Hospice Care

Hello everybody, welcome to Health Chatter. Today's episode, we're gonna be talking about hospice care, which is an interesting subject that's gotten a lot of attention lately. We've got a great guest and you will recognize him as soon as I introduce him in a moment. We have great, great crew that I always like to thank. And that includes Sheridan Nygaard, who's recording for us today. And she also does our great marketing. and research for shows. We have Maddie Levine Wolf, and also Sheridan works with her, and Deandra Howard, she works with them, and Erin Collins, they all do great research in the background. It gives, the research by the way for everybody gives Clarence and I an idea of what we should be talking about on all these shows. So thank you to all of you. Matthew Campbell is our production. who puts together all the shows, gets them out to you, the listening audience. And then of course, there's Clarence Jones, who's my trusted colleague and co-host for the show. We have a good time doing these shows and enjoy getting them out to you, all of you out there. So thank you to all of you. In addition, Human Partnership is our sponsor for all the Health Shatter shows. They are a great community health organization. We highly recommend that you check them out. They do a lot of creative things out there and you can check them out at humanpartnership.org as well as our website where we put all our research notes as well as transcripts for the shows at heal So thank you to everybody. So let's move on, hospice today. We have Dr. Barry Baines with us, who's been with us a couple of previous shows on health chatter. And he talked about, and by the way, I recommend you listen to these shows on ethical wills and legacy letters and serious illnesses and how to talk to your physician about serious illness. Barry has recently retired, he's joined the crew, and he's a family physician and hospice palliative medicine specialist in his practice. Does education at the University of Wisconsin at Madison and Georgetown University, and has co-authored a few books and publications. He has 25 years of experience as a hospice medical director and is board certified in Family Medicine. His book, Ethical Wills, Putting Your Values on Paper, is now in its second edition. And you can check that out. And we recommend you do that. Ethical Wills, Putting Your Values on Paper. Barry, thanks so much for being with us. Yeah, it's great to be back. Yeah, it's really, yeah, it's nice. You're a great guest and we appreciate all your great insights on a variety of topics, actually. Let's get this going a little bit. I know that we put together some of the research, but also you wrote me and said, I'd like to describe the differences between curative care, remissive care, palliative care, of which hospice kind of falls in line with all of it. So maybe you can start us all out by talking about that. Oh, that sounds good. So, you know, when people think about hospice care, to give it that context is that typically, when we have illnesses and different diseases, there are different treatments for it. And as you pointed out from my, from my notes, there's three types of care, curative care, it's sort of, you know, self explanatory, but that's care that you get to cure the disease. And So to give an example, let's say you have a strep throat, okay. And you go to see a doctor or nurse practitioner, you know, whatever, and oh yes, you have a strep throat and you are given an antibiotic and you're cured of your strep throat. That is curative. That is curative care. Remissive care is kind of a big word. And what does that actually mean? Basically it's care that's designed to slow down the progress of a disease. In other words, it's a, people have diseases that can't be cured, but they can be well managed. So one example is diabetes. Okay, once you have diabetes with rare exceptions, I know there are things like pancreas transplants and stuff like that, more esoteric, but in general, if you have diabetes, you receive remissive care, which basically helps to control the disease and slow down its progress. So in the diabetes case, it might be different. medications that you take or insulin. People are familiar with hearing that insulin could be something like that. And so it's, it's to slow things down. And in fact, a lot of cancer care, okay, is focused on remissive care to really control the progress of the disease, hopefully so that people are able to, you know, have a quality of life, but and be around for a while as they as they move ahead. Then the third type of care is called palliative care. And people may be familiar with that as care that focuses on comfort and treating symptoms. It's a kind of care that doesn't cure anybody of a disease. It doesn't slow down the progress, but the focus is on comfort so that people are comfortable as their disease progresses. Within that umbrella, if you think of palliative care as a little umbrella, under palliative care is hospice care. And that's exactly where it fits in. And hospice care is a type of palliative care for those people who have a prognosis or life expectancy of six months or less. And we'll get into this more. It's not an exact kind of thing where you have to, circle a date on your calendar and. Well, gee, if it's the wrong date, I can't get into