Everyone, thanks so much for joining us today for our session on Reflections in Hospice Care. Before we get started, I just wanna share a couple HMDCB updates with everyone. First of all, my name is Gina Parisi and I serve as the Executive Director for HMDCB and a couple upcoming educational events that we have. So Weatherby Resources will host their audit survival training this Friday, October 18th. You can register on our website and if you use the code listed here on the screen, you'll be able to receive a 10% discount. Our next webinar will take place on November 7th. It will focus on onboarding the hospice physician and that will take place at 2 p.m. Central. And then our final coffee chat of 2024 will take place in December. We haven't set a date yet, but it will be posted on our website soon. And finally, if your credential expires this year, make sure that you complete the longitudinal assessment by October 31st. And we're really excited to announce that HMDCB is partnering with AHPM to host the Hospice Superforum. This will be the first ever Hospice Superforum that we host. It's going to be a half day educational event that focuses specifically on hospice content. It will include three sessions, one in Hospice Ethical Challenges, Hospice Deque Prescribing and Complex Symptom Management. So you can visit our website to register or you can scan the QR code to register directly on AHPM's website. And if you aren't a member of AHPM, you can still receive the member rate by using the code listed on the screen. I also want to thank our gold level sponsors for sponsoring the 2024 webinar series, Gentiva Hospice and Heartland Hospice. Without their generous support, we wouldn't be able to provide these webinars for our certificates. So we greatly appreciate all of their support in 2024. And if you're interested in learning more about those organizations, we encourage you to visit their website. And then finally, I want to introduce our speaker for today, Dr. Shalat Rajaram. And I'm going to read his bio so that I can make sure I don't miss anything. But Dr. Rajaram is a current HMDCB Certificant and Volunteer and he's also an experienced Hospice Medical Director. He was a Medical Director for Newport Nursing and Rehabilitation for 20 years. Then he served as the Senior Medical Director at BTOP Healthcare from 2016 to 2021, and previously served as the External Faculty Director of the Palliative Fellowship Program at UCIMC from 2013 to 2021. Currently, he is the Clinical Assistant Professor of Medicine at UCIMC in the Hospitalist Department, a Facilitator for Medical Students at UCISOM Spirituality in Medicine, and a Subject Editor at Rutledge Review Online for their Death, Dying, and Bereavement. He is also a published poet and he'll be sharing many of his poems with us today. His poems focus on nature, journey into self, spirituality, and the meaning of life. In February, 2023, he was invited to read his poems at UCI Illumination's 6th Annual Poetry of Hope and Healing Symposium. So we're really grateful to have Dr. Rajaram here with us today to present this session. Dr. Rajaram, thank you so much for everything that you do within hospice care, and thank you for presenting today. So I will now hand it over to you. Thank you. Hello, everyone. So let me get my slide up. So, thanks to Gina and to the hospice medical director certification board for inviting me to talk on the reflections in hospice care, my journey in hospice medicine. She already mentioned my time at VITAS Healthcare from 2006 until 2021, that is for 15 years. I'm still part-time attending at VITAS and she mentioned the rest of the talks. Uma Rajaram was my life partner and my wife. She passed away in 2015 or died in 2015. So this spiritual journey, I'm still having the journey together with her for 39 years now. We were married for 30 years, the last nine years with her spiritual presence. I'm dedicating this talk to the patients and families that have taught us, to my colleagues, to you all, my colleagues for your lifelong learning, to the hospice medical director certification board leadership and Gina Parisi, the executive director for inviting me to hospice and palliative nurses, chaplains, social workers, the millions who died in the pandemic, all my UCI and VITAS Healthcare colleagues, fellows, residents, medical students and their learning. All this came together in March of 2024, March of 2024 had a special significance. It was at the Finnish Convention Center that the AHPM meeting took place and the Bell Bower Press Author Conference also at the same time at the Finnish Convention Center. So it looks like all the stars were aligned. And I have to thank Dr. Joe Shega, chief medical officer. I heard he may be attending this. He's at our program this week. So thanks to Dr. Joe Shega, chief medical officer at VITAS for inviting me to sign the books at the VITAS booth at the AHPM conference in 2024 at the Finnish Convention