And we'll go ahead and get started since it is 3 p.m. Central. So thank you so much for joining today's Coffee Chat. We really look forward to hearing from each of you. And before we get started today, I just wanna share a few HMDCD updates with everyone. So we have a couple upcoming events. We'll be co-hosting a webinar September 19th with AAHPM. So you can register on AAHPM's website and use the code on the screen. If you're not a member of the Academy, you can receive the member rate for being certified with HMDCB. And then HMDCB will host a webinar in October 15th at 5 p.m. Central, and it will focus on reflections in hospice care, which will focus on spirituality within hospice care and hospice medicine and what that means to the physician. You can register for free at hmdcb.org slash webinars. And then Weatherby Resources, for the first time, will be hosting the Hospice Audit Survival Training. And this is an all-day course that is on October 18th from 10 to 3 p.m. Central. So it's a great course to learn in depth about hospice audit. So if you use the code listed on the screen, when you register, you can receive 10% off. And then finally, just a reminder to anyone whose credential expires this year, you will need to participate in the Continuing Certification Program by October 31st to renew your credential. And just another quick reminder, today's Coffee Chat, all of our Coffee Chat and webinar recordings are now in our new Learning Management System. So if you haven't created an account yet, go ahead and do so for free and you can access all the recordings and visit learn.hmdcb.org. So today's Coffee Chat will be facilitated by Dr. Robin Turner. Robin Turner is a Certificant and current volunteer with HMDCB. So Dr. Turner, thank you so much for hosting today's chat and I'll now hand it over to you. Try and get off mute there. All right, wonderful. Welcome. We got through that pretty quickly. So it's still early in the hour. I expect more people to join. If you haven't been on these Coffee Chats before, we solicit questions prior to the Coffee Chat and we had a couple today that we'd like to share and discuss during the course of this Coffee Chat. But I also would like to open it up to the group and maybe if there's a larger contingency in the next few minutes, we'll stop and regroup and ask again, if there are any questions that you all would like to bring up today at the Coffee Chat. So David is on here, I see, and he had submitted a question about ketamine and we certainly can talk about that. Does anyone else, you're welcome to put it into the chat. Have any questions that you would like to bring to this group? So David wasn't the only person who had a ketamine question. There was one other ketamine question. Let me pull those up. David's was using a question about using end-of-life ketamine therapy in the hospice. And actually, Noel's was similar and included whether or not people are using oral ketamine at home. So if there are no other particular questions at this point in time, feel free to enter them at any point in time. I thought it might be reasonable to start with a couple of slides about ketamine. Would that be helpful just to get us on the same page? Can I jump in for a sec? Yeah, sure, David. My question wasn't, I mean, I use ketamine a lot for things like pain control and stuff like that. My question was more, I've been doing a lot of learning about using ketamine really more for sort of guided therapy, helping people deal with the psychosocial stress at the end of life, not about using it for pain management or stuff like that. So that was just to clarify my question. No, that's great. And I would love for you to share how you do that and what you know about that. And we don't have to have the slides at all. I just wanted to make sure that if people wanted to have just a two-minute review on ketamine that we could do that if they wanted. Up to you all. I'd like to see the slides. OK. All right. And again, these are just to review ketamine. I'm going to share my slides. This really is taken from a fast fact. Eric Promer did this, an update in 2016. And there is more information in terms of use within guided therapy, as David was talking about, and a little bit more on use in depression that these slides don't cover. But again, just to get us on the same page about ketamine and its current uses in hospice. My slide is not responding now, even though it did beforehand. Hmm. Sorry, give me one minute. I'm so sorry. There we go. OK. I think we all know that ketamine is a blocker of the NMDA receptor. And this will inhibit the excitatory effects of both aspartate and glutamate. The receptor is a calcium channel in the dorsal horn, and it is involved in central sensitization. So it interacts in complex pain, neuropathic pain, and is thought to be part of the wind-up syndrome. Ketamine also interacts with other receptors, such as the opioid, nicotine, and muscarinic receptors. And the pharmacology of this within pain, it is, of course, approved for anesthesia. It's being used in depression, as we'll talk a little bit more about. But with regards to pain, the routes available for ketamine include oral, intranasal, transdermal, rectal, and sub-Q administrations, IV, of course, as well. In the oral route, there is a conversion to the norketamine, which is questionably less active than the parent compound. And just as an FYI, the onset of action is 15 to 30 minutes, and the duration is up to two hours after administration. I think, importantly, it is stable when mixed with medications