hospice, whatever, if that's what's chosen. So we'll talk about that in detail. We'll let that spill out and spin out a little bit as we go ahead. But those are the different types of care. And quite honestly, a lot of people are not clear on the types of care that they're getting, especially when it comes to cancer care. And part of that, is that we want to be hopeful, we want to be optimistic, and we hear things differently. And I know there've been a number of studies where people who had very advanced illnesses, very advanced cancers, colon cancer and lung cancer, that they were receiving treatment that was clearly remiss if they weren't going to be cured of their disease. And they thought that the treatments that they were getting 70 and 80% thought that the care they were getting was going to be curing them of their cancer. And it wasn't. So again, you know, at the bottom line is always communication is very important. And so that people understand just to bring in a piece from the serious illness and talking with your doctor, that communication becomes very important. The other piece as well is what are people's goals of the care that they that they receive. And that's again, is another conversation. And we did cover a bit of that last time. So that lays out the four different, well really three different categories of care that people receive with the subset under palliative care being hospice care, which is what we're gonna focus on today. Yeah, Clarence. Yeah, Barry, thank you for that. I mean, that was so informative. In fact, as I was sitting here, listen, I said, we gotta put that on our website. We got to actually write that out so that people know that was very, very informative for me. But I think the thing that I want to say, I want to start off by just saying this. When somebody tells me hospice, I automatically think like it's over. You know, you said there's like six months life expectancy and things like that. Could you talk a little bit more about that? I mean, addressing that kind of emotional, I mean, hear that word is like, oh man, this is it. You know what I mean? So it really throws some people off, in terms of their really understanding exactly what's going on. Right. You know, it's interesting to bring that up, Clarence, because it's kind of like, there are certain words in the medical health arena that kind of make people shudder. Okay, it's like if you hear the word. cancer. It's like, Oh my God, I've got the big C. Okay. Or hospice all of a sudden, okay, that's it done. Right. So, and it, and it creates kind of an emotional response, but anyway, go ahead, Barry. Okay. And I'm going to do a little background painting as well, because even the term hospice has four different meanings. Wow. Okay. So I think we, you know, we're going to focus on hospice care. which is a philosophy of care. That's the type of palliative care. We already covered that. But hospice also has the meaning, it's a benefit that Medicare provides. It's a Medicare hospice benefit. And in fact, not only is that a medical insurance benefit, it's also present in a lot of public health insurance programs and many, many private insurance programs, whether it be Blue Cross Blue Shield, what do you know? whatever, almost all of those types of programs, the majority try and mirror what's considered the gold standard of a hospice benefit from what Medicare does. So even people who are not of Medicare age, if they have a terminal illness or a life-limiting illness, most of the time they would be eligible to go into a hospice setting or not hospice setting, let's stop and. repeat that most of the time they'd be eligible to receive hospice care even if they're not of Medicare age. The other definition when we talk about hospice is like a hospice program. Okay. So most people who receive hospice care, it's usually through a hospice program that's, you know, related to home health. It's all of the care systems, certainly within Minnesota have hospice programs within their services that they provide. And then the last thing is that hospice, sometimes people think of hospice as a place that you go to. And in fact, there are some freestanding hospice homes that people can go into. These tend to be private pay, but some people might be familiar within our community. We have Weedham Residential Hospice, J.A. Weedham. We have the Pillars Hospice Home out in Oakdale. We have NC Little in Edina. And then there's also our Lady of Peace, which is also in St. Paul that offers a place for people to actually go and spend their. and spend their last days. So Barry, let me ask you, are there also, with this, the kind of facilities, I guess, for hospice care that are in, and you're relating to what's going on in Minnesota, are there analogous facilities that you know of in other states as well, or does every state kind of have their own thing going? Yeah, I mean, every state can have their thing going, but those are the... you know, the standard things. The reality is, is probably less than 1% of people actually avail themselves of services within a hospice home, as it were. Number one, because they tend to be private pay and they could be, you know, expensive. Typically they're reserved for people who are really at the end, like days to weeks. generally speaking. And the vast majority of care and hospice is