9UNP1295SD_Kate_Schueller_WordPress

Good afternoon, I'm Marje Murray, director of Geriatric Services at UW Health, and it is my great pleasure to welcome you to our Better With Age program. We are just thrilled to have Dr. Kate Schueller, who is a fellow in hospice and palliative medicine at the University of Wisconsin Hospital. She comes to us after several years as a primary care physician with Dean and developed an interest in palliative care, and she is here to share what that is and why with you. So, help me welcome Dr. Schueller. 
(applause)

- Thank you very much, all of you, for coming today. It is my pleasure to be here. This is one of my most favorite things to talk about. As Marje mentioned, I, prior to doing what I am doing now, working as a fellow, I was working as a primary care physician here in town, and, along the way, I developed more and more of an interest in palliative care. And, first of all, I didn't know what it was. I had to learn a little bit more about it. 

We didn't get a lot of it in training when I first trained about 10 years ago. And little by little it's becoming more and more recognized. So this, the title of this lecture is The Science of Comfort.

And I think that's something that we all kind of aspire to and would like to have happen as we get older and as we age that it's not such a difficult journey, but, rather, one that we can kind of take with friends and family and make it as comfortable as possible. So, prior to working at Dean as a family physician, I had a little bit of time spent teaching. 

So some of that has stuck with me, and I feel the need to put objectives up on the screen to sort of outline and give some sort of a basis to my talk. So, just in brief, some of the objectives today. One, is just to explain what is palliative care. It's a term that it's a long word. A lot of us don't really know exactly what it means. So I hope that by the end of today's discussion you'll all have an understanding of what palliative care is. 

And then, of course, we can't really talk about palliative care without somehow talking about hospice because I think a lot of people think of hospice and palliative care as one in the same when there really are some distinctions. So I kind of wanted to talk a little bit about how it's distinct, and also what are some of the areas that they have in common. 

And I'm just going to touch on this a little bit, but why are we hearing about it more lately? It seems like 20-30 years ago this wasn't something that was talked about. So why are we talking about it more now? And then, because it is a field within medicine and there's a lot of emerging research, I just wanted to touch a little bit on that. 

It might get a little bit, too, kind of tedious, but also, I think it's our way within palliative care to show our role within the bigger scope of medicine and also support ways of learning more about it. And then, lastly, what is a palliative care encounter? What does that entail?

So, I'm going to start with, there's a quote by, I have several quotes kind of scattered throughout this lecture by a famous author. His name is Dr. Atul Gawande, and he wrote a book called Being Mortal. And I think that's one of the reasons why I think we're talking a little bit more about palliative care is partially because of the recognition that his book got. So, kind of introducing this first quote.

I think it's hard to talk about palliative care and not kind of talk about what it's leading up to, which is dying. So the very first quote here is, and this is directly from his book, "Death is the enemy. "But the enemy has superior forces, "and eventually, it wins. "And, in a war that you cannot win, "you don't want a general who fights "to the point of total annihilation. "You don't want Custer. 

"You want Robert E Lee, someone who knew how to fight "for territory that can be won and how to surrender "when it can't, "someone who understands that the damage is the greatest "if all you do is fight to the bitter end." And again, it's a fact all of us, all of us were born and all of us will die. So the idea is, what does this mean by the bitter end? Do we want to have a say in how we kind of frame the last years of our life?

And then here is just a slide of Dr. Gawande and the book that I think some of you are nodding that you may have read or you're aware of. And I think this is one of the reasons, like I said, this topic is picking up steam. His book is making the whole idea a little less taboo, I think, that we talk about some of these serious issues.

So, I kind of keep talking about the term palliative care. What do I mean by palliative care? And so what I hope to do is describe it in several different ways. Some way swill be fairly straightforward and simple, and some ways will be a little bit more complex with a little bit more depth. So, initially, palliative care, what is it? It's a specialty of medicine that focuses on providing specialized care for people with serious illnesses. 

It focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for the patient and their family. So, again, the key concepts that I just want to emphasize here is that it focuses... it works with people with serious illness, and the goal is let's focus on quality of life. And so I'll kind of, like I said, use this talk to discuss it in several different ways.

And so a little bit more, and, again, I'll kind of revisit all of these themes as we go. One of the other key features of palliative care is that it is delivered by a team, which is one of the main reasons I love it. I found when I was working as a family physician, I kind of did a lot of things in isolation. I had some great nursing staff and we had some good support people, but so much of it I was just doing on my own. 

Whereas, when I learned a little bit more about palliative care, I thought this is fantastic. This is a way of caring for people where we actually, we take advantage of so many different people and their skills. So palliative care is delivered by a team, and that team is made up of nurses, social workers, pharmacists, chaplains, and, again, physicians. Nurse practitioners, you name it. Together, along with people's regular doctors, we provided an extra layer of support. 

The other key feature of palliative care which distinguishes it from hospice, and I'll get into the distinction later on, is that it's appropriate at any stage. It doesn't have to be right at the final stages of somebody's life. In fact, we prefer that it happens much, much sooner so that we can help people optimize and have the best quality of life that they can have.

So, again, just a little bit more. Palliate and palliative, where does that word come from? So the definition of palliate is to make a disease or an illness or symptoms less severe or less unpleasant without actually removing the cause. he focus is really on the disease and the symptoms. Historically, it's not that, like I said, it's somewhat of a newer field within medicine. The term was first used in about the mid-1970s by a Canadian physician by the name of Balfour Mount. 

Now, he was working in Montreal, Quebec. He had studied under a very famous provider by the name of Cicely Saunders, who is originally from Australia, who is actually considered the founder of the modern hospice movement. And so he moved to Canada, he realized that he didn't really want to focus just on hospice and the end of life. 

He wanted to think about things in a way of let's find a way to treat people's symptoms and try to focus on the quality because right about that time modern medicine had made some pretty tremendous leaps. We are able to cure things that were previously incurable. And so we were focusing a lot of our energy and efforts and research on all of those things. 

But in the meantime, there were a lot of people that had incurable diseases that were living with these symptoms that people weren't really focusing on. So that's a little bit about the history of it. And I won't spend much time on it, but I do mention it because, like I said, we want to draw the distinction between hospice and palliative care, but they are tied together, at least historically. 

So here is one way you can kind of think about hospice and think about palliative and think about how they relate. So most people know of hospice as something that people do at the end of life. And in order to qualify for hospice you have to have a life expectancy of six months or less. Very different. Then you can juxtapose that here with palliative care. This is one of these Venn diagrams. So, with this, with palliative care, there is no life expectancy. It doesn't matter. 

We want to work with people with serious illness at any point of their trajectory. Hospice is much later on, but palliative care we do at any point. That's a huge distinction between the two, and there's some other distinctions. Who pays for it? Medicare covers most of the, pays for most of hospice care. Palliative care, again, this is happening much earlier, so a lot of times it's private insurances that pay it. Medicare will pay it too, if that's what's somebody benefits are. 

And then the other pretty major distinction with palliative care and hospice is that palliative care can happen at the same time in conjunction with any sort of really aggressive treatment that somebody may have. Whereas, hospice, the focus is on comfort. We don't treat those symptoms super, the cure, we don't attempt to cure things so much. We just manage the symptoms. Palliative care happens at the same time. 

Somebody can be receiving pretty aggressive treatment and still start palliative care. Huge difference. 

w, of course, there's a reason why I have this diagram where there's the left and the right, there's the middle part, the overlap, which is where I think a lot of the, not confusion, but why there's sometimes some difficulty in making the distinction because they do have some of the same things that they focus on, which is quality of life, and also we don't, both hospice and palliative care, focus not on just the person and the disease but on everything else that is needed to support the person. 

Emotional support, of course physical, and then also spiritual.

