Welcome everyone. Thanks for joining today. I know we're a little past 11 central so we'll go ahead and get started and we know others will join throughout the chat. So thank you all for attending today's coffee chat and before we get started I just want to share a few reminders and updates with everyone so a gentle reminder to remain muted unless you're speaking but we really do encourage you to come off mute if you have questions or if you want to share anything and you can also use the chat box to ask questions and share resources. So a few HMDC be upcoming events our next webinar will take place on May 29 and our next coffee chat will occur on June, 8, and these events that we're inviting both certified physicians and current HPM fellows so if you have any fellows on your team we encourage them to register, they can register and attend for free. And then we're also partnering with whether be resources to host the hospice audit survival training for us taking place on June 13, and you can receive a 10% discount by using the code and that code is available for certified physicians and initial applicants. Another reminder that the initial application is currently open and so you can encourage your non certified colleagues to apply by July 31, and if your credential expires this year, please make sure to renew by October 31. Another event update is that we will partner with HPM again this year to host the hospice super forum. This will take place on November 6 and the registration will open in September so just mark that date on your calendar. And a little bit more about HPM so they are a great partner of ours and they also provide great resources related to hospice and pediatric care, including the updated hospice physician and medical director manual. So you can visit learn.ahpm.org if you want to check out all of their resources. And if you miss this year's annual assembly, you can still watch the pre recorded material, so make sure to just register for that by May 14. And finally for today's coffee chat we will of course have an open Q&A like we always do and we will spend some time following up on our April webinar that was focused on pediatric hospice care so if you have programmatic questions related to pediatric hospice care, please feel free to ask those or ask any other hospice related questions. And today's chat will be facilitated by Dr. Sarah Ehrman and Dr. Kristen Schaefer. Dr. Ehrman was faculty for the April webinar and Dr. Schaefer is part of our education committee so thank you both so much for being here today and helping facilitate the chat. I'll now hand it over to you. Thank you, Gina. Big hello to everyone. We have a looking like the beginning of great showing today from Texas, North Carolina, California, Kauai. We're doing good. So welcome everybody. My name is Kristen Schaefer. I'm a hospice and palliative medicine physician and also hospice medical director and associate CMO in Boston area at Care Dimensions Hospice. As Gina mentioned, a member of the education committee and I'm happy to facilitate and welcome you all to this chat today. I was telling Gina before we all joined, in my opinion, it's a successful chat if we're all kind of jumping in and asking questions and sharing our perspectives. There are hot button issues in this work that do not have simple answers and we really like and just such a breadth of issues in this work that we do every day. So really happy for you to join and happy to help facilitate a conversation today. Sarah, do you want to introduce yourself? Yes. Hi, everybody. Thank you for inviting me to this coffee chat as a facilitator. I will admit that I feel a little bit like an imposter coming in, but I do want to share my role and a little bit about why I'm here. So I am a MedPeds trained physician. I work at Ohio State and practicing adult inpatient consults for palliative care. But I also through my work with MedPeds have become involved heavily with the Pediatrics Council and I am a council member with AHPM. And as this council has got itself up and running, one of the areas that we identified as a major need are adult-based clinicians, adult-based hospice teams who find themselves infrequently taking care of or being asked to take care of children. And we know that this group has a lot of challenges and are often under-resourced for the work that they're trying to do. And so part of my goal here is to listen in and to get a sense of what's going on in this area. And I would love to hear your all's experiences so that I can take some notes back to the Pediatric Council as well and we can work on trying to problem solve some of these issues to improve access for pediatric patients. So I'll stop there. Thank you so much again for inviting me. Great. So thank you so much, Sarah. A great opportunity for those of us on the chat today to think about our own organizations, our own questions, or things we want to share about doing pediatric hospice within our own organization. So please, yes, let's definitely take advantage of Sarah's presence here to share and think about that together today, as well as other things. So I have one question in the chat. Oh, let's see. We