Center. It was an amazing honor to be invited to sign even before my official book signing, VITAS had me sign the books for the participants of the conference. To Dr. David Wenzel and Gina from Hospice Medical Director Certification Board, they were at the conference as well. And this idea sparked there of a talk on healing. Specifically, Dr. Wenzel and Gina were interested in our membership, our physicians, our hospice directors and attendings going through this very difficult period after the COVID pandemic and the stress we all felt, all of our colleagues in nursing and chaplaincy and social workers, everyone who felt this amount of load on us. And so there was a need for healing. And that also sparked this plan for my talk. To Dr. Kristina Puholsky for the Iceberg course that followed AHPM, I met Dr. Puholsky at the academy meeting. Actually, I signed a book and we have a picture together. But she gave a session on the interprofessional spiritual education course at the AHPM meeting. And later on, the UCI faculty, including me, Rocky Allen, he's here at the talk today. He's a chaplain, Dr. Shiho Ito and Dr. Alpay Shamim, we four joined as faculty to take part in the Train the Trainer session in the summer that Iceberg had. Iceberg is out of George Washington University. So I'm thankful for that experience. To Balboa Press, my book publisher, for Firefly Racing with the Dolphins, the book that I published, a book of poems last year. To Dr. Shiho Ito, the professor of medicine at Palliative Medicine at UCI for including me in the spirituality and medicine teaching journey. And to Dr. Robert Gwynn and Dr. Vishen Bedi, the program directors now at VITAS for their friendship. And they have put together a watch party today and they are watching as well, along with many colleagues from VITAS. So I'm really honored for that. Mindfulness, healing, spirituality, self-care in this hospice journey, I do a daily self-care discipline of 30, 40 minutes every morning. And it's dedicated time for mindfulness, meditation, some yoga stretches, mindful walking. And my own reflections within my spirituality, in my personal life. And that has helped a lot in this teaching medical students for the last three years, all the four years with a two week clinical rotation in spirituality during their third and fourth year electives. And the poetry writing has also helped and many lessons during medical leadership. So those are some of the things I'll be sharing in the next 30 minutes or so. But before we go there, I just wanted all of us, everyone that has joined, to just become present in the moment. Why don't we all do a gentle Tonglen meditation? Tonglen meditation is a Tibetan form of meditation. It's a practice of sending and receiving. I got this from the Book of Joy. I bought this book. This is written by both Archbishop Desmond Tutu and the Dalai Lama. Archbishop Desmond Tutu flew to Dharamshala in northern India and spent a week with the Dalai Lama for Dalai Lama's 80th birthday. And this one week of conversations turned into a book and they called it the Book of Joy. And there are many useful tools in that book. And one of them was this Tonglen meditation. So wherever you are in different parts of the country that you have joined at different time zones, sit comfortably, relax your shoulders. If you're lying down, that's a great thing. Lie down and relax. Find a good posture. Settle your mind with several long breaths through the nose. Think of someone you know is in pain or suffering. Think of the recent many disasters and so many people who are suffering the fires, the floods, the two hurricanes, Florida, North Carolina, Georgia, all the destruction, all the suffering. We see it and we hear it and we feel it. Think of someone in pain there. Reflect that they too, like you, wish to be free of suffering and become joyful. Feel deep in your heart the desire for them to be free of suffering and pain. As you breathe in and breathe out, breathe in the suffering and pain and breathe out and breathe out compassion, courage, confidence, strength and joy. Breathe in suffering and pain, breathe out compassion, courage, confidence, strength and joy. Feel the pain and suffering dissolve in the warmth and bright light of your compassion. If you're uncomfortable in breathing in pain and suffering, imagine a glow of light or a bowl of light in front of you and you can bring the breathing in into that area and let the pain and suffering dissolve in the warmth and bright light of your compassion in front of you while you're breathing in and out. And repeat these steps with every breath in and out. And as you breathe in and out, receiving and sending, read a poem from Golden Light from my book. It was written in the end of January of 2023. The howling Santa Ana winds, the wild swaying of many a tall tree, golden color of leaves through the blinds, shining as brightly within, happy, free. Amidst the thrashing of branched tree, the