Now, the next slide is actually sort of saying the same thing in a different way. Again, I was a teacher, I remember back, everybody had different ways of learning things. So, some people are visual, like myself, and others like things more literal. So here is just another chart. Same thing. So hospice, another distinction is where the services happen. Hospice usually occurs within somebody's home or in an inpatient facility. We all know about Agrace Hospice in town. 

It can happen at assisted livings and nursing homes as well. Palliative care is a little different because it happens usually a little bit earlier. So that is often happening in clinics. So, sometimes within an oncology clinic or within a heart clinic or within a renal, a kidney clinic. Clinics like that. Also, we are involved in the hospital as well. The palliative care crew, there's a team. So that's the care, where it's delivered is slightly different. 

Timing, again, this is just a different way of saying the same thing. Six months or less usually for hospice; palliative care no restriction. It can start at any time. Payment and then treatment. Again, the big difference being people think hospice, oh, you can't do anything. There's no other medicines you can be on. You just focus on comfort. Palliative care, that doesn't matter. You do it along with everything else.

Okay, so I keep mentioning... palliative care and what it means and serious illness, and so some people, this is interesting the way the hyperlinks was not the way it's supposed to be, but that's okay. Some people wonder, what do you mean by serious illness? And so just some examples. Obviously cancer. That's the first thing we all think of. But then also heart disease. Some people live for many, many years with heart disease. Lung problems. Breathing problems. Kidney failure. 

People that have that also deal and struggle with chronic disease. And then there's some of the different neurological changes that can happen, that people can have, including Alzheimer's dementia, Parkinson's and so forth.

So, again, a little bit more about palliative care. We talk about quality of life and how do we help that. Well, we help that by focusing on lots of different areas, but one thing we're pretty good at are symptoms and what people may be experiencing. So here's just a list of some of the symptoms that palliative care can help focus on while somebody's getting treatment. So we're really good at controlling pain, shortness of breath, fatigue, constipation, nausea. 

Some of those things that really don't seem like that big of a deal, but I'm sure all of us have struggled with these, and they directly impact your quality of life and how you're feeling. How's every day going for you?

So just to kind of shift a little bit, here's another quote from Dr. Gawande: "How we seek to spend our time "may depend on how much time we perceive ourselves to have." And I think all of us would agree with that. If you think you have a very finite amount of time, you're going to spend that time differently than if you think you've got three, five, 20, 50 years.

So the idea is thinking about time. And our way of thinking about time in medicine has shifted, and I think it's necessarily. So here's an example. This is sort of the traditional way of care. The way things would go for people. Again, keeping in mind all the advances we've had in medicine. So, you know, more traditionally, people would, I don't have a pointer but that's okay, somebody, you can see the arrow on the left. Somebody gets diagnosed with a significant serious illness. 

And they go through time and they're getting all kinds of treatments and cure and more diagnostic tests and things like that. And then all of a sudden, we realize that none of this, isn't working. This person is dying. And then we shift. This is the old way of thinking. We quickly shift to, though this says palliative care, I would kind of argue it's more hospice at that point. This is like we're shifting into this totally different phase of care for people, and then people die. 

Well, the idea with palliative care is that we start, we get involved much, much earlier on. Somebody gets a major diagnosis, for instance a really advanced cancer. 

I'd like to get in right away and meet with this person and kind of be talking and saying, "What do you want? "and what are your wishes? What are your goals?" And so we can kind of start some of these conversations at the same time that somebody is getting chemotherapy or getting some of these treatments that are hopefully going to help them live longer and live better. So this is another way of kind of thinking about palliative care and its delivery. And then people die. 

We kind of work together. The whole time working together, and then with palliative care, as with hospice, I think it's also really important, we look at the person as a whole and within their family context. And when somebody dies, it's upsetting for everybody around, and they leave behind a lot of family and friends. And so in palliative care we hope to still be around and help support that family. Much like hospice, so like I said, there's overlap.

And again, same way of saying, same information but just kind of summarized in one slide. The bottom one being kind of more realistic with how things go.

