Hospice Experience Panel: Discussion with Families-Hospice Experience Panel: Discussion with Families

Hospice Experience Panel: Discussion with Families
Video Transcription
Hi, everyone. Thanks for joining us. We'll get started in about 60 seconds. So we'll let other folks jump in here and then we'll get started in about 60 seconds.  Okay, so good morning to everyone or good afternoon I guess it's noon Eastern time for those of you on the east coast but good morning and welcome.  So glad to have you with us for our third for HMDCs by HMDCs webinar of 2022.  This morning, we're going to have a, we're calling a hospice experience panel so a discussion with families who recently had loved ones receiving hospice care in an effort to help you with your practice moving forward.  As you can see on the screen here please, if you wouldn't mind remember to stay muted. If you're not speaking, and please submit your questions via the chat box.  I'd like to just take a quick moment. I'm Bruce Hammond I serve as HMDCs executive director, and would like to just take a quick moment to thank our generous sponsors for our webinar series for the year.  Those are kindred at home and bluegrass care navigators we very much appreciate their support of the webinar series and of HMDCB for this year.  I wanted to take just a couple of moments for reminders and then I'll turn it over to our moderator for today Todd Cote before we get going today.  Our final coffee chat of the year will take place on November 10 at noon Eastern time 11am Central time.  I just want to share that with you because these events give certificates a chance to really connect and discuss pressing issues with their colleagues in an informal way so we encourage you to attend those events.  The remainder of those, like I said the last one is going to be on November 10 for 2022, and our last HMDCB webinar for 2022 will take place on December 13, and the topic for that session will be on GIP and continuous care so we have three leader content  leaders for that who are experts in that area so we encourage you to register for that and take advantage of that opportunity to hear from them.  On the screen here you can see that you can have access to the hospice physician compliance conference recording you can get 15% off as a certificate of HMDCB.  You can reach out to Gina to get that discount code if you'd like to take advantage of that opportunity. And then our last, our excuse me our 2023 events will be posted soon so we encourage you to check back often to learn how you can stay connected  with HMDCB and connect with your colleagues who are fellow certificates so without further ado, I'm going to take a moment to introduce this morning's panel they'll give you a more broad explanation of who they are and and what they do but wanted to just  take a quick moment to introduce them and then I'll turn it over to Todd the moderator to get us going. First, our non HMDC on the panel is Sally Weir.  Sally is the former executive director of HMDCB. She served in that role from 2012 to 2019. And so she understands the organization very well so we appreciate Sally, spending some time with us today and being with us.  Our second panelist is an HMDC Suzanne Crefa Johnson. Suzanne initially certified in 2015 and recertified in 2021 so again she'll share more about her background and her role currently with you in a moment.  Our final panelist and today's moderator is Todd Cote. Todd is the chief medical officer at Bluegrass Care Navigators and is HMDCB's treasurer on our board of directors, and he initially certified in our first class in 2014 and recertified in 2019.  So Todd, I'm going to turn it over to you. And again, we appreciate you all being with us today. Thank you, Bruce and Gina and Suzanne Sally and all calling on.  Thank you for inviting me to this, this discussion. What we were going to do first, so I'm kind of a moderator but I'm also part of the panel.  So, what we wanted to do is share you our own personal stories and I wanted to reach out to all on the line that we respect that many of you might have had your own hospice personal stories also so we appreciate you giving us an opportunity to talk a little  bit about that. So, that's what we're going to do first and then we will talk about some priority questions which will be posted up on the on the screen for everybody to, but I'd like to go ahead and start and so Sally maybe if you could start with your story, please.  Thank you.  Thanks Bruce and Gina for the invitation I appreciate the opportunity to share.  As Bruce and Todd noted I'm the non physician on the call, but had been involved with the American Academy of Hospice and palliative medicine, and the hospice medical director certification board for many years.  I'm grateful for that opportunity, especially as it certainly prepared me a bit for the experience that I had.  My mom passed in July of 2021, at the age of 81, she was diagnosed with ovarian cancer in 2018, and she was on hospice for five months at home.  My father died in January of 2022, at the age of 86. He had battled dementia for about eight years, and coincidentally was also on hospice for almost the identical amount of time.  Two days longer than my mom, five months on hospice and a memory care facility.  We had two different hospices so I experienced in kind of consecutive time period, two different hospice organizations. My mom's was in the same system as her oncologist, who is fabulous and a great communicator and introduced palliative care and hospice,  kind of all along her trajectory which was extraordinary.  My dad was with the hospice that worked with most of the patients was a popular hospice at the memory care facility and we, when we initially met the nurse practitioner to interview her, because we were also looking at others which the memory care  facility had suggested. We really liked the nurse practitioner and certainly the frequency of the timing she was in the facility was certainly a benefit there.  