mind and thoughts run wild. The rays of the sun shine steady, show the way, calm the mind like a guide. Continue to breathe in and out, breathe in the pain and suffering, breathe out your compassion, courage, joy. The golden light within, shining at all times, from birth to death, beyond, in deep sleep, in waking and dreaming, to go back in, envision a stronger bond. The mystery of this life, meaning the same for them, you and me. The deep trust to keep forming the golden light, shining so brightly. And as you breathe in and out, at the next breath, you can open your eyes, find yourself more, more present as we move forward in this talk. Todd Sagan quoted that the notion that science and spirituality are somehow mutually exclusive, that's a disservice to both. My 18 year hospice journey has been seeking, finding unity in this continuum. At the Academy meeting in Montreal in 2023, on the final day of the conference, the State of the Science, the panel was gathered on the podium and the question that was posed was something similar to what Carl Sagan said in 1996. Is healthcare and spirituality the opposite ends of the spectrum or a continuum? The needs assessment as to why the hospital journey is more complete with this knowledge when we identify patients that most need spiritual assessment in different settings, demonstrate the positive benefits and barriers and negative consequences for patients, understand spirituality in patient coping, emotional states and motivation, know there is less physician and health professionals burnout and benefits when providing whole person care. The facts and the data guiding spirituality in medicine, teaching and practice as we do in hospice is that spirituality and health outcomes are closely connected. Studies show that most patients with serious illness desired spiritual beliefs be addressed by their provider. The palliative literature has been measuring these outcomes. The Association of American Medical Colleges, WHO and JCO, all recommend including spirituality in clinical care and education. Physicians feel that they are not adequately trained, do not feel comfortable enough to address patient's spiritual needs. As you contemplate on these facts, read a poem, Spirituality, written in 2022, spirit actualization, spirituality, exploring with caring mentality, trust building, sharing honestly, walking together this life journey, a pause, a glance, silence, a tool, gently breaking defense. This then a lifelong practice within, with or, hers, his. In hospice leadership, I've been medical director for 15 years. The quality journey is very important. The hospice quality reporting program, QAPI, QAPI in 2011 had probably six standards at that time. Now it's filled with much more. As medical directors now, as you all sit in your QAPI, there is a hospice item set, there is the hospice care index, there's the HVLDL or the hospice visits in the last day of life, and CAHPS. And I'm going to take only one aspect of that, which is incorporating emotional support in the plan of care in CAHPS, treating the family member, caregiver with dignity and respect, assessing spiritual distress, providing support at every visit, and asking about religious, spiritual beliefs in hospice patient and family. Even today at the IDG, we were dealing with inpatient hospice deaths in the GIP program. And the chaplain brought a question from August of 2024, and a particular family member, the one who is a bereaved person who is now in her grief journey, a volunteer had made a visit. And this person spoke to the volunteer that she wasn't prepared for the patient's death. So in other words, did we do enough to make them aware of this impending death? So these are the these are the questions that CAHPS sends to patient families after a patient dies, and we need to be prepared to understand our quality perspectives in it. So if I go back to that same thing, the emotional and the spiritual support, they're going to ask how much emotional support they got from the hospice team while their family member was in hospice care. How much emotional support they got from the hospice team in the weeks after the family member died, support they got for their religious or spiritual beliefs. And this is part of that consumer assessment of health care providers and systems or CAHPS. Spirituality and religion are defined in many ways. It can be a person's sense of purpose in life and the connectedness to that purpose which they find meaningful. One's worldview, one's connection to realities larger than oneself. The way you find meaning, hope and comfort. Religion has rules to guide behavior in living and doctrines about life after death. Spirituality has become largely self-defined, can mean almost anything that the person wants it to mean. This is from Dr. Koenig, D. King and Carson. I have this book, second edition of Handbook of Religion and Health. And if you go to MedlineSearch and in the toolbox, you