have several questions coming in. You guys need to hold me accountable, too, if I miss a question in the chat. But it looks like Kristen. Kristen, can you say more about are you recruiting? Kristen, is that what this is? Say more, Kristen, what you're thinking about right now. Can you hear me? Yes, we can. Hi. Oh, fantastic. I'm in San Diego. So this is perfect. Yes, I'm the CMO of a very large program overseeing several hospitals. And we have a really robust palliative care program. So I am looking for an inpatient palliative care provider to oversee. NPs, several NPs, chaplains, social workers. So it's a real deal. It's a very mature program with a thriving ED and newly opened neuroscience state-of-the-art for San Diego. So it will be a center of excellence for that. So that's one full-time position. I'm also looking for a full-time community hospice doc that wants to work, you know, doing IDTs and seeing patients, the normal face-to-face stuff. And to see if anybody has any interest in working in our hospice homes, which have a total of 20 beds, four different locations in the San Diego area. And that's really all I have to say. My cell phone is 508-360-7371. And I put my email in the chat. So if anybody knows anybody or wants to talk about it, it's a great place to live. And SHARP is a wonderful organization. Thank you. Okay, thanks for sharing. Ayela, did I say your name correctly? Where are you? Hopefully I said your name correctly. Asking the question of the group in the CTI, for periods first and second period, does the patient need to be seen by the physician for recertification? Is the question at hand? No, my question is in the period one and two. Ayela, how do you say your name? Sorry. You hear me? How do you say your name? Layla? Yes, correct. Good. Please tell us. Yeah. So in CTI, to physician certification in period one and two, a patient does not need to be seen. So is a physician can certify whatever is an assessment would be okay? Say a review of medical record and assessment, we certify the patient in our hospice care. Is this okay enough? Yes. So the process would be in the setting of the IDT with IDT conversation and the physician is a part of that IDT review and reviews the chart to see the nursing assessment, the comprehensive nursing assessment. Based on that data from the chart and from the IDT conversation, the physician can certify for the first and second period, but for the third period, there needs to be a face-to-face visit. Yes. But the citation from the third period, patient need to be seen face-to-face with the patient. The physician has to be the patient. Yes, the third period. And the other question is the telehealth has been expanded up to end of September. Is that correct? Is that okay? Telehealth visit with the patient? I'm not sure about the exact date. I know it has been extended. I don't know if anyone else on the call has the exact date of the telehealth exception. Yeah, Lainey. Oh, sorry, you were. It is extended until September 2025. Good question. So it has been extended? Maybe it didn't go through yet. Okay, well, I'll look at it again. Great. Face-to-face for recertifications. I think there's some people that are not on mute. There's a lot of background noise. Yeah. That seems better. Was there someone else speaking up? Yes, I did. Are we talking about face-to-face requirement for recertification being extended? The exception for visual visit being extended to September 2025? Or are we talking about something else? I missed it a little bit. What being extended to September 2025? What being extended to September 2025? The face-to-face visit, the telehealth bill. Oh, Gina, thank you. The telehealth extension for face-to-face visits? Yeah. What were we talking about? It looks like Gina has put in a link for us in the chat. That's linking, yeah, directly to the congress.gov bill. Yep. Great. Yeah, what is on people's minds? I have some questions that people submitted ahead of time. But also just curious for the people who have come today, if there are questions on people's minds or topics on people's minds. Or also any follow-up if you were able to attend our session on pediatric hospice and questions about that. Okay. Anna has a question in the chat. Could you clarify hospice-appropriate meds covered by hospice? Many of our patients want to continue very expensive meds. That is not comfort meds, in my opinion. How would you approach this? I know this is an issue that we face every day. I don't know if anyone wants to lean in to kind of share their approach to this. How you approach this in your day-to-day practice? I think that approach is really pretty simplistic. There's lots of flow sheets out there. If the medicine relates to the terminal diagnosis or... contributes to a diagnosis that contributes to the patient's six-month prognosis, the law says that we are supposed to pay for it. May I ask a secondary question to that? Let's say a patient with cancer, stage 4 cancer, has been taking in a very expensive oral medication. And wants to come into hospice and want to continue that medication. That's something that I just can't seem to... I guess to me, it's just not