The bottom slide, the bottom diagram here. Somebody gets diagnosed with an illness, they make some improvements, palliative care gets involved, sometimes things are going well, sometimes they have a setback, sometimes they do well, kind of. So we're working together the whole time. The idea isn't one or the other. It's how can we be together to help people. Okay. Now, this is going to be a little bit tedious, I think, but I'll read this quote, and then it kind of sets up the next few slides. 

And you can read this as well for yourself. "A few conclusions become clear when we understand this: "that our most cruel failure in how we treat the sick "and the aged is the failure to recognize "that they have priorities beyond merely being safe "and living longer. "That the chance to shape one story is essential "to sustaining meaning in life. 

"That we have the opportunity to refashion our institutions, "our culture, and our conversations in ways "that transform the possibilities "for the last chapters of everyone's lives." So, that's kind of a lot of things to think about, but what it made me think about is the need that we have in medicine, and this is my bias as a physician working within medicine, but we have to sort of start to shift how we think about things. 

How we think about people and illness and our treatments and what we're doing. And so that requires us to sort of take a step back from what we've been doing, and let's think about it in a little bit different way. So now the next several slides are going to try help illustrate kind of why this might be important to do. So bear with me because it's kind of a little bit tedious. Okay, this is a way we can kind of try to look at things differently. So, here we are. 

We all recognize this, I don't think.. I think Capitol Lakes might even be on this map? Yeah. Pretty close. Yeah, it would even be on there. So, this is just a map. So, imagine you're walking down the street here, and you see a tourist from Japan. And that tourist approaches you and asks, "Well, what's the name of this block?" And you kind of look. You're like, hmm, let's see.

So they're right there. What's the name of this block?

And then you're looking around, you see, and you're like, "Okay, I see the corner of the block here.

"Why are you asking this? This is West Wash. "Here's Broom Street; there's Mifflin, and there's Henry. "So these are the streets. "I don't know what you mean by block." And so here's some slides that kind of illustrate West Wash. Then he asks again, "Well, what's the name of this block?" And you're kind of both getting frustrated and clearly not understanding. Well, you say, "But the blocks don't have names. 

"The streets have names, and the blocks are just kind of "the empty spaces in between all of the streets."

And, hmm, okay. So you don't really, have to understand where the Japanese tourist is coming from, and I can actually speak from some experience. I lived in Japan for a couple of years, and my address was not at all a street. It was a block. I would have no idea how to have found it in the first place, but fortunately I was taken to it the very first time and then I was able to find my way back. But there were no streets, it was blocks. 

So understand why they're asking you about directions in terms of blocks, you have to look, that's how they, in Japan, what they do is they label their maps by block numbers. That's how they do it. They don't have street names. So like, okay. So you start to see, well, what actually is happening, if you were to ask them, what's the name of the street, they're like I don't know what the name of this street is. It's this block, and then the other block, is that block. There's no street name. 

And so, suddenly it starts to click. They name their blocks; they don't name their streets. And so the blocks are named, and you can see there are no street names. Now, I will argue in the big cities they have some street names, but in the small areas this is the case. So, really, just like in the US where the blocks are empty spaces in between the streets, in Japan the streets are just empty spaces in between the blocks. So just a different way to kind of think about things. 

If one way is true, then the other must be as well. So, this is just kind of another example. We're back to this. And I think this is one of the ways I understand how palliative care fits into the American system.

Our medical system, and again, I'm speaking from my experience, is really, really focused on diseases and treatments and diagnosis and that's what we're good at. We learn that, and that's what we're trained in. We're pretty good about caring for these diseases. But I think that...

We need to start focusing things a little bit differently. So here's just an example. We are good about looking at the diseases, which we consider the streets. Diabetes, lung breathing problems, CHF is a fancy way of saying heart problems, heart failure. And then the other direction are all the treatments. We're really good at doing angioplasty and dialysis and then, if those don't work, then, you know people, then hospice is another kind of treatment.