that we use often in hospice, which is dexamethasone, Haldol, and metoclopramide. And, of course, you have to be careful with certain medications that interact with the SIP system. The adverse effects at the levels that we use it for pain are really dose-dependent. People at anesthetic levels will experience the psychomimetic effects, but it's more dose-dependent at the levels that we generally use in hospice. So the side effects tend to be dissociative, nausea, sedation, delirium, hallucinations. And occasionally, Ativan or Haldol are administered to minimize these effects. Long-term use, I have not used ketamine long-term. I don't think the use that David is talking about would be a long-term use, but should someone have chronic pain for which ketamine or long-term pain, I guess, for which ketamine would be appropriate, you do need to worry about neuropsychiatric delirium, toxicity, urinary toxicity, and liver effects. And ketamine, you develop a tolerance pretty easily to ketamine because it induces its own metabolism. And again, at this point in time, when I took a look at the literature as well and checked around with some other people who are using ketamine, the main uses remain pain control. But there aren't any large controlled trials that support the analgesic effect of ketamine. There are lots of case reports. I can certainly share. I'm sure all of us can share with each other case reports of ketamine being quite effective in control of, in particular, neuropathic pain. Ischemic pain is another common one. Several inpatient units I'm aware of, and certainly within the hospital, combining ketamine with morphine for dressing changes is effective. And we're all familiar with topical uses for neuropathic pain as well as mucositis. Another area of use for ketamine in palliative care patients are de-escalating high-dose opioids. The dosing for, in particular, I think Noel, and I'm sorry, I don't know if Noel is on at this time. Home dosing, home hospice patients can, in some areas, get oral ketamine. Usually, you start around 10 to 25 milligrams. I tend to start on the low side of the dosing. And you titrate up by 10 to 25 milligrams, although there isn't any particular recommended interval. Initial IV dosing tends to be around 50 milligrams a day with a titration of 25 to 50 milligrams per day. Some maximum doses that are recommended are in the literature. And a lot of times, IV medication, IV ketamine for pain is administered initially in a burst dose. So maybe three days worth of a higher-dose ketamine to see if that's effective. And again, if you're going to use it in a patient who has a prognosis of greater than a few weeks, it really isn't recommended to continue much longer than a couple of weeks, as the long-term toxicity, neuropsychiatric and liver, tend to be seen. So there is information about use of ketamine at the end of life, again, mainly case reports. And I think there's a fair amount in the psychiatric literature. And so I would just like to open it up now for further discussion around David's particular question. I don't see Noel on. Use in guided therapy at end of life. Is anyone using ketamine for this effect? And David, I'd love to hear your experience with it. Hi, this is Alan Rosen. In my 24 years of hospice, I've worked with a variety of organizations that have mostly relied on it more for the pain, also for a bit of the existential element, because like you mentioned, Robin, with the dissociative state, so sometimes when there are really horrendous or horrific types of invasive cancers that can be disfiguring or directly involved neuropathically in direct destruction, it has been helpful. I'd be curious to hear what others have done. There's more that's coming out. In terms of the guided imagery and preparation, and there's some of the guidance that's also, if I recall correctly, Zach Sager and some others doing research with psilocybin and other things, and where in the dosing and which patient selection would be most helpful. The last point that I'll just add for anyone considering it, before you go ahead and have it on your formulary or actively pursue it, I strongly suggest having policies in place for staff training, as well as when and how it might be used, because I've also been in situations where there have been many more requests than were appropriate, and so just like you may get requests and hospice for euthanasia or other things that might have a popular misperception, some of the current media attention on ketamine likewise could be misunderstood. So what is everyone's experience with ketamine and how are you managing policy and, as Alan suggested, perception around the use of ketamine? So, what prompted my question was, I've had several patients and their families, actually the request initially came in for use of ecstasy or psilocybin, which is, I know, being used a lot in end-of-life care, particularly on the West Coast in California and stuff like that. And I subsequently actually did a couple of training courses with an organization. I personally would not be comfortable using a Schedule 1 substance, but of course, ketamine is legal for me to use. And there is, it seems, some use of people using this for end-of-life stuff. And of course, it's now being used fairly frequently for depression and post-traumatic stress disorder and other situations in the non-end-of-life care population. I guess my question was, how are people, I'm having trouble figuring out how people are maybe incorporating these kinds of sessions, which are relieving suffering, but not