hospice-appropriate. We're not here to cure anything. You're right. This medication also maintains this patient's or keeps this patient's disease at bay. Would you be willing to admit this patient with this medication, even though it will take a hit to your budget so severely that it may compromise your ability to remain open as a hospice? And this is an ethical line that I can't seem to reconcile. So I'm hoping that you all can give me some wisdom. Yeah, I know there is some wisdom. Alan is raising his hand. Alan? So, I don't in any way want to minimize the challenge you're expressing, Anna. It's very real. And it happens in a lot of different ways. One of the things in hospice that I love about the interdisciplinary approach is that there may be more solutions and compromises than we're familiar with in other aspects of medicine. And what I mean by that is, first of all, yes or no is up to every hospice. And the Medicare conditions of participation even say consistent with philosophy, other things. Be careful. You cannot differentiate based on payer source, what is covered and not covered, and some of those things. But what I mean by the creative space in between, if that family, if that patient has another one week, two weeks of medication left, whether they continue that, that is not necessarily a financial risk on your hospice. The other thing is going back to what their goals are. Because it again goes to what Ronald mentioned, in the 2010 regulations update, the change from six months, anything related in that estimated timeframe is not the diagnosis. The word was changed in the regulation to prognosis. It also depends, if you've been on prior coffee chats, who your Medicare administrative contractor is. If you have Palmetto, they've interpreted this certain times and have said, if someone comes on for cardiac failure, they fall, break a hip, go in the hospital. That debility that caused their fall is related to their terminal prognosis. And therefore, they viewed it in all the jurisdictions within Palmetto, that that hip surgery would be covered. Now, the last thing that may be helpful, and I want to give others a chance, is that you may talk with the oncologist who's prescribing it. One of the things that I found is that the literature shows many of these more extraordinary palliative oncology regimens are not appropriate when someone has an ECOG toxicity of three or four. So that is something that, again, what might be the goals and evaluation going forward? And I'll just plant one last seed. What we define as heroic can really be a moving target. I came to terms, and I personally support, providing outpatient, home, ventilator support for those that are chronically on a vent. Because, no offense to any pulmonologists on the call, many have heard me say this before, I don't differentiate between a nasal cannula oxygen and a trach, a vent, if the goals are the same. How many of our patients in hospice would not survive 15 minutes without nasal cannula O2? Now, if the family's expecting respiratory visits, managing, changing other things, your staff isn't equipped, you don't have the protocols in place, well, that's not a philosophy you're able to embrace right then. I'll shut up there. Thank you, Alan. Yeah, it looks like two other people can weigh in. Lainey, did you want to share? And then Sarah, I think, can share from the pediatric perspective as well, perhaps. Yeah, this is a really tough issue. What we've done is we kind of have a guide for what meds or procedures we just will not cover at all on hospice, and it's like a hard stop. If you want to continue chemotherapy, we can't take you on hospice. We have a really robust palliative care team, though, so we can offer that. Some of the higher dollar meds that we can't cover, I mean, we're not-for-profit, so the budget's always an issue. Things like Entresto, some of those types of medications, it's a pretty hard-you can finish this up if you have it. If you need a little time, maybe we could cover one month, but it's not-we don't make that a hard stop to admission to hospice. It's really the chemo drugs there, but the Entresto, we can't support that on an ongoing basis, and we make this all clear up front. So we're having all these conversations at admission or if they're on palliative care before admission, so everyone's prepared for what it's going to look like when they come on hospice. Now, on the other hand, we also have come up with a guideline for some advanced palliative interventions we will cover. So we have 600 patients, over 600 now. So we will cover 14 days of dialysis, possibly 14 days or a month of transfusions for blood cancers. But they're very prescribed, and that's something our CMO came up with. But it really helps with the decision-making when all our providers are aware of what we do and don't cover, what's a hard stop to getting on to hospice versus what maybe we can cover a month or two before we can't cover that medication anymore. Won't there be retribution when you make those decisions based on what you can't cover? I mean, won't, you know, won't that be something that CMS can say, no, that you're not appropriate? So technically, I mean, we