I did not meet the medical directors in either case of the hospice, but we're in the Chicagoland area and we were fortunate enough to have a consistent nurse practitioner on the, as a case manager for both my mom and my dad.  But very different experiences as you can imagine, my mom, we could communicate with the hospice nurse practitioner could communicate with, and with my father was a very different experience.  At this point, we had just moved him into the memory care facility, the beginning of 2021, right before mom entered hospice. So, two different experiences but both overall, very good.  And I'm extraordinarily grateful for the work that you all do. Thanks, Todd. Thank you so much, Sally. And we've all supported each other already with our losses, so thank you.  Suzanne, please. It's wonderful to be here with all of you today.  I'm Suzanne, I've been a hospice physician since the early 2000s, have worked in, mainly in California, but for a few years in Florida.  I've had the privilege of all these years as a staff physician and also a hospice medical director for hospices that have ranged from ADCs of 80 to 100 to the mid 400s, both not for profit and for profit hospices.  So I feel like I've had, I've seen a good kind of slice of hospice around here in this country.  My mother, Rena, died in January of 2019 at the ripe old age of 97, having had an extremely diverse and rich life.  She was admitted to hospice in 2018 with the diagnosis, principal diagnosis of hypertensive heart disease. However, with a really, really strong debility, secondary condition.  What can I say that sort of to zoom in.  The experience for me as the daughter of my mother, their patient, and there were two different hospices because primarily, initially we were in Florida and then I was recruited to come back to a hospice here in California again so we, I made that change  professionally and she came along with me she'd been living with me for seven years after my father died.  Two different hospice experiences. Overall, really good experiences and my mother was well cared for her, any symptoms that did arise were very well addressed efficiently appropriately in a timely manner.  Some of the areas that I had challenges with, and that I wanted to share with you all we'll talk a little bit more about these as well. When the areas of communication, especially the areas of physician communication.  I actually because of my schedule and some of the glitches and communication was not able to meet the hospice medics director in the hospice here in California, and the one in Florida, the ones who came out to provide care.  And not I wasn't able to meet them but didn't didn't have initiation on their part to have discussion with me in terms of what was going on with my mother and their assessment.  And this became sort of more of an issue that I stepped in and  was proactive in terms of eliciting that communication when she became a long length of stay patient because overall my mother was on hospice for 12 months a year.  So communication issues there. Other issues were around.  What we call total pain, looking at some of the sort of psycho spiritual aspects of her pain my mother was a doctorate in theology had done pastoral counseling, but was really afraid to die.  And for my daughter. It was hard for me to have that conversation, both for reasons of my own I think certainly, but also for my mother to be able to talk to me about that and I don't that never really got addressed.  I thought, as, as, as in as focused and as clear manner as her somatic symptoms.  So I think those are things that certainly I'll speak about more as we answer some of your questions. And I think sort of wrapped up that's me and most importantly, my mom Rena.  Thank you, Suzanne. I think we all want to meet your mother her wish we could have.  Wonderful. Wonderful. Yeah. So, so my quick story, and again I appreciate many of you might have stories also so thank you for letting me share but my father did die on on hospice services in January of this year.  Two different hospices actually for almost 10 months of service.  My parents lived in California I'm in Kentucky, which was probably my biggest challenge to be distant I did have siblings that were very involved. We were all very involved.  So it was a wonderful experience the hospice hospices were both wonderful. I think an attentive.  I always struggle with being 33 years career now with as a hospice medical director and the first hospice that came into my dad's life.  He was 88 years old, by the way, mostly frailty lived a wonderful life was healthy, up until three or four years before his death when heart failure and some Parkinson's and so on so forth that kind of picture that bound that sort of thing.  But the first hospice that came in was actually owned and operated by friends of mine from California that I knew and loved and had been in touch with over the years.  I was actually present when they first came into the home in California.  And what I was most impressed with just some, some interesting little points that I made to add to the discussion is there was this very strong focus on what the hospice wasn't going to do, or didn't do pretty much as I was trying to be a son and just  pretty much focused on the regulation, you know relatedness those types of things.  So I was most impressed with that versus just the focus on how are we all doing that sort of thing. Also there was a very difficult. I really came to respect even more after 33 years this difficult transition from the health care that we all know acute care curative  that my dad had been through in the previous few years to now this kind of more comforting focused care that my mother appreciated but it was pretty much night and day overnight I mean it was just a 180 degree turn.  