relieving necessarily physical suffering, but they're relieving, as you said, Dr. Rosen, existential suffering, hopefully, you know, talking about using, you know, one or two, you know, guided sessions in appropriate patients. And I would be the one doing this. I wouldn't, I wouldn't, you know, I feel like I've spent a fair amount of time learning what people are doing when they're doing this. And I wouldn't want to delegate that to somebody who hadn't been trained. I'm not sure I've been trained. I'm trying to get more training. But I guess what I'm wondering is, how do we incorporate this? Or is there no way to incorporate this into routine hospice care? The people I've talked to seem to all be doing this kind of work outside the bounds of hospice. Maybe with hospice patients, but outside the bounds of hospice. And so I didn't know if anybody had experience doing that. So I know, in North Carolina, I mean, there's, we, use of ecstasy or psilocybin is not legal here. So I don't know about the West Coast. So if that's being done, it's being done either in trials, or I think there's a, there's some kind of underground folks doing it. But in hospice, we don't, here we don't even have the option of doing those, using those modalities. OK, well, I guess if the answer is no, then the answer's no. It's, it does sound that way. David, would you be able to share or maybe send to Gina for people that are more interested, love to hear more about where you had the training because a lot of us either on the job training, so to speak, or we happen to know someone and we go shadow them. And I think it would be an important resource and reference to know about organized opportunities for this type of learning. I certainly can. It's the end of life psychedelic care.org, E-O-L-P-C.org, which is put together and run by a woman named Christine Caldwell, who is a non-physician. I think she may, I'm not sure exactly what her specific training is. But when I've done their training sessions, there's everybody there from physicians to pharmacists to social workers to nurses. It's the whole gamut of people who engage in a lot of end of life care. And I've done a couple of courses with them. And again, they run the gamut from psilocybin and MDMA, which are apparently legal on a state basis, if you will, but still run afoul of the federal laws. And therefore, I would not be willing to use those substances. But again, ketamine, of course, is not illegal. And I feel good. I'm a former emergency physician. And I've given ketamine over 1,000 times. I feel very comfortable with the drug, per se. So yeah, eolpc.org. I mean, I've done a ketamine training course. And some of the physicians I work with have done a ketamine course. And we don't even see, again, in North Carolina right now how to even incorporate it into hospice. We were talking about, would we bring people to our inpatient unit? It requires therapists to help process the experience. It seems like just such a massive undertaking to use ketamine in that way that we just haven't pursued it at this point. Yeah, I mean, I would anticipate doing it in somebody's home and just being there. As you know, ketamine really does not cause respiratory or cardiac suppression. So it's not as though I really have to have somebody on a monitor. Yeah. I just, I know when I did the course, they really emphasized it takes at least six They really emphasized it takes at least six sessions before you really note changes. Now, would that be different in someone who is near end of life? And then a lot of work with incorporating the experience with the therapist. And I don't know. I just don't know how feasible it is. Yeah, yeah. I think when you incorporate these, right, I would agree with Elena, the feasibility. In addition to the feasibility of just doing the process, as Alan mentioned, policy, procedure, helping staff be also comfortable with this. I think I see Alan's hand up, so going to hand it over to him. But my experience in doing new and novel things and bringing them into hospice, there's a lot of work with staff that needs to be done as well. So it sounds like a big, big push to bring this into a hospice. I'm not saying that we shouldn't and learn more about it and support it, but. The comments that I would add on to Elena's point, it also depends what those studies we're looking at in terms of the patient population and their end points and goals. And it may or may not be applicable towards our population. I can tell you, and I'd welcome David's impact, that at some hospices, and this is going back a number of years, and I'll explain why in a moment, but there were benefits directly seen after just a couple of doses. Now, what I put in the chat was also a humbling experience. After being at one hospice, I thought, OK, I know this, I can do this. Well, lo and behold, I went to a hospice that had their inpatient unit on a medical campus, and that hospital had limits. Their policies, and this has happened across several states, either the hospital limited ketamine use only to the OR or only by anesthesiologists and or the ICU. Now, some of that may have been historical, but those are the types of things to be aware of. Where do you provide your care? Understand what the policies are, because the last thing you want to do, even if everyone's been trained and you're supportive, come to find that the physical location has a different set of governing policies that will derail what you intend. Yeah, well, in our setting, I mean, our hospice pharmacy stocks ketamine, we've used it, I've