put religion, religiousness, religiosity, spiritual, health, medicine, patient care, and look for the answers. The data shows that between 1902 to 1981, there were about 3,400 articles in an 80-year period of time. Between 1994 to 1999, there was almost that same amount of 3,000 articles. Between 2000 and 2011, there were almost 10,000 articles in peer-reviewed journal on religion, spirituality, and health since 2000. So there is a lot of evidence and data that is going into our understanding of spirituality. This was the 2023 State of the Science final day of the conference at Montreal. And the first journal article that was picked by the faculty at the podium was Spirituality in Serious Illness and Health by Dr. Tracy Belboni and others, published in JAMA in 2022. And the panel at the podium spoke to us, the audience, and asked us to leave the conference with these six take-home messages. One is that health efforts for well-being should include benefits of the spiritual community, to educate public health professionals about spirituality and health outcomes, to recognize spirituality as a social factor associated with health, to incorporate spiritual care in serious illness care, to include spiritual care education for interprofessional team members, and to include spiritual care experts in serious illness care. Another comment the panel made was, your patients and families are not the cause for your moral distress. In other words, pointing words at us to say, look at yourself, find your own spiritual journey to understand what they're going through. So the benefits of early spiritual intervention, positive ability to cope with illness, positive quality of life score, positive relationship with the health professional, compliance with medical treatment, positive response to treatment, prevents burnout in health professional, providing the whole person care, and positive beliefs result in positive emotions. Other data that came out of all these articles that I quoted from Dr. Koenig was that spiritual assessment and goals of care discussion by medical team may reduce aggressive treatment focusing on needs central to the patient's quality of life. If spiritual care is only by religious communities in highly religious patients, there is definitely increased aggressive care. And many of us have experienced this and many of us have experienced that in the ICUs, care as a form of divine intervention, God acting through physician to cure, fighting disease until death, and the sanctity of human life. Recommendation from studies suggest combining high level of spiritual support from the medical team and educating on the medical realities, the spiritual community that will produce better outcomes. Negative consequences about spiritual assessment are very anecdotal and very few in the literature mentioned. There is very little published literature on negative consequences. Anecdotally, it's when prayer is initiated by a physician without the patient requesting it, or if a social worker left a hospital's brochure of a religious faith at the patient's bedside and the patient belong to a different faith. But they are very anecdotal. Studies on positive benefits of spiritual assessment far outweigh the negative consequences. And while you all think about and contemplate on these facts that I mentioned, this is from Poetry and Pain Management, a poem that I wrote in 2016 at the HPM meeting in Chicago. This is part of it. I love this idea to write a poem seated on top of that large dome, feeling the wind against my ear, the radiant warmth, feel without fear. So I hope to ease my pain and yours, know that there are no rules or laws, just you and me to relax and trust. The healing comes like magic dust. Remember, Uma passed in 2015, and this was my first trip outside. And so we had this poetry breakout session, and I was able to write about my own journey, partly in this healing of poetry and pain management. FICA and sample questions. This is from Dr. Christina Pohalsky from George Washington University. And this is used now, this tool is used all over the world, and our students use it here at UCI. And when we attended the I-SPAC or the Interprofessional Spiritual Care Education, the FICA came up there as well. So the F-I-C-A stands for faith and belief. You have spiritual beliefs that help you cope with stress or illness. What gives your life meaning? The importance, what role does it play as you deal with illness? Does it influence how you care for yourself in this illness? Are you part of a spiritual or religious community? Is this an important part of your life? Are there people you rely on during your illness? And how would you like me to address, the A stands for addressing care, how would you like me to address these issues in your healthcare? Hope is a tool from Dr. Gauri Anandraja and Haidt. They're from Brown University. And the hope is very similar to the FICA, source of hope, meaning, comfort, strength, peace, love