But I think what I'd like to challenge all of us in medicine to do, is to not just focus on the streets, but we need to focus on the space in between. And I think that's the patient centered approach in thinking of people. People that are inhabiting that space and trying to make sense of all these different treatments and diagnoses, and what does it mean for those people.

I think we need to kind of orient our way around the blocks and not so much just the streets. Does that kind of make sense? We're just switching things a little bit. Let's look at the whole picture. Let's not just look at what we're used to looking at.

So these are just kind of more or less the same way of saying what I've already kind of said. We've got people that, everybody's born, and over time everybody will die. So there's the normal population curve. Somebody gets sick, and then you can see their trajectory changes. They have a disease, and they die sooner.

We hope with our medicine, modern medicine, that we can cure them. That would be fantastic. Then they kind of go back to the same trajectory, and they may live a little less longer, but they've done well. We've really done well. The idea with palliative care is that-- Oops! I'm going to step back. Sometimes we can also then, you know, somebody gets sick, we can't cure them. We can't get them back on that same curve, but we can help them live longer, and that's important. 

So that's what we can do. And then palliative care is just the idea of working together while somebody is kind of facing some of these serious issues. So, this is kind of another way. So palliative care actually has no impact on survival. It doesn't hasten it. It doesn't postpone it. It simply, hopefully, improves the quality of life and the symptom, the burden that people may be feeling. 

And I will kind of tease it to say there is some data and some arguments to actually support that good symptom management will actually prolong life for people.

Okay, let me just... This is just another way of, again, sort of saying it. Most people will live for many, many, many years and not even think or care about hospice or palliative care unless it has something to do with their family member. But over time, as people accumulate several different chronic conditions then it becomes more, it really impacts things a lot. So then we may get involved, and it may just be a small part of somebody's life. So to switch gears, another quote by Dr. 

Gawande: "You may not control life's circumstances, "but getting to be the author of your life means getting "to control what you do with them." So palliative care exists, but it's still relatively new. And, as I said in the beginning, that's why we're trying... we are trying to do more research and learn about what benefit it has, what impact is it going to have for people going forward. So it's kind of exciting because it's a new area in medicine and a lot of new research is happening.

So this is probably the most exciting one. And this is one that kind of really changed things, I think, for palliative care. And this is kind of a tedious graph. I mainly put it up there just as a way to kind of introduce the idea and this particular research project that was done. So, this is from, and I'll explain it because, again, it's a little bit technical, but this was done, published in the New England Journal of Medicine, which is a pretty big deal in our field, in 2010. 

And I was actually at a presentation, a palliative care presentation, where the lead author on this presented. And she kind of gave this background information, which was interesting. She said, "We went about doing this study "expecting one thing, "and we're surprised to find something else." So what the study was she worked within a big cancer clinic, and they had people that were diagnosed with advanced lung cancer. Very advanced. Already metastatic lung cancer. 

And they thought, well, let's take a look and see what happens to people with that diagnosis, we'll split people up into two groups. 

One group that gets traditional treatment, chemotherapy and imaging and all those things, and another group that gets all of that, do the chemotherapy, the actual directed treatments, but we also start some palliative care in conjunction with it, and let's see how they do because some people start to think, geez, palliative care, you guys talk about dying, you talk about all this really tough stuff. You're just going to make, people are just going to die sooner if you do that. 

They're going to lose hope. So that's kind of what, they kind of wanted a study to see what happens. 

looked at the data, and again, these people were all matched to two groups, the people that had the early palliative care along with all the other treatments actually lived longer, and it was statistically significantly longer, which is kind of a big deal, which really kind of got us all excited because what we thought just made sense, common sense medicine is the way I think of palliative care, suddenly we had some data and research to support it in its role and that people actually do better. 

Not only do they live longer, because I think it's not all about length, it's they live better, and that's what we're really all wanting. So that was really, really exciting. And so now I've got several slides that more or less say the same thing. But I just wanted, what I'm trying to communicate is that there is data, good data about this. So this study was actually done here at the UW by some of the people that I work with now in the department. 