used it in patients for reasons other than what I'm talking about here. And certainly when I was in the emergency department, emergency physicians used ketamine all the time in the hospitals that I've worked in. Again, from a comfort standpoint, I'd be perfectly comfortable using it in somebody's home. And I have no problem obtaining it, both in terms of the nasal spray that's available, and also in terms of parenteral ketamine. They're both available through our hospice pharmacy. Yeah, we use ketamine for reasons other than the dissociative kind of psychedelic effects. And that's fine. We don't use it a ton, but we do. And I'm very interested in being able to use that, or MDMA, or psilocybin to help with that sort of end of life existential issues, which is why I went to this ketamine course. The other thing that after I went through it, the other thing that kind of got me worried is some people do not have a good reaction to it. In fact, it can be really scary. And then so how do we manage that as well? So that's another bit that kind of, I don't know, it's just another piece of this puzzle on how we use these medications. You're talking about what they call the emergence phenomenon? Well, so during the, if you're doing it for just the large dose or the dissociative effects, sometimes those can be extremely unpleasant for people. And so then you're there sitting with a patient who's going to be having a really bad experience for 30 minutes or however long the experience, 30, 45 minutes. Yeah, and my personal experience with that is I've, again, using it for a different reason. I've only ever observed that in one patient, although it's certainly well-known in the literature. And I treated it with Ativan, which worked well. Ativan and reassurance and holding hands and stuff like that. Mm-hmm, mm-hmm. Yeah, a common combination for alleviating the anxiety associated with that, I think. I'm going to, if it's OK, Noel is on and had a comment on in chat and also a question around ketamine similar to David. So welcome, Noel. Did you have something you wanted to join, comment on? Sure. Yeah, so I had, I have a woman, very young woman, who has been home on hospice for about a year. We've obviously underestimated her life expectancy. She has terrible dermatomyositis and developmental disabilities. And she has painful calcifications. Her fentanyl, we had her on fentanyl, CAD, I put her in the hospital, GIP, for intractable pain. We got her on a fentanyl CAD and she was on 200 micrograms an hour. And she was on 150 milligrams of methadone a day and initially had some relief. But pretty quickly, within a few weeks, went back to having more intractable pain again. And so I decided to bring her in for ketamine. We have a ketamine protocol at the hospital. I do palliative care at the hospital also. So we have a ketamine protocol for the palliative care team and for a separate one for anesthesia and a separate one for the ER. So we brought her in. She was the first person I had done this with. We put her on the parenteral ketamine for, plan was five days. And I wish I could remember the doses. I'm not near a computer, so I can't remember exactly the dosage we used, but it was per the protocol. And within a couple of days, she had significant relief. The reason I chose ketamine is because I find her pain to be in part neuropathic in origin by her description, and that's why I keep trying to get her more relief with methadone. But she just wasn't getting relief. And I feel like a lot of her pain was existential. And the family was to the point where they had heard from somebody at some point that when she was bad enough, she could go into the hospital and be put on propofol and then she would die. So they were begging me, and the patient was begging me and her parents to bring her in to kill her and with propofol. And so I chose the ketamine. And her response has been incredible. Now, we are seven weeks out now from the ketamine. She's not had any ketamine at home. My question for the group was, should I maybe send her home on ketamine? What I chose to do is since she was in the hospital setting, I pretty aggressively increased her methadone because I could watch her because I was going to see her while I'm here rounding. And so her methadone now is actually at 180 milligrams a day. Her fentanyl is still at 200 micrograms an hour. She's not on oral ketamine or anything at home. And her pain is actually very well managed still. We're seven weeks out from doing ketamine. But now she's back to having a lot of that what I would call more existential pain and insomnia and fear. And it's basically the way it was before the ketamine. It's not worse. It's just she's just gone back. And I don't know if I should have maybe sent her home on an oral dose of ketamine for some maintenance. I've never done that. And I was hoping for some feedback on that. But the hospital, the inpatient is not my challenge because we have good protocols in place. Yeah, so you chose ketamine just so I'm clear, the group maybe, but if I might be clear, you chose ketamine for help with relief of pain and maybe opioid manipulation a bit. And then what you found is that she improved so much, you wondered if it addressed some of the underlying existential issues. Is that kind of what I'm hearing? Yeah, I looked at the ketamine originally. My original intent was she was having intractable pain. Some of her pain was neuropathic. I felt that she was experiencing existential pain also. And so I felt like doing this was a good option. And it helped with all