So, I know my mother shared a lot of thoughts on that issue.  And by the way, we were privileged to have a personal caregiver, six days a week, 10 to 12 hours a day. My mother consistently confided in me she just did not understand how families could do this alone.  And really emphasize this caregiver point that we know all so much so it only made me humble, more and more, and again my mother saying this consistently I just don't know how to do this without our, our caregiver who was a wonderful person in numbers so  emergency kits I'll throw that out. That, you know, we've struggled with that over the years and hospice state regulatory struggles, how to do it right.  medications and putting them in the refrigerator and I know, but I will say and I think all of us have experienced that the, the, it's wonderful quite often to have the emergency care was profoundly important for my father who had some Parkinsonian dementia problems  to have that available at the, at the end to so my mother really appreciated that my siblings appreciated that.  And lastly to him, you know, it was a long stay so he actually was discharged at eight, I think the third period after eight months, and he was doing okay although again my mother was noting some decline.  That maybe could have been addressed, but the, so he was discharged and within a couple weeks later, again, significant problems was readmitted only to a different hospice because his internal medicine doctor who bless his heart stayed with my dad for many years  before and throughout this whole process was actually a medical director of another hospice. And so brought him in there for another three or four weeks until he died.  So, so, you know, I felt communicating a prognosis, something, an idiom, idiom and we can talk in our discussion that we teach is communicating a prognosis over time to family members particularly in patients is as important as determining the prognosis over time.  And I certainly felt that throughout this whole long process and of course my family's coming to me, although I have a nurse and a pharmacist sibling and all that so they were very involved.  But, but I thought communicating what was going on over time was so very important, particularly for my mother, who was very attentive so that's my story and again thank you for listening to all of our stories, we would like to  start some priority questions now pertinent to kind of what all of us have been through.  And so I think Gina's going to put up on our first question there and I'm just going to go ahead and read it, and it will comment, and again we have three or four questions.  If that will comment on, and then at the end, if please open up for any dialogue discussion, otherwise we do have other questions but time may limit that.  So how might hospice physicians medical directors better elicit important quantitative and qualitative data from patients and families about the patient's trajectory, especially when assessing long length of stay patients for extended prognosis?  I think that's a compelling question for all of us that we've had to deal with.  In our hospice service that we support. So, thoughts from Sally and Suzanne, please.  I happen to be an artist with very small a, as well as being a physician, so I think I want to kind of draw on a little bit from that from that experience.  You know, we all know, sitting around the IDG IDT table or having conversations with our team members. You know, we, we hear that those three words paint the picture.  So for me, I think the core of this is about looking at the whole picture.  Trying to  elicit information data, qualitative and quantitative, that allow us to see the patient in the context of their personal, their medical, their communal story.  And to do that, just like with art, you have to kind of step back. So you have to step back and look at the patient as a whole.  So, I think, you know,  of their personal, their medical, their communal story. And to do that, just like with art, you have to kind of step back. So you have to step back.  And I think often it's easy to become somewhat myopic.  And especially with all the angst that we feel regulatory wise in terms of that X number of months, six months prognosis and our long length of say patients,  you know, still being able to literally step back, take a deep breath in and see how both as physicians and along with our team members and with the patient and their family,  we might be able to, as it were, paint this picture.  So what I have found, and I found this with my mother as well, is that it's often in the stories of the day-to-day  and those stories best are elicited from patient and family if possible, but also within our teams, you know, the home health aide, the one who, as we all know,  literally does the most touching and at all different levels, multidimensionally of the patient and their family. So, you know, I think it's easy to get caught up in the,  you know, you've got to get the quantitative data. Yes, that can be there, but sometimes that's given to us in a qualitative way. And, you know, it's the home health aide  who is able to say, you know, I used to, our patient used to be able to, during the bed bath, turn over, grab the handrails,  and, you know, we would chat while I was sponging her bath. And now our patient is, I've literally got to turn her over. I've got to hold her there the whole time with one hand.  