are required to cover any medication that is related to the diagnosis, but we can have a formulary, just like an insurance company does. So we just don't cover Entresto. We can cover your diuretics, whatever for your heart failure, but this is, if you're coming on to our hospice, this is a medication we don't pay for. You can continue to pay for it out-of-pocket, but yeah, CMS doesn't put, you know, we can come up with our own formulary, essentially. Mm-hmm. Sarah? Yeah, I was worried I wouldn't know a lot to contribute to this conversation, but I can add one of the areas where pediatrics is trying to address this is concurrent care, of course, which is fraught with its own level of cognitive complications as you try to logic your way through different care plans. I think at its core, when you have a patient who's coming to you and wants to continue an expensive medication, and they're looking for hospice care, there's two questions that you have. There's the clinical question and the emotional question. The clinical question is what's the benefit of the medication? Is it adding meaningfully to prolonging a quality of life that the patient wants? For example, transfusion-dependent leukemias. Transfusion can often buy good quality time, but it's a very burdensome and expensive treatment. Same with anti-rejection medications for transplant patients, where if you stop those medications, you may run into very severe symptoms very quickly. Same with some types of cancer treatments. And that's a question to ask, because the cancer treatments have gotten so complicated that it's really hard to know, for an individual patient, what happens if we stop? How does this change your clinical trajectory? And going in with an informed decision like that can help make the decision about whether or not enrolling in hospice, even when it would otherwise be medically appropriate, makes sense for the patient based on their clinical need and just the practical logistics of what can we do to support a care plan. And there's workarounds. Prescribing 90 days of a medication and then enrolling in hospice is one thing that some of our transplant patients do for their transplant meds. They fill a 90-day supply and fill it before they discharge from wherever and enroll in hospice care, so they have it on hand. Enrolling, engaging with patients with a company's palliative care arm and then making the easy transition when they decompensate later and flipping them over to the hospice benefit are some workarounds that I've seen. Thank you. Alan, did you have something else to add? Oh, thank you. So, yeah, a couple things I was putting in the chat. There was a question. First of all, I agree with everything Sarah, Lainey, everyone's mentioned. And again, going back to Ronald, there was a follow-up question in the chat about the diagnosis not being included to the hospice admission, so medication will not be covered. I wrote it depends, and I appreciate the humorous concurrence by Sarah, but it really does depend because the other thing to be aware of, there have been hospices that have come under regulatory scrutiny for over-covering and promising meds, things that they couldn't get elsewhere. Now, there were very flagrant situations where it was inducement, and so that's where the regulations came down. You're trying to induce this patient by paying more than you should or doing whatever. That's a whole nother set of circumstances. What I also wanted to mention, though, is that these questions and the answers are all about communication. And sometimes we, as the medical directors, get in a challenging spot when the oncologist, cardiologist, whoever the referring provider is, says one thing, when our own marketing and admissions team says something, and what the family hears, what the patient wants, all these different dynamics. I've mentioned on a prior coffee chat that one of the things that I found helpful is as a physician, regularly meet with your admissions and marketing people. Hear what questions they're getting asked by the providers, referrers, patients, and others, and help coach them instead of saying, we're stopping all of this. We're going to simplify. We're going to consolidate. Let's prioritize. If they come back, well, there's this type of treatment that the oncologist wants to provide. Do you know the ECOG toxicity? What are the things you can help empower the marketing staff and in the communication so that it helps eliminate the later challenge? Does it solve everything? No. But we can talk further, and I'm happy to talk offline. I'd love to hear how others handle it too. Great. So I think take-home points I'm hearing on this topic are a hospice can have a formulary, right? If we don't cover something, we can offer formulary options and try to navigate that. Really starting with, you know, what are goals of care? We don't want to limit access to hospice if someone really needs and wants hospice, but then needing to really dive into trade-offs, conversations about trade-offs. Loved the comments from Sarah about then we also have to think about at least to advise the patient or family that's considering hospice. If it's not covered, think