given in the person's home. Okay. Or the place where they're living that they call home. So it'll be either, you know, in their home, their, you know, a house, their apartment, you know, what have you. Or if they're living in assisted living, or if they're living in a, they're needing long-term receive care there. Hospice goes, hospice programs go wherever the people are. And that's where they deliver the care. And most people would prefer to be in a comfortable place, their home surrounded by their loved ones. And that's sort of where the care gets delivered in the vast majority of cases. But when you talk about hospice, sometimes people think, oh, that's a place, right? Well, but hospice care you receive wherever you are. And in fact, if you start up in your home and you're receiving hospice and then you need a higher level of care. So you go into an extended care facility or long-term care facility, hospice follows you wherever you go. Wow, okay. That's really good to know. So let me ask you this. Talk about hospice professionals. So who are they? Are they physicians? Are they nurses? Are they just home care providers? Who are they? And do you have to be trained a particular way, et cetera? So there actually are a group of people, hospices very much. When I was very involved with that, it's really a team type of care. I always say it's a team, hospice is a team sport, but that's where the lighter kind of thinking that only a hospice medical director might say. But it's very important because within that Medicare hospice benefit when people receive hospice, that benefit requires that a hospice provide nursing care, skilled nurse, social work. a chaplain to deal with spiritual issues. Usually they have home health aides to provide some help at home with bathing, things like that. A medical director that sort of oversees things. Then in addition, they also have to have volunteers. 5% of the hours of care that hospice provides under Medicare have to be involving volunteers. Like what? What would be a volunteer to just be with the person? Right, exactly. So let's say I was in hospice as a patient and a person could refuse that, but hospice volunteers are trained. Actually, I usually, in my hospice medical director days, I usually am part of their orientation. And then they volunteer, they work with you know, with patients, they don't deliver medical care because they're just like, I would say normal people, you know, they're just normal people. And so let's say that I'm home and my wife is sort of taking, you know, care of me, but you know, she needs to go out and go shopping as an example. So when a volunteer comes to stay for an hour or so, that would give, you know, my spouse some respite to go out. do some shopping, maybe go for a coffee with a friend outside. So they kind of do that. They could, we have volunteers that will play music, would read to them. Hospices, a number of hospices, these aren't required, but additional services, music therapy, pet therapy. So imagine that they, I don't know if Murphy or Riker would meet the criteria for that. But a lot of people, they really connect with animals. There's a lot of hospice programs have, you know, what's called pet therapy, you know, hospice, you oftentimes the music therapist will also, you know, sort of get a twofer and, and cover, you know, not only the music that they bring. And that's very important because, you know, really, it's soothing for the soul, you know, you have music that you like, you know, have a dog who hops up on your bed and just sits there and you could you know, pet them and that does make you feel better. So the array of services that you can get from hospice, there are quite a few of them. So where do these, just for instance, where do hospice volunteers get trained? I mean, I kind of perceive it as a neighbor. Could be a neighbor that comes in and, you know, just spends time with you, but they're not necessarily trained. Yeah, typically what happens, the vast majority of people who become hospice volunteers Not surprisingly, are people who had a loved one who was in hospice and the care that they receive. Hospice requires that if you did have a loved one in hospice, you had to wait a year before you could apply to be a hospice volunteer. Interesting. Okay. The vast majority have that experience. Yeah. No, I really learned a lot. from the work that you're doing. But how long does hospice care last? I mean, you mentioned that Medicare, Medicaid, I mean, is there a certain period where people are in that category called hospice care? Yeah. So the way the benefit works, again, it's designed for people who have a life expectancy of six months or less. The reality is we really don't have a crystal ball on that. Okay? And it's not like, oh, your six months is up, so you can't be in hospice anymore. The way it's set up is for under Medicare, there's a benefit periods that they call. So the first benefit period is three months. So the person gets enrolled in hospice and three months, you know, goes by. And then if they still at that time, after three months, if everyone agrees that. given the likely course of their disease, their prognosis is six months or less, they can be recertified. And then there's a second benefit period of three months. Okay, so that gets you the six months. Here's where the math gets