And I can tell that rather than being able to answer, you know, or engage in conversation, you know, maybe even short two to three word sentences, now it's one word at a time,  because I can tell it might be because of shortness of breath. It might be because she's having to really summon every bit of reserve she has  to be able to just stay in that position, even though I'm holding her. So little stories like that, the stories of the social worker or the spiritual counselor who says,  you know, when I used to come and see Mr. X, you know, he would meet me at the door, albeit he was on his walker, albeit he had his oxygen going, but now he's come early,  he's opened the door and he's back resting, because he says it's just too much to be able to have to do that when he hears the doorbell.  So little stories like that that are qualitative, they seem that you can really translate them into quantitative measures. And I think the richness of this painting  of the picture of the decline or terminal trajectory,  because sometimes as we know, we don't see decline per se, has to be composite. It has to like in a painting, you know, how different colors, different textures, different depths,  and that can only be elicited in a conversation  that taps into multiple contributions. So I think for me, that's kind of where I'd start. Please jump in.  I'll be short in mine. You'll hear a theme probably in my conversations.  My mother and father were both well taken care of on the clinical side, never having too much pain that was well managed and some of those other clinical pieces.  But it's the importance of the extended interdisciplinary or transdisciplinary team  that I think we could have improved on in both my mother and my father's case. So on the clinical side, the MP would come in and my sister and I kept a journal  of all of the medications. And I will put a hundred exclamation points on Todd's comments about the medical kit. For as long as I was involved in hospice and palliative medicine,  I know at some point I heard about the medical kit, but then when I received it as the non-medical person and had it in my, especially my mother's home,  it was transforming for her care.  It was also very difficult for a non-physician to really, my mother would have never been able to manage it on her own.  A lot of information at the beginning about it, a great chart, kind of a cheat sheet for it,  but yet a cheat sheet that even I needed some help with the medical language. And I gave that feedback to the hospice. But there was lots of interest from the MP  directly with my mother on how are you feeling? But the MP didn't really look at the journal to follow the story of the medicines. And we also wrote in there some other pieces,  depression or anxiety or things like that. And other than asking mom directly for that, didn't really look at the full story there.  So were the hospice physicians and medical directors in the IDG asking about these things? What was that like? What other questions, as Suzanne has related,  could we ask about qualitative data that's available?  Especially as my mom was there five months, it was a long journey in our eyes. And a little bit more of that could have been questioned  or inquired about. Todd? Yeah, thanks, Sally. And listening to you too, yes, I agree. Question number two, by the way, may kind of nicely move into open discussion,  but on that question, number one, illicit is so important.  And Suzanne wrote this question wonderfully. And better illicit, it's interesting. And again, in my brief experiences, because again, I was distant,  not always in California with my dad and my mother,  but the hospice team members would come in and do their duties. And again, it gets back to this kind of regulation and worry about audits and we better document this  and we better collect this information  quantitatively particularly, without the focus of just simple, sit down and ask, how has it been going? How have you been doing? I saw you last week, that sort of thing.  And such an important reminder. One thing we did at Bluegrass was standardized visits. And I was a little reluctant to, oh, well, isn't that gonna make everybody robots  again and again? But the first part of this standardized visit is what you say when you walk into the house, just kind of reminding ourselves to ask,  particularly the spouse, how are you doing? How's it been going? What's been going on? Not like, okay, I'm gonna assess you for pain. I'm gonna do this.  All those important things that we need to do, but there's so much value to, again, eliciting important information, particularly from family members.  And I think that's just kind of what I think we all need to remember and share with our team members and colleagues in hospice. We can move to question two,  because I think it jumps right into, and again, I'll just read it briefly. How can physicians improve communication in hospice care?  Very broad question that includes communication with IDG members, patients, and families. And what are engaging important questions that physicians can ask family members  to ensure they understand the details of their loved one's care?  Suzanne, you wanna comment on that? Certainly.  I think, first of all, what I'd like to say is that,  from my experience as hospice physician,  often communication, at least within IDG members, is relegated to team meetings, unless there's some crisis issue during the week.  And I think communication, if it can be seen from a broader perspective of ongoing, so the fact that when you come together with the IDG team,  that's certainly a very focused regulatory exercise and incredibly important. And yet, during the week as well, that IDG sort of one-to-one, one-to-two, three, whatever it might be,  those lines of communication are every bit as important because, as we all know, when things happen in time, that's the best time to communicate them.  