about, you know, how essential that medicine is to the patient's comfort. If they were to come off of it, would they have flares in their symptoms? All these things to consider as we're advising, really, patients and families as they're weighing a decision. And I think that's the other take-home around upfront, like managing. I really appreciate it from Lainey, this idea of telling people, putting it on the table upfront. You know, I think sometimes a no is helpful, right? It's not covered. So let's work with that. How can we get to hospice even if it's not covered? It's helpful for people to organize and know their trade-offs. So some really helpful comments in that regard. Thank you. I wanted to switch. Kenneth Curtin had submitted this question and asking again, Kenneth, thanks for being here. I wonder if you have a specific case in mind as you're asking a question about discharge for cause and how to navigate that. And if you wanted to share with us any specific case you had or if you wanted to elaborate on that question. Sure. We seem to have had maybe a little bit of run of various cases where safety, harassment issues, those kinds of things have played a role. And we've been sort of struggling to come up with the best process for navigating those. But I'll kind of use the last one was a 57-year-old male with advanced lung cancer, but still able to be up and ambulating and still fairly mobile. He was living with a brother. They were both codependent and struggling with substance use disorder issues. And the brother was varying levels of inappropriate with our staff relative to a sexual innuendo and those kinds of things. And we struggled with how to support the nursing staff, particularly the female nursing staff, how to assess the level of risk in the situation and what kind of process we need to go through. In particular, we had kind of a dichotomy in the nursing staff. Some of the older nurses didn't feel it was as great a threat as some of the other nurses did. And for me, that was difficult to navigate because I mean, their behavior around me was going to be different than their behavior around individual X, Y, or Z in our organization. And what level of inappropriateness or how to go about assessing those situations and sort of making a fair, ethical decision on what's the right thing to be doing in a patient with a high level of need with multiple issues that made it so that predictability of how those individuals were going to be behaving could very, very greatly change from one visit to the next, depending on what substances they had potentially been using during the lead up to that. And so looking for a little bit of guidance, I always struggle as a male trying to say, you know, what level of threat or safety should a female colleague be willing to subject themselves to? And those kinds of things. And yet, what does the law say we have to do? So looking for advice in that arena. Great. So question about operationally, how people can weigh in in their own hospices and organizations operationally, how you have kind of successfully grappled with this or managed this. And then also some questions about the individual role of the physician in this setting and kind of and how to manage our own individual role and responsibilities in this situation. Thank you for bringing that. I can speak to this again, because we were pretty well versed in this. So we have several years ago became clear, you know, we have a patient's rights handout that is given when a patient enrolls in hospice, but we now have like basically a patient and family responsibilities handout that we give them where they need to provide a safe working environment for our staff. Nurses or women physicians being repeatedly sexually harassed is not a safe working environment. What we would do in that case is we would have what we call a complex case where we have the team nurse, the team physician come together with a leader like the medical director, the CMO, social worker, compliance, if needed, and we talk about the situation. And in this case, I know what we would do is we would write up a, the compliance person would write up a behavior contract, you know, referencing the patient responsibility document, our staff need a safe work environment, you have been, you know, and then write it out, you cannot continue to sexually harass our the female staff, blah, blah, blah, they have to sign that. If they don't sign it, then we discharge them for cause. If they break the contract, we discharge them for cause. I have a very low threshold for our staff being like for discharging patients for cause, if I'm hearing that our staff don't feel safe, per the law, you do have to show and document that you made some attempt to modify the patient's behavior. So if that's like misuse of medications, you know, you get a drug contract in place. If it's sexual harassment, you get a behavior contract in place. But if they don't, they won't sign it, then I can't ensure they're going to provide a safe space. And if they break it, then we come together again with a complex case meeting and our compliance person and make sure all our staff are safe. And make sure