of those things. Right, a trifecta, yeah. Incredible relief for weeks, but now she's going back to having more of the, she can't sleep, she's very fearful, she's afraid of death. She's, it's, I feel like a lot of what she's experienced now is existential. She no longer has terrible pain in the legs that she had. She's not having this radiating neuropathic pain that she was having. Partly, did you use doses that were kind of to reset those receptors? Is that kind of what you were doing? Like the lower dose, and I wish I remembered, but I haven't done it a lot. It's all on the protocol. And there's someone in my office doing a phone call, so I can't go in, but somebody might be more familiar. And I can actually mute myself and listen a little bit and go back in, and I could put it in the chat what the doses were. What does the group think? Now, I've put people on maintenance ketamine at home with a very specific goal of managing neuropathic pain and opioids, and not to address the existential or spiritual issues. David and Elena, you've had more exposure and experience with this. You know, maybe this is a person where utilizing ketamine longer term, even though it's not the guided therapy or a session, maybe it would be helpful. I don't know what people's thoughts are. So Noelle, what you may not have heard is we were talking about use of ketamine in a very specific use of guided therapy. Therapy at end of life for the existential suffering. So the choice of use of ketamine was for existential suffering. But it can be used at home, can be given at home if you are in a state or have a compounding pharmacy, have protocols within your hospice to support it. Alan, you're putting an awful lot of resources in the chat. Thank you. Is there anything particular that addresses Noelle's question? I was trying to finish typing. No, I didn't see. And again, this may be something that the HMDC community may find. And if people have an interest, have some experience, the way to move it forward is a group come together, talk about submitting a presentation or an article. And from there, perhaps getting a pilot study or something else. And looking at what we mentioned earlier, Noelle, is some of the work by others in the field, even specific to the hospice population with psilocybin and other newer opportunities for approach. When David was mentioning how utilizing ketamine in more of an existential role. If you look at the psychedelics, there's literature coming out about the need to do adequate preparation. What are the settings, music, stimuli? Because while nothing's guaranteed, you don't want to increase your risk for an adverse outcome. Personally speaking, and I'll tell you, I may be biased because I've never done long-term ongoing. It has only been in an IPU with immediate symptoms. I think this is part of that perhaps evolution depending on the symptoms. What I might also reflect back and be curious about, whether someone comes into hospice, they have their view of death. Like you said, for this case, they wanted a propofol, thought that would be the end all. Well, whatever issues were leading them to that have not gone away. And so this might be an added interdisciplinary opportunity for the chaplain, the social worker. And if the family resists that or the patient exploring and maybe doing a joint visit, no pun intended, to enable some of the other disciplines to get in. Yeah, in our particular circumstance, we have the best of the best of our team already seeing her. And like I said, we completely underestimated her life expectancy. She's been with me a year. And so spiritual care is in there. The family is religious and social work has been in there trying to work with her on kind of cognitive ways to deal with insomnia and the anxiety that she's experiencing at night. She's had chronic disease since she was a child and she has long standing trauma, right? Just from her life, her long life of living with a terribly painful disease. And she really has, she's been open to everything. Our pastor or pastoral care folks just did send out an email recently. We do communicate, we do home visits. I do home visits on her fairly regularly. Like I'll jump in and do the face-to-face on her just so I can see her. And I always bring in at least a different member of the team so we can interact in different ways. But the chaplain that's working with us did have a little breakthrough with her recently. But it's a year into this, it's taken us a long time to get these breakthroughs. I just, when she was here, I thought about sending her home on ketamine because she was doing, her response was profound. It was amazing how much better she felt. And she was making phone calls to family members. She hadn't been able to hold a phone up to her ear for months, you know? And so I wondered, but I had never done it. And I was, to be honest, I was nervous about sending her home on ketamine. And I just didn't really know whether that was the right thing to do. Well, she certainly tolerated it in the hospital, right? And so if she did, I mean, other people who have done it in the home setting certainly can chime in, but you certainly could send her home on a low dose and titrate it up, you know? But, you know, this is an amazing conversation and that underscores the power, I think, of ketamine and that we need to know more about it for hospice and our patients and its multiple uses. One of the things, you know, the AAHPM also has a group that is, you know, working with and very knowledgeable about use of medications like psilocybin