And often when we wait, we lose some of the savor or we lose some of the real engagement with whatever the issue is at hand. So I think part of that starts with, as physicians,  us kind of taking the lead, us taking the lead and reaching out to team members when we do have questions, and being able, if it's within the IDG meeting,  not to just, and none of you, I'm sure, do this, but have that sort of older model of reporting data to the physician, really having a conversation, being able to ask questions  as the RNCM gives her or his report on the patient's symptom management, to then not just even on the data side, but if something sparks, the patient's pain is now worsened  or other symptoms are exacerbated, us taking the lead and sort of saying, well, what else might be happening in that patient's life? Has there been any change in terms of  who's around the patient? Is there anything else that has been brought up by the families that might be stressing the patient and bringing in anxiety?  So sort of us using what I think as our physician  gift of really being able to hold that whole patient in his or her entirety and being proactive. So in terms of actual questions to ask family members,  I think we all do this, I think, fairly well, but again, stepping back and asking them when we come in, what might have changed?  Is there anything going on in this patient's environment that might be different from what has been there before, what we might be able to see on the surface?  With my mother, it was an issue of, as I said, her being deathly scared of dying. And I don't, and I know it did not happen that either anybody in the team  really posed questions to her that would allow that to open up. So, you know, however one wants to do that, having the ability to engage in  what we call those courageous conversations.  So my mother, you know, maybe just saying something like, Rena, you know, this is, how are you feeling? Just starting with how are you feeling? You know, do you think at all about  what your life was before and what is this now? You know, are there things that concern you? How are you sleeping? You know, do you dream at all? What do you dream?  I mean, these are not typically somatic types of questions, but if these had been posed to my mother by anybody on the team, mommy would have opened up  and it might not have been easy, but I think with time she would have been able to kind of rest with some of what was going on there. Let me see and see if anybody else  has contributions on this question.  So I will share how important it is that you ask those that are seeing the patients about all the other services that hospice provides.  The intake nurse who first came asked wonderful questions. My parents had been involved in their church since they were two, very strong faith.  They were also both very musically inclined. My father, until he could no longer read music, was in the choir some 60, 70 years. And for a dementia patient,  music, as you all probably know, is one of the most incredible things that you can still connect with. Even until the last month, my dad, they had musicians come in  to the community room on Wednesday afternoons and my sister and I would take turns and take him down there. My father couldn't put a sentence together or three or four words,  but he could sing an entire song and remember every word.  Greatest gift. So in both cases, the intake nurse shared all the services that were available from the hospice, both had music. And in fact, the one at the memory care  had reinstituted in the middle of COVID pandemic, pet care. My father was also, if any dog in the neighborhood knew my father, that was the one he,  the dog would always go to him for treats. He loved animals.  So two key things.  We had to ask after a month for mom to see a social worker. It also took about a month and a half to get a chaplain to see her.  So these were things that were available, not really considered short staff, social worker a little bit, but we had to inquire about those things to get them to come.  It was never one of the questions that the nurse practitioner asked along the journey. That holistic piece is incredibly important,  especially once you're taking care of the clinical side, which was, you know, wonderfully done.  But especially for my father,  quality care would have been the music and would have been the pet care and those other things. And for my mother, that chaplain, we brought in,  they had just removed to Chicago before she was diagnosed. So didn't have the community, the church community around her. So really asked for the local church  that we were involved with to come over and meet with her until we had the chaplain who ended up being just wonderful. But again, things we had to initiate.  So I would encourage in IDG meetings, IDG meetings for you to ask the nurse practitioners, have you asked about the other care components  that we can provide by those engaging important questions? Thanks.  Thank you, Sally and Suzanne. Yeah, great points. And I noted that Alan and Jay are making some great points too. Thank you for contributing on the chat line.  Yeah, I just wanted a brief commentary and a little different character on the second part of the question of engaging the family members,  which is something that I think hospice medical directors, as Suzanne alluded to, kind of do well as far as basic communication skills, opening questions, that sort of thing.  Always really important. It's eager for us as hospice medical directors when we actually are doing patient visits in the home, we've usually hopefully studied the record very well.  We know we bring in our knowledge and experience over time. So we're very eager to tell families what's gonna be happening.  Without probably sometimes sitting back and just listening to the family members, again, eliciting a response. So initially, asking what do you understand  about what's been going on with your dad or with your loved one, that sort of thing. Those open-ended questions, I think, are very, very obvious for HMDs,  but I guarantee are not obvious for the rest of our colleagues, specialists in internal medicine and docs. And some of them do a little better than others,  but I've been to many family conferences where they just jump right into all the information and data, and the family listens because we're the experts and doctors.  