all our documentation, we have all our ducks in our row, and then we just will discharge for cause. And we have had the state reviews all our discharges for cause. And we've never had a discharge for cause that they said wasn't appropriate. As long as you have good documentation in place, you're going to be fine. Great, that was really helpful. Yeah. And kind of hidden in that excellent advice and summary is that you do have to, at least in Massachusetts, I assume it's true elsewhere, you do have to alert, we have to alert our Department of Public Health when we discharge for cause and also our MAC. Oh, that's right. So we have to alert the state. That's for every discharge for cause. Yeah. Yeah. So that's why in our organization, we do have someone from our quality team involved in that. And they help us do that. So this idea of a huddle to lean in to cover all the bases, kind of as an organization, what we have to do to cover the bases. And then also huddle kind of bringing in expertise or ways to, we have to come up with some things to try to address the situation. And if what we've tried doesn't work, that's where we can make the case that we need to discharge for cause. Yeah. Other thoughts or experiences, good, challenging or otherwise in the discharge for cause issue? It should be a rare event. I don't know, Laney, even though it's true. I think we would say the same thing that we would, we have a low threshold to do it, but also it's something that we don't do frequently because we're kind of leaning in to try to problem solve. Yes, we do a lot of problem solving. I don't know if it's because I'm in Western North Carolina, but we have just a rural Appalachia, but we had some crazy unsafe situations involving weapons, threatening with weapons. So, I mean, I feel like we have to do it maybe not once a month, once every two months, something like that. Yeah. And definitely it's a part of our onboarding for employees around safety training. That's another feature of kind of onboarding, safety training, et cetera. Rachel. I've been here the whole time. I just had my camera off. So I'm in rural Vermont. We have, I think, a similar demographic as you, Laney, probably. And, you know, they're wonderful, but there's a lot of poverty. One thing we come up with, you know, with frequency, which is hard is when you have a patient who is having their opiates mismanaged, maybe diverted, it's unclear, but the patient is really dependent on the people around them and does not want to, you know, and they need them and they want to stay home. And I guess this isn't really, this is like an ethics question more than discharge for cause, but like there are rules that we're supposed to report any diversion to police and that might completely jeopardize this person and their living situation. So it's just something we really struggle with. I'm curious about other people. We do too. The component of this last case scenario that I outlined as well, that need for the caregiver and the caregiver was actually the greater problem relative to those same issues. So yeah, it was difficult to know how to navigate. About the caregiver, we've sometimes had an equivalent of a behavioral contract where we have to ask that that person not be in the house, right? If we're going to be able to do a visit, again, it gets to Rachel's questions of ethics. If that person is the number one caregiver, these are complicated situations to navigate effectively, but that's another solution that we've employed. And that's great if there's more people, but sometimes there's nobody else. Rachel, we've run up against this situation several times and they're some of the hardest situations. I would say that we have a lot of conversations, being very frank about things. Sometimes we'll even get our compliance person on the phone to talk. We give a lot of leeway in this situation, but I do remember one patient very dependent on her daughter and behavior contract, controlled substances contract, we did all the things and the daughter was still diverting the medication. And we had to discharge for cause because we just can't, our prescribers can't keep prescribing opioids. Do you inform the police? We don't ever inform the police. No, I don't. We might get APS involved. We probably get APS involved, right? Because that's dependent elder abuse. But what I do remember from that discharge is that no one was surprised. The daughter wasn't surprised, the patient wasn't surprised, and there was no pushback because we'd had so many conversations like, this will happen if you continue this. And it was unfortunate, but I felt like we did a really good job preparing everyone for what was going to happen if the behavior couldn't change. But that is the hardest for the staff because the patient is just a victim and it's really heartbreaking, which is why we take a lot of steps and try to make a lot of encouraged change before we would discharge. Yeah. Great. And, uh, we, uh, were you trying to, were you trying to, were you trying to, were you Great. And, um, uh, we, uh, were you trying to? Yeah. Thank you. Now we are, um, uh, so, uh, calling the police, believe it or not, the DA, uh, officer, I