and connection. Part of organized religion. P stands for personal spirituality and practices. And E is effect on medical care and end of life issues. It's nice to keep these as you go in, as you're not into it much to kind of have it available. And then it becomes a part of you as you ask the questions. Again, hope, the H is what are your sources of hope, meaning comfort, strength, peace. What do you hold on to during difficult times? For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with their lives ups and down. Is this true for you? Do you consider yourself part of organized religion? How important is this? Are you part of religious, spiritual community? Does it help you? How does it help you? Do you have personal spiritual beliefs that are independent of organized religion? What aspects of your spirituality or spiritual practice do you find most helpful to you personally? Prayer, meditation, reading scripture, attending religious services, listening to music, hiking, communing with nature. Has being sick or your current situation affected your ability to do the things that usually help you spiritually? As a doctor, is there anything that I can do to help you access the resources that usually help you? Are you worried about any conflicts between your beliefs and your medical situation, care, decisions? Would it be helpful for you to speak to a clinical chaplain or a community spiritual leader? As you all think about FICA and the HOPE tool, this is from Illuminating Me, written in 2019. With this mind, I thought and learned. I cried, laughed, sometimes in anger burst. I dreamt, imagined, braved and feared. My ego controlled, new techniques gathered. My soul and I have often been seeking. The one had been waiting, prompting, shining. My consciousness in depth, so knowing. In death, still alive, still illuminating. So both Dr. Anandraja and Dr. Pahalski at the ISPAC mentioned this spiritual generalist and a spiritual specialist. Just like we have cardiologists and endocrinologists and gastroenterologists, and we as generalists refer to them for specialists in spirituality. We are all considered generalists, all of us. Physicians, nurse practitioners, nurses, you know, and physical therapists, social workers. But so we can recognize and tend to the spirit of the other, providing our compassion, presence, real listening, and encouraging realistic hope. Can be given by anyone who has a genuine concern and compassion for the patient. The word spirituality, God, may never need to be mentioned. I use this quite a bit in my teaching, I use this quite a bit in my teaching for med students with the use of the word generalist. And I equate myself to being a generalist that gives them that even as an experienced physician, I'm still a generalist. And then the specialist, the specialized spiritual care, which came up a lot in the ISPAC kind of train-the-trainer session. Straightforward again in the role of the doctor's role as a generalist and complex issues. The role of the trained specialist addressing specific theological concerns or needs, the spiritual counseling. With the chaplains who are actually listening, we tell the med students, when you assess spiritual history and you find spiritual distress, then you shine the light to the specialist, which is a chaplain, let them come and help address this, and you can learn from how they're doing this. There are challenges with special and diverse hospice patients and providers can have agnostic and atheistic healthcare providers, students, patients, families, growing up with many faiths. Students often speak about themselves growing up in so many faiths and conversion, distress by believers, non-believers, diversity of our cultures and faiths, LGBTQ, homelessness, substance use disorder. The role of multi-faith panels, of course, in hospice care, IDT discussions, when patients of different faiths and the different spiritual distresses that we need to understand. And that's where the chaplain comes very handy. So what are the emerging themes in this? Students and physicians are becoming keenly aware of own spirituality through spiritual care education. Spiritual care education is being expanded for all healthcare professionals. Spirituality is being discussed more in academy meetings and since the pandemic. I-SPEC, the Interprofessional Spiritual Care Education Curriculum. Better self-care helps with patient care. Better self-understanding helps with understanding others. So coming to you now, the audience, what do you do in your self-care? What do you do to keep your values and ideals alive as you go through your career? What gives you strength? What energizes you, fills your cup? What inspires you? What are your self-care practices? As I mentioned, my own is daily meditation, mindful walking, and poetry when it is necessary. And it inspires me, I write poems. But I think all of us need to have these to extend our journeys further in