just a little bit, it changes a little bit. At the end of six months, once again, the patient comes up for recertification. Okay, they've been in hospice for six months. Has their disease been progressing while they've been in hospice? Have they been deteriorating or sort of, going downhill basically. But yeah, they've been alive for six months, but reasonably you would expect that their prognosis is still six months or less. And so they could be recertified, then the benefit period shortened up to two months at a time. And those require the medical director making a visit to the patients wherever they are and agree. Cause the medical director is the one who has the magic of signing the paper that says, I recertify John Doe as being appropriate for hospice for another two months. And then, and so literally every two months a patient can come up with recertification. And all of us have heard stories, certainly in medicine, of people who have cancer, which is a high frequency reason why people are in hospital. Though these days we also see a lot of Alzheimer's disease in the end stages, end stage Parkinson's disease, some of the neurologic diseases like ALS, what people know as Lou Gehrig's disease. Heart failure is another. a big reason why people go into hospice as their heart function declines and different lung diseases, COPD, chronic obstructive pulmonary disease, those kinds of things in addition to different cancers. So- So let me ask you something. You mentioned the link between hospice care and Medicare. Okay, where Medicare will cover hospice care. All right, is it typical for health plans or insurance companies to cover hospice or not? And if not, what do people do or what can they do if a person that they know is coming to the end of their life, what do they do if hospice isn't an option for them? through insurance. Yeah. Well, if that's a very difficult question, so I'm gonna put that out there. Because the vast majority of people do have access to hospice care. In addition, I can tell you that certainly within the Twin Cities, there are many hospices that will take patients and enroll patients in their hospice if they don't have insurance. Okay. And so they provide the care. The focus again for hospice, the compassion level is very, very high. And to think that someone who has a very short life expectancy is effectively dying and having symptoms that are creating a lot of pain, oftentimes not only physical, but psychological, spiritual, and those services. I mean, part of humanity is to be compassionate and to try and accompany people on this last journey that they take. you know, hospice care, but in general, like I say, the vast majority of people have access to it. That being said, one of the biggest issues we see, right, we talked about the other side, oh, well, six months, and I told you what happens after six months. And the big reality is that for this benefit that's designed for six months, the median length of stay in hospice, so that's 50% of people are enrolled in hospice die in two weeks or less. Wow, okay. 50%. Wow, okay, yeah. Okay, so what winds up happening is that people are referred to hospice very late in the course of their illness. Why does that happen? We alluded to some of that. It's about some miscommunication about the kind of care or treatments they were receiving, right? If someone thinks, well, I'm gonna get cured. I'm not going to go into hospice, right? Because typically when you go into hospice, the focus is just for symptomatic kind of medications and treatments and things that oftentimes, if it's not comfort focused, if it's designed to slow the disease down, usually that's not something that's covered. So Barry, let me ask this question. As you're talking, I'm thinking about the individual that's getting the hospice care. What about the families or the caregivers around them? I mean, what kind of information is being provided for them or, you know, so they can. Yeah. Deal with it. Yeah, it can deal with it. It can deal with it. I mean, is there a gold standard? Is there requirements from the organizations that, you know, that there are certain things that they should be providing to the families because that's tough for everybody. Yeah. Well, this is actually, Clarence, that is such a great question many people think that if you're getting hospice care, that you're going to have hospice care providers in your home 24 hours a day. Yeah. And that's not the case at all. In fact, for home hospice, if to, to deliver hospice in your, in your home, you need to have the family support that's going to provide the majority of the care basically. Okay. In terms of making sure that, skilled nursing visits, usually once a week or once every two weeks. More frequently, certainly as the disease is progressing more, you'll get social work visits every month or so, you'll get chaplaincy visits every week or two, you know, just depending. But most of what's done is educating the family for how to care for this person that is, you know, that is dying. And again, Home health aides will come in a couple of times a week to help like with bathing and things like that. But it's the family that's providing the majority of the care, again, under the guidance of the hospice team. And the hospice team, they're always available if issues come up for managing