have his telephone and my phone and I do not hesitate to report the diversion. So, and we have many cases. In fact, we have one case where the mother, uh, ended up calling and the patient, the son ended up going to the jail because she was, uh, lung cancer. He was feeling hair, morphine, sulfate for his own therapy. And she was leaving her suffering. And he changed the, uh, medication from the bottle that they read, they read morphine sulfate to something else. So the short answer, I do not hesitate to report him. And they know our patient, they know, like, uh, about this issue. Number two, about if I have any, like too many people, we have a lot of problem with too many people and who's manage you. So, uh, often we have to have contact with the patient. We're going to have one patient controlling those medication. They had to provide with the lock box. One person has the key only, and we will count the, uh, medication at every single visit as well as, um, again, we have somebody get caregiver, never give the opiate to the patient. And we do have very uncommon, like once a year or probably max twice a year, do random testing on the patient. If I believe the caregiver stealing the opioid and not giving to the patient because the nurse is always complaining that the patient system is not managed or, or they believe for some reason they did not, I'll do a drug test. And if they are, if they are using 60 tablets or 80 tablets of morphine, sulfate or oxycodone, and now the, uh, urine test is negative, this is a problem. So it's, I mean, it can go in and out basically, but I do call the police often for those. Thank you. Thank you for sharing. I was just wondering as a follow-up question to this group, because I'm on the inpatient and outpatient side of things before hospice enrollment, for instances where there's concern for diversion, we have a harm reduction protocol that gets enacted, and that is regular drug testing of the patient, that is shorter prescription duration, that is the lockbox and other strategies. Sometimes it's a change in medication. I imagine with hospice, you may be limited with formula, but we'll often transition the patient to long-acting patches or things like that, where you can go and invisibly see that the patch is on the patient or not. So I'm just curious if others have developed some harm reduction strategies that they've been able to successfully employ in the hospice setting. Can I comment? So for the long-acting, first of all, I practice in Ohio and the zip code where we practice the really high rate of polycystic ovarian syndrome dependency. In fact, at one point, we had one of the highest mortality rates related to the opiate overdose. So the problem is in our community. So for some time, you do have a patient where it is documented that polycystic ovarian syndrome is used, SRE-DUG, and so on and so on. But unfortunately, they have stage four cancer, and they have legitimate reason now. So again, you do one step by step. If they have somebody, if they have caregiver, we'll put the protocol where the lockbox and so on and so forth. But often, those patients, I may change the medication there, prefer medication right away. They tell you one oxycontin or something or something. I use methadone as a long-acting and short-acting a lot with those patients. Now, when they become at the end of transition where they are down nowhere, I may reintroduce the morphine sulfate or raxicodone. But I do negotiate with the patient, even on the admission, before admission to hospice, okay, I promise I'm going to treat your pain, I promise I'm going to treat your symptoms, but I'm not going to promise you any medication name. I will choose the medication based on what we believe is medically appropriate for you, including the methadone. So some patients, they would not sign to start with, but we are in the area where I think it's too much risk to take those medication without one, two, three, before they start on hospice. Yeah, nicely said. I mean, I think harm reduction is implicit in the hospice model, right? Because we have an interdisciplinary team, our patients and families kind of have, we're leaning in with an interdisciplinary approach and with regular contact in the home, which is different from other, you know, palliative care, for example. And so we have, it is a harm reduction, it's a model where we can do harm reduction, but with guardrails, I think, like Maweah is describing some good examples, yeah. So in the chat, Rachel, another Vermonter, had posed, what does it mean about federally? I've actually used that at different places I've practiced. For example, when I was in Chattanooga, we had someone on our inpatient unit, a son who was disconnecting the PCA, obviously using it because suddenly there were air bubbles in the PCA, and he comes out, look, oh, and this is, again, picking the right setting, but I get a lot more brave when I'm on our inpatient unit, and I know there's hospital support staff, and personally, I know I can reach for my stethoscope if needed, and you don't lock the door for someone and don't be in a closed environment, but I did make it very clear, I said, I just