But it's so important to try, again, to elicit response from the family, where they're at, what they understand. So much so that you're going to probably learn a lot more  than you did just by looking at the chart and looking at the patient, that sort of thing. So it's really critically important. And I probably teach that more now  to non-hospice doctors than to the hospice folks,  but it is important to remind our colleagues, the other clinicians on the hospice team, that kind of aspect. Then translating, if you have opportunity,  and I've seen this always consistently, families are eager to understand trajectory. What do we expect? I know that I think Jay and Alan kind of comment on that.  We see this all the time, and they're just dying for information. What do you expect? Now, it's easy to jump into that without asking, would you like to kind of know  what my experience has been with people like your dad? That sort of opening question. So sometimes you do get kickback, but of course you get families very interested in that.  And that's where just good old prognostication science comes into act. This trajectory of typical general population, people with cancers, with heart failure, with lung failure,  and then the frailty like my father, we kind of, that's been well-published, but most of the medical community does not have any understanding of these simple charts, really.  I found myself getting pieces of paper and diagramming the trajectory of the general population of people like your dad.  Then you go into, again, prognostication science of specific prognosis or individual prognostication. And that's where knowing that patient's so important,  what the family tells you, what the chart tells you, what the treatments in the past have told you. Then you pull that in. So again, talking to families to me,  is a translation of prognostication science when it comes to that kind of aspect of what's gonna happen to my loved one. And most siblings and family members  and spouses really want to know that. And they look to you as hospice medical director, whether you're a new hospice medical director or like myself, you know, I always say,  well, gosh, I've been doing this a long time. And they ask in like 33 years. And of course the comment you get is how have you done that  for so long, but what it does is empower myself in my experience and expertise to share the family if they're ready to understand that.  And that is initial, but also you can interplay that over time, particularly if things are happening longer and longer. And of course, it's the strength of your dad  is just such a strong person and that sort of thing that comes into play. So you can still identify prognostication science even over a long period of time, not just initially.  So in there, we'll go to our third question.  How, and again, it kind of rolls off of our discussion so far, how as physicians can we both during our patient visits and in education of the hospice team,  ensure that identification and management of non-somatic symptoms of total pain are as highly prioritized as somatic symptoms?  I think we've alluded to this a little. Suzanne, some thoughts?  Well, I think just as I think most hospice team members are very comfortable and understand the need to keep their eyes open no matter what their discipline  for physical pain symptoms and somatic symptoms. And we report that to the appropriate team member for assessment and further management.  I think this might start with that conversation  within the discipline so that each discipline might be able to share from their experience and their expertise, say in social work, what do we look like?  How do we identify issues that might be contributing to that patient's dis-ease, unease  from the social aspect of their life? Such the same with the spiritual counselor because I don't think that we can assume that even as a physician that I might really understand  what spiritual pain looks like or might sound like. And so being able to be teachers one for another within the team, I think is really important.  The other thing is that there are tools for assessment. And I don't know what your experience has been, Todd, but certainly I have found that some of the tools  say for spiritual assessment, like Christine Pokalski's FICA tool from the GWISH Center, GW.  I always had to introduce that and teach that. And I was just fortunate that I stumbled on it  many, some time ago and then been able to share that information. So I think looking for tools that exist, and we all know there's a paucity of tools  even within say the prognostic world,  but looking for similar types of tools, both in the world of spirituality and in the world of social health and determinants  to be able to have those to apply and get quantitative data and qualitative data.  I'm trying to think if there's anything else I wanted to share. So yeah, I think just finding tools, interdisciplinary communication and sharing, and then understanding.  And I think that in these areas that are non-sematic,  many of us have our own issues around feeling comfortable with looking at those. And so my sense, and I'm an old woman now at 67, is it's really hard to teach or share  that which you do not know. So in terms of say spiritual assessment of total pain, if you don't understand how to assess yourself for spiritual unease,  how are you going to be able to ask the question of someone else of where they are? So I think it's personalizing that experience as well so that we're not there as outside experts,  but we're there as co-humans who are sharing this journey. And even though we're not on that end-of-life trajectory, we still have the same components of our own beinghood  that we're exploring with those that we're taking care of.  