those kinds of things. And that's pretty much how the care is delivered. It's not like a nurse from hospice who's... you know, sort of, you know, in your house, eight or 10 hours a day, it's called intermittent nursing care. You get a couple of visits always available by phone. And the focus is always, especially, let's say if there's pain issues, then there will be more intense visits to make sure that the pain could be well managed to the extent that the person wants their, you know, their pain controlled or other symptoms, breathlessness, let's say if they're having, you know, heart failure or lung problems. And so hospice will provide oxygen. They provide all the medications they pay, you know, so you don't have to pay for any of the hospice medications. That's all included. Equipment, if you need a hospital bed, for example, because people, you know, can't get up, you know, easily anymore. So a lot of the, what's called durable medical equipment, that's the term for that. So it provides all of those ancillary services. plus in the medical services. And the hospices that I work with, the primary doctor for that patient, the programs I've worked with, we've always kept those doctors as being still the primary care. That's another reason why people don't wanna go into hospice because they're worried that they're gonna lose their doctor. And oftentimes, who knows the pain? It's the doctor who's been taking care of the patient. for years and years and years. They know them and hopefully the family, as well as that trust piece is there. And that is so very, so very important. You can see it's a team. There really is a team sport here. You know, it's interesting for, if you ever, what I have noticed at least is whenever you read an obituary after somebody has passed, Oftentimes I will read a really special thank you goes to the hospice team that cared for the individuals. So people really connect with, or at least it seems as though they connect with the hospice providers of care. So here's another thing, kind of sidebar helper assistance. So you mentioned like a spiritual leader. We had one of our shows was on spirituality and health. And so help me, I assume, besides pets may be helping out, but maybe a pastor or some clergy or a rabbi connects somehow or other with hospice care providers. Is that? Well, they're actually hired by hospice. There are chaplains that are required. Chaplains themselves, okay. To be, and I mean, chaplains are clear, however you wanna. Yeah, right. Turn that. They are part of the integral hospice team. You can't be a Medicare certified hospice if you don't have chaplaincy services as part of your hospice program. And are they trained as well? Or are they just? who they are as rabbis or pastors or whatever. Most of the chaplaincy that are in hospice have special training that focuses on dying, on people who are dying, and dealing with their issues. And even though they may be from a particular denomination, they take people where they're at. And, you know, we certainly try if someone, let's say, you know, let's say his Muslim needs an imam, the chaplains, you know, they have their network. Yeah, right. In the community. So, or if it's a Jewish patient who wants a rabbi, you know, or a Catholic person wants a priest or a Protestant wants a man, you know, they reach out to help. The other reality again is that people are connected to their church. Okay, in a, you know, generic sense, their house of worship, they're connected to that. And, and hospice again, reaches out if you've been in a religious, you know, setting with, you know, whether it be minister, you know, priest, rabbi, Imam, yeah, you know, you sort of want to continue with that and hospice, what, you know, makes the connections to let that happen, because oftentimes, those people, again, they know the patients, they know the families. And so we try and keep everybody in the loop as much as either the patients and their families and those providers would want to be doing that. Does that- Yeah, yeah, yeah. Clarence. Yeah, so Mary, I think you mentioned that the medium stay in hospitals like two weeks. Yeah, the median, that's 50% or less die in- in two weeks or less, yeah. Wow, wow. My question to you is this, and you talked about the fact that sometimes people come in at the later stages of their disease. Do you think people do not utilize hospice because of the cost? No, because for, I don't think so, because the majority of people, there is no cost to them to enroll in hospice. Well, do they know that? I mean, that's the question. Do they know that? I mean, because a lot of times, because people are unaware. That's why I think this program is gonna be so helpful is that because they're unaware of exactly what does that mean. And there's a lot of times there's not that information or access to people that can accurately describe what's going on because people will say, well, it's over. I mean, so people have their own emotional conversation about this. So I'm just asking, two weeks, I mean, that's... you know, that, that sounded like a family has gone through a lot. Yes. What did, you know, and I'm thinking like, is it, is it cost? Is it just an emotional thing? I don't know. I'm just asking that question. I just wanted to. Yeah. I don't think it's, it's not cost. Okay. However, you make a good