And I won't go into great detail, but it has to do with people, same thing, advanced lung cancer. Two different groups, essentially. One group that had this kind of routine information given about their illness and some resources online that they could read themselves, and another group that was actually given a more specific, it stands for comprehensive health support system online, that their caregivers could partake in. 

And so when they compared the two groups, those that had standard treatment and this extra layer of support with a really robust computer program versus people that just had standard treatment, the people that had this extra support and this more information, they lived longer, and then the caregivers felt much more supported as well by having that information and that support. And I think it was probably their caregivers doing so well that helped people to live longer. 

So there's a lot of room for more studies to be done, but some of this is really, like I said, really exciting.

Same thing, more or less.

You know, this I put up simply as when I kind of mentioned that first study, people that had the more traditional or just the standard of care, which is meeting with the oncologist and talking about treatments and the diagnosis, and the people that had that and palliative care, this slide tells me I wanted to kind of explain some of the different extra things that were done at the palliative care visits. So they talked more with family. Palliative care engages family more.

We talk a little bit more about coping. Your oncologist is often really busy, and they've got a lot of people they're trying to help. They don't have time for some of these difficult conversations, and so these are some of the things that happen in a palliative care visit.

But we'll get into that in a little bit more detail later. Again, same way of saying the same thing. Okay, and this is, I think, the last study I have. So bear with me. What this chart is showing, and this was published in the Archives of Internal Medicine in 2009, is that, and I'm going to read my notes here otherwise I may end up making it more confusing. 

So, patient/physician discussions about end of life wishes, according to this study, were associated with lower rates of intensive, like ICU admissions. Intensive care. Intensive interventions Patients with advanced cancer who reported having these conversation with their physicians had significantly lower healthcare costs. That kind of makes sense. You're thinking, okay, they have fewer interventions kind of at the end, they're going to have lower costs. 

And is that a good thing or is it not? But when you look at the data, actually the part that's kind of exciting is that the people ended up, so the higher the cost, the more money that was spent at the end, actually resulted in a worse quality of death. And it's kind of a hard thing to even think or talk about, but what we think about when we're thinking about quality of death it's what we watched our family member kind of go through at the end. 

And also, how did it leave the family and the caregivers around them feeling? How did that go for them? So you can see on the left here, the quality of death score is much better the less money that's spent because the more money that's spent, then it's usually in a really difficult setting that's hard for families to cope.

So, that's... So, again, this kind of summarizing those slides.

A lot of this is talking about people understanding their illness, having the time to go over it with their doctors or other support people, what their prognosis is. Everybody, I think, knows what the word prognosis means, but prognosis is just a way of saying how are things going to go? How serious is this? Give me a sense of timing on this. 

And we know that people that have a better understanding of things like prognosis have a better quality of life, lower costs, which that's not the point of my visit. I don't really worry so much about the cost. I'm focusing more on people and how they're doing. But, also, like I said with that last slide, lower risk for families and caregivers for complicated grief. 

Everybody's going to grieve and everybody's going to be, go through a period of bereavement for a loved one, but depending on how that end goes for somebody, it can impact the people around and how they cope and how things go. And sometimes it makes it much more difficult. So we focus on not just the patients but also the family and support around. What's so exciting, and, again, this is just oncology, and I was telling you earlier, palliative care isn't just for cancer patients. 

Just a lot of the research is done there. It's for people with lots of different chronic illnesses. But we know that, in conjunction with traditional care, we can get improved quality of life, improved satisfaction from everybody, equal or improved survival, which is really great, and also the cost is either equal or improved, and then no patient harm. So I don't, to me it seems like it's pretty exciting. 

Okay, and then the last little bit here I'm just going to talk about what does it mean for a palliative care encounter. And what do we do? What are some of the skills that we bring as a team in talking to people? So, again, we work as a team. They can happen, as I mentioned earlier in the talk, it can be in a clinic. A lot of times we're asked to kind of help when somebody's in the hospital. So, often, that's where we work with patients. 