Thank you, Stan.  Sally, thoughts? You kind of alluded to this a little bit.  I did, I think I shared.  Yeah, thank you.  I guess my only thought is that my colleagues have already heard, and I've kind of been on the mantra about this over the years.  Interdisciplinary is defined very clearly by CMS,  but I keep being an anarchist to try to rise above interdisciplinary to transdisciplinary, which I think Sally even alluded to a little bit,  which is sharing knowledge.  We all have our disciplines, particularly in a hospice team, the core disciplines, they're so well-defined. And we all focus on that. We all develop our expertise on that.  But over the years, I've realized that as just the spiritual talk we've been having, it's really important for me, even as a physician, to, whether I'm comfortable or not,  to at least understand the research and concepts that have been developed in spiritual counseling over the years, particularly in end-of-life care.  So at an interdisciplinary group or team meeting, whatever you like to call it, we share our information with our team members versus sharing the knowledge we have.  And I think as hospice medical directors,  have a great opportunity for the in-service time period,  usually 10 minutes, right, at an IDG, or if we lecture, give a lecture to our colleagues in the hospice, to be able to kind of assimilate  all the research and science that backs even, again, non-somatic symptom control in end-of-life patients. So it's a duty for all of us,  no matter if we're physicians or social workers or chaplains or nurses, to, I think, to bring that knowledge into other disciplines also.  I can never be a nurse, I could never be a social worker, or maybe I could, like Cecily Saunders was, all of them, right, but don't have the time to study,  but I can learn from my teammates. And I think that's really what I'm kind of getting to, that acknowledging our other teammates' expertise.  Also, we do live in a hierarchical world in healthcare where the doctor and the hospital administrators are above all, right? But I do think that there's a wonderful opportunity  to humble ourselves as physicians particularly, and share our knowledge, but also get and receive knowledge from our other colleagues.  So that's kind of what I wanted to say on that. Thank you, I think...  Todd, I think you got muted somehow. Would you unmute, please? I'm sorry, did I mute it too early? I hope I didn't.  I was asking, Bruce, I was asking Tina if we have a little more time for this question, or should we jump into some open dialogue and discussion?  We can open it up, Todd, and see if anyone has questions, and then jump back to this if you don't see anything come through. Feel free to ask questions either in the chat,  or you're welcome to come off mute as well if you have a question for the panel. Yeah, thank you. Anyone, please, you made some great points, folks.  So anyone have a desire to ask a question  or to unmute?  Hi, it's Alan, not Bashful.  One of the things that I'd also, again, to practice what we preach is if you do IDG audits  in self-improvement quality assurance, are you including what disciplines are represented? I've been at some organizations where when I joined, it was just one of the CNAs.  It wasn't the full team or the volunteers. And again, I think that says something to how we may value the team members. But if that is happening,  what are you doing to make sure all of those reports are being passed along and included,  not just for the admissions? The other thing, going back to the anticipatory process  in the guidance, for those that have Jewish patients  or families, are you aware the next three to five weeks are the holiest holidays in the faith coming up? Are there anticipatory guidance? Are you aware of what's important  to those patients, families, and what may be involved with family members? And what about the other faiths represented by your population to be proactive  or even for self-care for your own staff? And so those are things I'd want to just remind people, again, not just in the Jewish faith, but any faith coming up.  Yeah, thank you, Alan. Also very important, it kind of gets to that point of particularly when we're entering people's lives. And as we all know, you know,  50% of hospice patients admitted are dying within 18 days, right? So, but the other 50% are living long and 12 to 17% live past six months.  So my point goes to understanding the culture, culture, how people live each day, whether through religion, through social structure,  through other ways, is so critically important initially. We have to humble ourselves in front of our families and patients.  It's hard to do because we have our own cultures personally and our own struggles, particularly with the pandemic and so on and so forth. But learning that right off the bat  and talking about it with the family and patient and then sharing it with, of course, the team is so critically important. That helps the plan of care, right?  That's hopefully a purpose of the plan of care, of anticipatory, what are you supposed to do? And their well-being as well, and their religiosity,  their social structure has to contribute to that. And it can't be automatic. It has to be elicited from the family. So thanks for sharing that, very important.  Others, please.  There's a question from Jay in the chat about maintaining boundaries from our sharing stories and then how to balance being a hospice physician  and being the patient's son, daughter. So I'll just very quickly say, especially to that second part, I decided I was just going to be Suzanne. I was gonna be Rina's daughter  because I wasn't sure that I could trust myself otherwise. I wouldn't necessarily have that objectivity. And also I wanted to be given the gift  of being able to be the daughter losing her mother and not have to wear those two hats. So obviously, we can't forget what we know. We can't stop being who we are.  