point. If someone is not aware of that, then they may think that there's a cost. Okay. And that would keep them away. Um, generally speaking, hospice programs, uh, need to do like, uh, evaluations from families after they deliver services. And for years, again, I've been, you know, in the business for 25 years. The number one thing that families report is I wish I had gotten my loved one into hospice sooner. Yeah. That's the number one thing. Now, every doctor and nurse knows about hospice. Every long-term care facility, they know about hospice. Every hospital, you know, knows about hospice. And they certainly do talk about it, okay? You know, when people are, you know, are in there, have you, you know, thought about that? Can I push you a little bit? Yeah, yeah, push me. Okay, okay. So, families are saying, yeah, I wish I would've got them in there earlier, but do they say why they didn't get them in there earlier? Because I think that for me is, I wish I would've done that. There has to be some kind of barrier. Right. And the only reason why I'm asking that question is this, is that You know, I think this is, I'm more seasoned now, so this is much more relevant for me as well. But I think that there's something that people are not getting about this. And this is something that comes on, I'm speaking now as a physician. Okay. That's our fault. Okay. And there have been a number of studies to give you, this will explain why is it two weeks or less for 50%, okay? Yeah. Studies have shown that in general, physicians overestimate prognosis by 500%. Wow. Okay. Wow. So, if your prognosis is two months, okay, that's. that realistically you're going to live for 60 days. Okay. Most physicians will think that you're going to probably live about a year. And since hospice is six months or less, okay. Well, you're not ready for, for a hospice because you know, and part of it, it's not, like I say, it's, it's on the physicians, but there's a dynamic, it's, it's the doctor and the patient to get together for this because people want to live. So it's a hard conversation to have, but that's one of the things. So in fact, one of the things that has been done for hospice is to get doctors to think if they have any patients, like if you say, do you have anybody that is going to die in six months or less? Well, if you overestimate by so much, you almost have nobody. who meets that criteria, but we changed the question. We call it the surprise question. Doctor, do you have any patients where you would not be surprised if you open the paper in the next year and saw their name in the obituary that they had passed? Wow, wow. And once you, that's a very different, because six months or less, well, I'm just a doctor, I'm not God, I don't know. I don't know the end. But generally speaking, you say, would you be surprised if Mrs. McGillicuddy died in the next year? And then you think, well, boy, probably not. She has pretty bad heart failure. And I know I wouldn't be surprised because then that's the patient that you can be referred to hospice and hospice will have that conversation with you. You don't have to choose. to go to enroll in hospice, but then, if you get the referral at least, those conversations could happen more with people who this is what they do all the time and they can lay things out. You know, Barry, I wonder if it's part of the- Let me, let me, let me, let me- Yeah, go ahead. Yeah, let me, cause I love this conversation. This is why this is called health chatter, okay? Okay. Yeah, we're all chattering away. Yeah, yeah, we're chatting now. Okay, because I think that part of what you said, I mean, the 500% overestimation, that's big. I mean, is it that the doctors are overestimating their work, I mean, what they can do? I mean, you know what I'm saying? I mean, as a doctor, you wanna be able to say like, hey, you know, I had a patient come in and we were able to help them to get to this level, we helped them to get healed. That's really... I love that you entered this conversation, but I think that that's something that, you know, I'm gonna ponder about. Okay. You know, it's interesting. I was gonna say kind of the same thing. It's kind of my perception of this 500%. It's kind of counter to what physicians want themselves. They want to be able to cure or, better disease manage. But as soon as the word, I guess, hospice comes into the conversation, that's counter to what they're trained for because they're trying to keep them alive and healthy and happy as opposed to death and dying here. Right, and to be clear, this is not, this is not meant to be a blame game because I can tell you the dynamic here. you know, it takes, it takes two to tango, right? And when, you know, for most people, as they go through their illness, their goals change over time. Okay. And many people's goals are, I want to live as long as I can. Okay. And as you know, in medicine, we continue to have treatments that may or may not help, help that goal. And so it's one of these things where everybody is hoping for the best here. And so it's easy. Again, this idea of six months or less, that's a hard thing to, you know, to get your head around, and then you also have patients and their families and you have families that are not, have you ever heard of families that are not on the same page on things? Never. I don't know