and ketamine at the end of life for these uses. So to Alan's point, maybe there is something, Gina, that we can all look at, the education committee can look at and see if there's a lecture, somehow bring the information back to our certificants here. But- Some things, of course, from AAHPM in the chat, but we can definitely take a look at it as well. Advanced pain management, yeah, so. I also wanted to add something else as a leadership consideration for people that are on. Given everything you've said so far, Noel, personally, I probably would bring in for another one-off in the inpatient unit. And I'm saying that in a leadership role to look at what the staff may be comfortable with, what we do and what the perceptions are then in the community and otherwise. And if we're going to talk about ketamine, I may equate it with paracentesis or pleurocentesis, where before I put necessarily an indwelling catheter and leave it, I may see how they tolerate one, how soon, to what degree symptoms came back, do perhaps one more with the pros and cons. And so I think you have some leeway before having to go. And there may be that benefit instead of the individual perceiving, I was only better because the ketamine and all of this, you might get a more clear response and offer some of the leadership in ongoing management. The last thing I'll just mention for patients with existential challenges, sometimes leaving a legacy or looking at other things that might be able to offer meaning, maybe a non-pharmacologic way that helps to absorb energy focus and perhaps purpose, not with everyone, but just want to put that out there. Yeah, got a lot of good suggestions here, Noel. And she is not going to get better care than she has gotten from you anywhere else at all. And I struggle with patients like this because one, we don't do a great job of transitioning these patients who've had childhood illnesses into adulthood, number one. Number two, we don't teach them to live with their illness, I think. But number three, I just wonder, is she gonna die soon? Or is this a chronic illness? So interestingly, since the ketamine, the ketamine was the first time I've been worried that I have to discharge her from hospice. Before that, her oral intake was so poor, she's lost, even though she's been with us a year, she's lost a lot. She was losing a ton of weight. She wasn't eating, she's got wounds. Everything was, it was just this slow decline. And then I gave her the ketamine and now she's eating again and probably much, she's not really gaining weight, but she's at least stabilized. And so I do have that wonder now if I need to actually discharge her because she's doing better. Right this minute, I just resorted her because she does have a new wound that is tunneling. So maybe she really is gonna have more trouble and it's draining, kind of, it's bad. So, but she's well better, she's better nourished now than she was before the ketamine. Well, it's a very challenging case and we have had a great discussion about ketamine and maybe we can bring more information in a more formal way to our certificants. If there are any last thoughts, I'd love to entertain them. We have one other person, Layla Hanna had a question that I wanna make sure we get to before the end of the session, but any other thoughts on ketamine or two? Would this group be interested in, did you put in the chat an educational program, Gina, around ketamine? HPM has a course and we can definitely talk about creating something. Okay, cool. And we can maybe focus a bit on the existential uses or at end of life for existential pain, so. If anyone's planning some research, count me in. David, I'm curious, where is your hospice? Where are you located? I am in the Philadelphia, Pennsylvania area. I mean, that's our agency, the hospice is national. Yeah, I'm from North Carolina too. And we just, I don't know of any place using ketamine a lot for any reason, anything. Sounds like Elena's had the same experience. And you know, I mean, I'm a little, I've looked to see if there are quote unquote ketamine clinics in the area. I'm a little skeptical about the way it's being used with some of these people. And it's, I mean, in fairness, I haven't thoroughly investigated them, but it seems to be another kind of way that people are making money maybe without real efficacy or safety in play. I think they're using that low dose ketamine for depression symptoms, that's kind of my understanding. That also, I mean, I have a couple of friends who are psychiatrists actually who have found that it's, they're using oral low dose ketamine for a couple of their patients with severe depression and PTSD that have been resistant to other forms of treatment. But again, they're not using it for real kinds of existential distress at the end of life. Right, right. One thing they really stressed at the course I did, and you know, it was run by therapists and a psychiatrist was that integration was key so that after you have the experience, you have a trained therapist to help you interpret and work through what comes up. And I think those, in Asheville, we have ketamine clinics that have just popped up in like strip malls. So, and I think that those places, what concerns me is I've heard there's no therapist doing any sort of integration work. So you get your ketamine dose, you have the experience, and then someone drives you home. Maybe they can go next door and get the unnecessary IV hydration therapy. Yeah. The oxygen. Yes, the oxygen. Take a lot of antioxidants and they go to the oxygen bar. That's