disease, barriers to hospice evaluation, death before assessment for hospice. So, you know, remember those patients that we send our admissions and they've already died before we go in there. So these are the late referrals. So there was a lot of work done, accuracy of medical local coverage, determination and guidelines. Can we help broken hearts hold on, exploring the prevalence. So interventions and predictors of transition to hospice. So it goes on and on. So I sent that to Gina. If she can add it to this call, then people can go into and look at that actual number of the poster and you can open it. And if you have the academy website, you can actually go and see it. And I'm planning to get some of my CMEs now afterwards, because I didn't do every lecture or everything. But so I hope this was helpful. Thanks, Dr. Rajaram. I can include it in the follow-up to today's session. And Andy, I just want to point out Melanie had put a question in the chat about recommendations for getting the word out about hospice and palliative care, especially within the native Hawaiian community. So I don't know if she's still on the call or if anyone has any recommendations to assist her. I'm sorry, I'm not looking at the chat, so I apologize. I'm just going to share how I found it to be the most productive way to approach the conversation, because it's never easy, right? People tune out when they hear the word hospice, because again, it's become medicalized and it's associated with this abandonment or giving up. That's at least the perception. I think, however, if you address the conversation by sharing, I'd like to give you some education, I'd like to talk to you about a benefit that you have. Start off with that. And I've never had anyone say, oh, I don't want to hear about anything that I'm not aware of. I've never had anyone say, oh, anything that I have and it's a benefit, what are you talking about? And there's something I don't know about. So that's where it gives you at least the foot in the door to start talking about hospice. And you don't have to rush in and say, well, I'm here to talk about hospice. I'm here to talk to you about the benefit, a federal entitlement benefit that you have. Would you like some information about that? And my experience has been when it's approached in that manner, people are receptive. They want to hear it. You mean I paid for something and I don't know about it? Really? Yes. Of course I want to learn. And it's sort of, so this is what I've noticed, right? So when it was initially, hey, I'm here to talk to you about hospice. So like, no, I don't want to talk to you, right? Because I don't want to hear this. This sounds like bad, ominous, um, I'm not ready for this. Um, no, I don't want to stop this. As opposed to, I'm here to talk to you about a benefit. You keep people's curiosity. So at least the way that you're approaching it is going to at least open the door for them to be a little bit more receptive to you having the conversation. And once you start having the conversation, that at least gets them to start thinking about it. I always say there's no harm done because again, anything, right? Even if they say, no, I'm not ready for this. I don't want to, I don't want hospice. It's not for me. At least you have done a civic duty. This is the way I look at it. It's a civic duty because we are educating about a federal entitlement program. And if they say no, at least they know what hospice is. They didn't shut you out. They didn't say, I don't want to hear it. Leave my room. That's my approach to it. And it's, it's so far, it works well for me. I rarely have had anyone say, I don't want to hear about hospice. I don't know if anyone else wants to share their approach or their experience of how they address the conversations around educating people about hospice. Thanks, Andy, for answering that. I know we only have a couple minutes left, so I don't know if anyone has any final questions or thoughts that they want to share. I do want to maybe perhaps share this. I just want to thank everyone. I really do think it's a privilege to be able to talk to fellow hospice and palliative medicine physicians. It's always nice and rewarding to know that we're not alone, that we all come and have different experiences in different work environments, but to have a forum where we can exchange ideas or have discussions about topics, agree on certain issues, disagree on certain issues, is really a great opportunity and a great venue. I just hope to hopefully see more of us participate in these coffee chats and all the activities that HMDC is providing for us. Thank you so much. Thank you, Andy. You did a great job of bringing us together. Gina, it was wonderful to see you at the Academy, and nice to see you today. Thanks, everyone, for attending. We'll send out access to the recording to the email you registered with, and we look forward to seeing you at future events. Thank you all for everything you do. Happy National Doctors' Day. It's really an honor to support you. Thank you.

Coffee Chat session

hospice care

palliative care

HMDCB

medical aid in dying

depression screening

clear communication

palliative care integration

interdisciplinary care