what you're talking about. Then there's all these family dynamics as well that happen. So it's very complicated. Again, one of the things that helps is the idea of reframing this, even though yes, six months or less. But if we think in terms of a larger timeframe, we know that it's going to be less than that. most likely, okay, because we tend to overestimate prognosis. So that to me is the key. That's sort of the key. And that was why I wanted you to enter that question. Okay, I hope I answered it. No, no, you did. You did. You did. Yeah, but you answered it in a sense of this, that it's a struggle for everybody. I mean, it's a struggle for everybody. I mean, as you just said, Sam talked about the fact is that, you know, he wants to... he or she wants the person to live, the family has dynamics, the patient has dynamics. And so when you get to this point of talking about hospice and hospice care or end of life kind of conversations, you have to be exposed to the variables and not have a fixed mindset on this is how it's going to be. And that's why I pushed. I think it's great. And the other thing to realize that a lot of people probably don't know this. When I was just doing my regular family practice stuff, not my family practice with seeing patients and things like that, I used to do what I call womb to tomb. I had very few patients in the course of a year who died. Do you know what I mean? I had maybe a handful. And so if you just run into that every few months or so, unlike treating diabetes or high blood pressure or strep throat, where you see a lot of that, you sort of, you know the drill, you know what to do. With end of life care, it's, and it doesn't, for again, the general a primary care physician, an internist, a family physician, as opposed to, let's say, geriatricians or oncologists, cancer specialists, you know, even cardiologists who tend to see the more difficult heart failure things. If you don't see lots of patients, you don't, you don't learn the drill for how to have, you know, how do you have those conversations, which as you can imagine, are very... sensitive conversations. They're very difficult conversations to have. Let me ask this question. I sense that, Barry, when you're dealing with hospice care, you're also dealing with cultural issues. For some people, somebody who's dying is, oh my God, it's the end of the world. On the other hand, know, people celebrate, you know, there's some cultures that really celebrate that. So how does hospice care deal with cultural issues? Yeah, that's another great question. That's why I love being on Health Chatter. Yeah. Our conversations are just so, they're so good. So actually, everybody is aware of cultural competency. Yeah. Or at least they should be. and hospice, the hospice team is very sensitive, okay, to the cultures that they're working in, which are a diverse set of cultures. And you could be part, as we all know, you could be part of a culture, but you still need to know individually, what does that mean to that person? Okay, you can't say everybody, you know, who's part of this culture acts in this way and has these wishes. No, it's not the case. So it's recognizing and asking the question directly. So how do you, you know, what is, you know, how do you and your family approach end of life? And then when they tell you then, and that informs the treatment plan moving forward, because then you know. So it's being humble enough to know that it's okay to not know. And- and be culturally sensitive and ask, okay, I don't know. So, you know, I would ask Clarence, what has been your experience with people in your family who have, you know, who have passed? How did that go? And how do you see this for yourself? And so you ask, you listen. And that's the other thing is that hospice care in general doesn't have, we don't have our agenda. Like our agenda is sort of, what are your goals? and how can we help you to meet your goals? That might not be what I would want to do. Yeah, yeah. But it's not about me, right? It's about you. So let me interject real quickly again, okay? Yeah, yeah. I'm in a probing mode here. I'm in a probing mode here, okay? When you talk about being culturally competent, I mean, I think that question should be asked to everybody. because just because a person looks like you does not mean that they think the same way that you do. Exactly. To think that it's only with those people, really throws the thing off. We're human beings. So even though we look alike, does not mean that we have the same life experiences, emotional experiences. So I think that's a great question to ask everybody. I agree 100%. Okay. We are all unique. We are all unique. So Barry, here's, you had mentioned at the front end of the show, palliative care, which in my, the way I kind of perceive that is overall disease management, but let's, for the listening now, let's do this. Somebody's in the hospital, a loved one is in the hospital and and they're not doing well and it's end of life is coming. Take us a little bit step by step in order to connect everybody to hospice. Okay, so like, use me, I'm in the hospital and I'm dying. Okay, what would, what would healthcare providers do for me and for my family in the hospital to step by step to connect me? Who connects me to hospice, for instance? Okay. Well, if you're in the