right, that's right. And they have flavored oxygen now, right? Oh, do they? I've been missing out. Yeah, I think in Asheville even, I don't know. Probably. If you're a skier, they definitely have it in Colorado. All right, well, good discussion. Thank you so much. Layla, you had sent in a question or a comment. How can this group help you today? Hi, I'm Layla Hanna. I have a patient who have an experience with hospice for her husband, and she's a writer, and she want to write a note or a letter to put all her positive and negative. Hopefully, she said it would help to teach or the hospice people learn how to improve their service and what's the patient like and not like. So where she can put her letter or how to... Yeah, this is what she came and she asked me where I can put that letter or where to send it or how to put my idea, what happened. Hmm. So kind of where would be a good place for her to send this, her experience can be shared with other families? Yeah, with the hospice also. And with hospice. Yes, yeah. Do you have a way within your hospice to accept letters like this and... We can, I can take from her the letter, yes, but how she want to know how he can improve the experience with other hospice. So she want to know where her letter or her experience be sent. Maybe that's something that as a hospice, you could present at one of the, you know, present a case study almost or something at one of the national events or I don't know, just a thought. Is any newsletter for hospice or do you have any newsletter for hospice or hospice staff or anything that you have it on a monthly or yearly basis? I don't know. I don't know, Alan, do you think NHPCO? And as an FYI, for those that didn't know NHPCO has now merged with another National Home Care Alliance, another calling themselves the National Alliance for Care at Home, NACH, N-A-C-H. One thought that I had, Layla, was as Robin mentioned and perhaps Leah, that there's currently a call for case studies that's happening in the hospice with the Academy for the hospice, I'm sorry, for the annual assembly for hospice and palliative care 2025. That call is currently open. If people are interested in submitting something, I can help give additional guidelines to make it more likely to be successfully chosen, such as having multidisciplinary involvement, so it's not just physician, but other members of the interdisciplinary team that you also show the patient family community impact. And again, this could also be a differentiator when you're looking to recruit staff because going with higher quality, better outcomes, those are things that typically higher quality providers like everyone on this call, of course, you're wanting to learn and grow and add to your capability and impact. So those may be options. Another one that I'd put out there would be to consider the center to transform advanced care, CTECH and ctech.org. They focus on anyone with advanced illness and I would champion, why is it people who have to be end of life dying come to hospice to get really superb interdisciplinary coordinated care? And so if we might broaden, this is hopefully a success story, not just for hospice, Layla, but for all appropriate high quality care. Mm-hmm. Mm-hmm, okay, very good. So, okay, so I would ask her to write her experience and then I will keep in touch with Gina or... Gina Parisi, yeah. Yeah, and see where it can be sended. Okay, how it can be organized. Layla, where are you from? Where is your home? I'm from Los Angeles, California. Okay, so we've given you some national forums to look at and local forums, local newspapers, some areas have supports for families of the elderly or those with dementia. So there are some other local forums I think you might be able to look at as well because I think it sounds like she wants to be quite, yes, you can do a letter to the editor as Alan is saying, but all of the information it sounds like she's going to share would be very helpful for different disease-related organizations as well. Alzheimer's, I don't know what her husband had, but maybe even going to, if it's cancer or Alzheimer's, you could go to those organizations as well. So I think we're all on here with the idea that it would be wonderful to have this exposed nationally and that would be great, but I think local would be helpful as well. Okay, very good, thank you. Any other thoughts, suggestions? All right, well, great conversation. Lots more to think about for future discussions as well as educational opportunities through H, I can never say it, the Hospice Medical Center. HMDCB, it's okay, everyone confuses it, it's not a letter. I'd like it to be fewer letters. So thank you all for joining. Quickly, before we leave, I think we have like 60 seconds left. How was this time for everyone? Is this a good time? If you want to just put a thumbs up, thumbs down, just a quick straw poll from everyone. Perfect timing. Okay, anybody else? Okay. This works for me, but I can't figure out how to put my thumbs up. Okay. Yeah, me too. I'm like, by the time I figure it out, it'll be over. Fair, that's fair. Okay, wonderful. So we got- This is a good time. I couldn't understand when it was scheduled on Wednesday morning, because that's when most of us have IDG. Yeah, yeah, yeah. Fair. Thank you, that made my day, that made my day. All right, so good. Thank you all for that. And thanks for joining. Thank you so much. Thanks everyone, thanks for leading, Robin. Take care. Thank you so much. Have a great day, bye.

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