So I certainly probably had a huge advantage in terms of being the daughter as I looked at medication management and all of that. But I just certainly decided that I was,  I was Suzanne and I presented myself to the team. They knew I was a physician, but I never sort of spoke in that sort of language or came from that place or with that kind of energy  because I didn't want them to relate to me as physician. I wanted to be related to his family member and his daughter.  What was your experience, Tom?  Yes, similar to, I was very clear. I just wanted to be the son, but of course the hospice folks that I knew and grew up with were asking me all kinds of questions.  And how do you guys do this? And how do you do that? Kind of wanted to say, you know, it's just my dad and can I just be, but then again, it's interesting  that I don't know if it's related, but a part of this discussion on helping people identify with where they're at with their loved one that's dying is asking a simple question.  Have you had this experience before?  Have you been through this as a son or daughter or friend? And when there's an identifiable, and quite often actually half the time you get,  no, I never have seen someone die, you know, this sort of, but the other side of the coin is you have had sons and daughters that have been through a lot  with other parents or other friends and family. And so helping them restructure and identify that experience is really important, I think.  So as I share with my colleagues, you know, life is sometimes the best teacher. So I learned so much from even in my own professional life  through my personal experience with my dad. And so to me, it's interchangeable. So I think it's really so critical. And what I learned most is that we get so robotic,  particularly in the hospice Medicare model, that it doesn't allow this emotional experience as much.  I mean, because you're just so busy getting that work done. And that's not a bad thing to get that work done because all of it's been looked at over the years  as good stuff, but boy, is there so much more. To me, it's a minimal, you know, regulation and laws and rules are just the minimal rules and regulations.  There's so much more to gain. And I think stepping back as just the son really helped me gain a new perspective on all of that, that there is a whole nother side of the story  that we don't often involve ourselves in in good ways because I'd hate to have my family members dying all the time, right?  And then maybe the next big thing in our life will be our own death, of course, experience. So hopefully a long time from now.  I think in terms of the boundaries too, that I find at least what I'm comfortable with is having patients and families help me define what boundaries they're comfortable with  where I'm concerned. And so if patients ask me a question about, well, what would you do if this was your mother, you know, or there's an opportunity to share my experience,  you know, and I'm sorry, I'm a physician who actually has cried with patients  and families as they're crying. And I find no problem with that, especially if they're comfortable with that. And so I sort of try to follow both verbal  and nonverbal cues as to how much they wish me to open and engage with them. And then that's what I respond to.  May I say one other thing that we haven't brought up? We've talked somewhat about it, but very quickly,  cultural competence, you know, as a daughter of an African and an African-American mother,  you know, I feel that cultural competence as comfort and understanding about different religious traditions is really important. And, you know, I know say as African-Americans  we're woefully underrepresented as patients in the hospice community. So if you, you know, if you have patients who are say African-American and you don't have any staff members  or anybody in your community, in the hospice community who is, then maybe in say that sort of situation, it's important to actually get somebody  who understands and knows that experience and can share it with you. So it's not just a book thing on your mind, but you really are able to hear from someone  for whom that is their true experience.  Yes.  Critically important, I agree. Alan, thank you.  I can only relate to Suzanne to many years ago in California in hospice when several nursing homes were using nurses from the Philippines  because there was a nurse, profound nurse shortage, believe it or not, way back when. And the Philippine community was,  professional healthcare community nurses were having struggle with how to do end of life care.  So we actually hired, just straightforward, hired Filipino nurses in hospice to, and they helped us understand competency of their culture to just put it bluntly.  So I agree with you that we just have to continue to be attentive and it just makes us better at what we do and helps us better.  Gina and Bruce, I think we've almost run out of time. One minute, I think. I so much appreciate, I'll just say quickly,  for all of you attending to let us share our story in the dialogue in the back. We probably could go on for two or three more hours, but so much appreciate the opportunity.  So thank you so much.  Yes, thanks everybody for attending and thank you all the panelists, Todd, Sally, and Suzanne for sharing your experiences and sharing your stories of how you manage this situation.  So thank you very much. Thanks to everybody for attending. Gina will send out a survey, I'm sure after the session is done. We appreciate you being here  and we'll hopefully see you at the next Coffee Chat, which is in November, and then the next webinar, which is in December again. So thanks again. Thanks so much for being with us.  Appreciate it. Bye-bye. Thank you.