hospital, probably it would be either your attending physician, your doctor, or the nursing staff. They may have Um, really we, we just, uh, there really is, is not, uh, anything more that we can do at this point to slow down the way your disease is going. Okay. And realistically you have, um, a few months, you know, left, left to live. Okay. Let me tell you about hospice. Okay. The doctor will say, let me tell you that we have this other, you know, kind of care called hospice care. that focuses on keeping you comfortable and improving the quality of your life as best as can be done in the remaining time you have. Is that something you'd be interested in? You would say of course, yes, I think I've been on this road, I've been back in and out of the hospital every month for the past five months, whatever. And they say, great, we're going to have, person to come in. Well, oftentimes hospitals have palliative care teams, okay, in hospital services who can come in. They're not hospice, they're palliative care, but they can come in, they're well-trained, they will have those conversations with you and together you'd say, you know, I think I'd like to go with hospice. Got it. And so they do that with you. and your family. Yes, yes. These are these are family conversations. And then while you're still in the hospital, either they can get hospice to come in to see you, but hospice really can't enroll you till you're home. Okay, so it might be Stan, we're going to send you home tomorrow morning. And tomorrow afternoon, hospice, there's a hospice program that's going to come out and talk with you. Hopefully they could come in and say hi to you while you're in the hospital and say, Stan, we'll see you tomorrow after you get out and we'll get everything together, talk about your symptoms, making you comfortable, et cetera. The interesting- So it starts with the attending physician. Oftentimes, yeah. Okay, got it. Yeah, but it could also be friends and family, people who have had experience with that. The information can come from anywhere. This is one interesting point. People with... with very advanced lung cancer. They just looked at people who just received the regular treatment, okay, of chemotherapy, all that stuff, and people who had all that same treatment. In addition, they also got palliative care, not hospice, but palliative care, which again is designed to focus on symptom control, et cetera. People with the same prognosis for cancer, if they also receive palliative care, Yeah. They lived a month or two longer than people who just received remissive care. Interesting. So that's where the disease management comes in. Well, the symptom management and it's more because then your mindset is there, your mental stuff is really, the mind can do really big things for us. And so that's just another thing why trying to get people involved early. And that's why you see people asking for support in the obituary and they talk about how great hospice was and my family say, I wish we had this for longer. It's still a gift though. Even if it's a short time, okay? There's a lot of things that can get reconciled, that can get done to put everybody at peace. And so even two weeks- I love it. Even two weeks could be a gift, you know what I mean? I always say we want more. I love that. I love that what you just said, because I think that that's the issue that happens so many times with family. There's so many unresolved issues at the end of life. What didn't I do? What didn't I say? I always say, when I die, I don't wanna have to say I wish I would've. Right, right. I think if you got two weeks, if you got... If you knew you had two weeks, you could get a lot of things resolved. So I appreciate this conversation. I know that we're coming to the end of our show, but I really appreciate, I mean, cause you really seriously, this has been a great show. In fact, I'm thinking about who do I serve this show to specifically in my life. And I'm hoping that our team, well our research team will put together those three, those actually those two sets of terms. that you talked about, because I think that would be very important for people to really, really understand when doctors are talking to them or when they are presented with these opportunities, what they're really looking at. I guess what they're really, really looking at versus this whole idea about, I think, now we need to know that we're on the same page as you talked about. So thank you, Mary, for my perspective. Oh, you're welcome. You had great questions too. You know, it's interesting, you know, for our listening audience, my pooch just came in and is sitting next to me here. And it's interesting, you know, I was thinking how it is that we humanely deal with end of life for our pets, okay? And how much of a major, major difference there is between... how we as humans deal with that. It's much more complicated and harder, but perhaps there's some lessons to be learned from our pets in our lives as well. So Barry, I truly thank you for your insights. This has been a really, really great show, and hopefully our listening audience will appreciate the insights and the information. and hopefully it'll guide their decision making when they need to going forward. So for our listening audience, I wanna say as I always do and end our shows, keep health chatting away.