hospice medicine and in things that we like doing as well. As you think about that, your own self-care and what you're going to be putting down into your notes, this is from a poem, Brilliance, written in 2021. It was two days before the end of the year on December 29th. The birds balancing on the highest branches for the sight and warmth, the glory of this brilliant sun. This moment in time, the year draws to a close, a year full of promise, of love, kindness, a year still marked by the pandemic. The sun, however, is constant, ever-present in the heart, illuminating this brilliance. So spirituality and self-care summary, the definition of spirituality is inclusive and broad-based, such as meaning, purpose in life, allows the patient to define what spirituality means to them. Spiritual care is part of whole person care. The patient and family needs this. Improved health outcomes, patient-doctor relationships, decreased cost of care, compliance with treatment, reduced health provider burnout is all proven. Hope and FICA can be used as tools to incorporate spiritual assessment and spiritual history in patient care. Spiritual care is an integral part of whole person care. It is a must, not an option. We do not treat the disease, but treat the person with the disease. Our patient is a physical, psychosocial, emotional, and spiritual being. He will not be able to provide the best care if you isolate one component. Better self-care and self-understanding can stretch our hospital journeys. Some takeaway points. Incorporate self-care into your daily lives. Add spiritual assessment in the patient that needed the most at the start. Follow up on their responses to care. Reflect on the benefits. Network with like-minded colleagues. Share stories. Be leaders and educate others. Send your thoughts and questions. I'll provide my email at the end. As we close this, from Spiritual Times, which was written on August 8th of 2009. A time for prayer to clear the mind, feeling the soul that ties unbind. Feelings to detach, yet very blessed. What families, present, past, future held. Invoking families, parents, and ancestors in thoughts, dreams, and prayers. Dedicating the soul to the Lord. Spiritual times while still of this world. Years now have passed. Growth, spirituality, what has mattered most. Losses help the look within. Seeing that which has always been. These were all the references and they're available. This is Firefly Racing with the Dolphins, published by Belvoir Press in 2023. It's available on Amazon if the poems interest you and you want me to read more about them. My email address, chalag.rajaram at gmail.com or chalag.rajaram at vtas.com. Rutledge Resources Online, Death, Dying, and Buryment is a Taylor and Francis publication from UK. I'm the subject editor for the medical portion of this. There are six subject editors and I'm the medical subject editor. The entries are meant for mainly graduate students, academicians, libraries to shine a light on death, dying, and buryment. 17 entries have been accepted so far on my side of it. Plan for publication in 2026 and for online updates every two years. If anyone of you who's watching is interested in being an author, please contact me. Again, the same email address that I provided earlier. Thank you so much. Thanks for your patience. Thanks for listening. Hi, Gina, are there questions in the chat or are there? You don't see any questions now. If anyone has questions, you're welcome. We'll keep the webinar going for a couple minutes. You're welcome to post them in the chat box or by coming off mute. You're also welcome to leave. So we thank you so much for being here with us today, but we'll keep the webinar going for a couple more minutes. Thank you for sharing. Thank you so much, Dr. Rajaram. I'm seeing a lot of thank yous in the chat box. I think everyone really appreciated your insights. Thank you. I was trying to make a journey of this. I hope that it was enlightening, it was relaxing. It was supposed to be more of a healing and a journey of relaxation. So thank you. Thanks, Natalie. Thank you, Dr. Rosen. Yes, this was incredibly well done, Dr. Rajaram. We really appreciate you being here with us and sharing your journey, your personal journey, your professional journey. So from HMDCB, really appreciate your time. If there aren't any questions, we can officially close the webinar. And Dr. Rajaram's information is in the chat box, so feel free to purchase his books. It's a beautiful book of poems. I think it's really helpful within this field. And then if you are interested, if you have questions for him, or if you're interested in publishing some work, feel free to email him as well. And thank you everyone so much for being here with us today. We appreciate it. Thanks, Gina. Thanks for your support. Bye, everyone.

Hospice Care

Spirituality

Dr. Shalat Rajaram

FICA and HOPE

Patient Outcomes

Self-care

Spiritual Community

Professional Development