want to remind everyone involved with hospice, whether patients, staff, or families, that any diversion of a patient's medication or anything inappropriate is considered a federal crime. This is actually viewed as drug diversion or other things, and we are mandatory reporters if we see it happening. It didn't happen after that. That type of approach, but anyway, if you escalate it that this is a mandatory reporting, that this is diversion, even if your loved one may not use it, if that person gives it to someone else, some states now even have the alcohol liability clause, so where parents would allow kids to drink, and then they'd go and have a car accident or do something, well, the parents were held liable, so that family member could also be held liable if their friend who comes over and takes or whatever else, and they know it, and emphasizing the federal nature makes it a little bit more impactful. Can I have a follow-up question regarding the same subject, if I can, please? How, this has always been a challenge for me. In Ohio, about two years ago, they introduced the law where recreation marijuana become legal in the state, so how any provider can answer how you deal, what's your comfort level prescribing high dose? I am using the recreation, not the medical prescribed marijuana on daily basis, where I do not know how much he use, I cannot control how much he use. Thank you. So, I do have a comment on prescribing marijuana. It's illegal for us to do that, because it's still federally illegal. You can lose your DEA prescribing privileges if you prescribe it. That's number one. Number two, I know of no proof that marijuana does anything symptomatically except perhaps for nausea or anorexia. I appreciate Ronald's comments. One thing I want to just add again in response, do I pronounce this right? Exactly, thank you. It depends, and whether or not it's legal in the state, other things, I know organizations that will not handle it. I have heard secondhand, I don't know firsthand from someone at Mount Sinai in New York, that their inpatient unit reportedly has a safe, like you see in hotels, that gets the number set by the family change, whatever. But the point being, the staff do not handle, administer, or do those things. Okay. So, if they used it at home and they were doing so, that is separate from what the staff provides. I will say that Krista and myself, Gina and others on our education committee of HMDCB are working on arranging a particular webinar in service looking at this and some other substances. So, by all means, please submit your questions. There are a little bit more nuanced answers as well, that there are differences between edibles and inhale. There are differences in strength. Also, in the pediatric realm, when I was CMO of an organization, one of the largest pediatric population in Illinois, our pediatric patients could benefit. Their seizures decreased. There were some other things. But those, again, had very specific protocols and others that I want to go back to. There's more to practice medicine than just the medicine. And training your staff and all that will be important with policies given where you live. Sure. Important. I'm sorry. I'm not sure if I made the question clear. I would never write morphine. Okay. Professionally, I'm against the marijuana use for whatever. But I'm talking about the pre-existing patient already using the marijuana. What's your threshold for writing the opioid for those patients? In fact, our organization to prevent this issue, they prevent us from having the medical marijuana license, apply for medical marijuana license, then I am legally, and I have to prescribe it. Forget about the federal law and so on. So, we cannot prescribe it. My question is, the patient already using it at his home, how you want to control your opioid doses, how you want to gauge it? It's almost like you're writing opioid for a patient telling you, I'm going to be drunk every day on alcohol. What's your threshold for that? That's the question problem. It's a great question. We're at the end of our hour. So, of course, we're going to leave with a cliffhanger. But, I mean, Gene, I think it's a good question. We could think about picking up again at another coffee chat. I think there's going to be a range of tolerance and experience and practice in that answer. I know in our organization, one thing to say is that we do document. We find a way in our chart to document so that all members of the team know if a patient is using recreational marijuana. So, at least we're kind of all aware. So, our prescribers are all aware. That's one thing we did. But I think, yeah, I thank you so much, everyone, for your participation today. Really appreciate it. Really look forward to ongoing conversations. And I'm going to do the hard job of saying that it's time for us to close, right, Tina? So, I hate to cut this off, but I really do appreciate the great engagement. And thank you so much. We look forward to seeing you next time.

hospice care

palliative care

collaborative problem-solving

pediatric patients

drug diversion

ethical dilemmas

interdisciplinary teams

substance use

regulatory compliance