And the other key thing is that we usually spend a lot more time with people and families. It's not uncommon for us to have a two-hour visit because we really want to get to know people. We want to know what makes them tick. Who are they? What do they want? That's what we focus on because I think that is so important to the whole way of delivering care.

And then, these are some of the different skills that the one of the reasons why I'm back in training, is so that I can really hone these skills. But these are some of the different things that we hope that we can bring to patient care, specifically care of the dying, like I said. We are very related to hospice, but we are also distinct. But that is something. We work with people on advanced care planning, communication, which I think is the key, symptom control, and so forth.

And then this is a little bit kind of detailed.

But it's some of the key features of these encounters that we have. So one of the things when we're working with somebody for a palliative care visit, we want to find out what are your symptoms like? How are you feeling? Maybe it's not pain. Maybe it's just really tired. Or maybe really nauseated. 

How are you doing, like, socially and spiritually? Are you a spiritual person? Have we talked about that? Is that something that, I would argue, we should be thinking about and how it relates to your overall health? What is somebody's understanding of their illness? Because I will be the first to admit that in medicine we use all kinds of long, fancy terms, and it's confusing. And I have sat there with family members who I consider very intelligent people getting all this information. 

I'm like, they are not getting this at all. I can just see their face, and the doctor walks out of the room and I'm like, "You didn't ask any questions." And they're like, "I thought you could just "translate it for me." And I did, but it happens so I think we need to do a much, much, much better job as doctors and healthcare system communicating what's going on so that people can understand it. It's our job to make it so that patients can understand it. That is key. 

So you need to know what your illness is. You need to know what your prognosis is and what your treatment options are in plain, clear understandable English, or whatever language.

Because that is when, together we get that information and then we get to know somebody as a person, we find out what are your goals? What are your wishes? What are your dreams? What are your hopes? And we kind of work together, knowing all the medical information and knowing people as a person, and help people kind of navigate this and make decisions because it's confusing and it's hard. And then we help with when somebody's discharged. 

This is a little bit more detail on the same, each section of it. I don't need to go into that. I've pretty much done that already. But I really think the key things that we do, and hopefully we do well, is that third one under there, making sure that people understand what their options are and their prognosis and their illness.

And then, again, the key, we are often consulted in the hospital to talk with patients and families and to go over what their goals are. And this is where, for me, it's a little bit hard because I will say, from my perspective, this is something we should all be doing as doctors. It shouldn't take a group of specialists to come in and go over these things with people. This is something we should know already how to do, but we don't. We're not very good at it. We haven't been trained. 

We're focused more, again, on the streets. The diseases, the treatments. We're not really focused on the communication aspect, which is really the most important part of this. So, that's where we do our best to try to make things clear for people. We do a lot of listening, which I love. I love that part of it as, getting to know people.

So, these are just a couple summarizing slides. And, again, I wanted to sort of explain palliative care in different levels. In general, these are some, just in general it helps, PC is palliative care, it helps patients and family make informed decisions about what the treatment options are and are they consistent with what's important to the person. Is it consistent with their values? We care for the whole person. So, again, we don't so much think of people as their illness. 

Oh, this person has cancer. It's, no, this person is a wife, a mother, a former this, loves to paint, and they also have cancer. So how can we let them do all those other things and still live with their cancer? So that's what we need. We worry about, we think about the whole person because that's so important. And then, also, again, the reason we do this is so that we can help people with these life changing illness, live as well as they can, as long as they can knowing all the information. 

So this is my simplest way of explaining it. If I had to explain it in just, like, what is that, seven words, or eight words. We aim to match treatment, medical treatment, to what patient goals are. And that's what we try to do. So, this is, I think, important for us in medicine to always keep in mind with A famous quote from Hippocrates: "To cure sometimes, relieve often, and to comfort always.

 And those are the, that's why I went into medicine, and I think we need to spend more time on the "relieve often, comfort always," and hopefully cure as much as we can, but knowing we all know we were all born and we will all die. And I think we need to pay as much attention to the dying process as we do the birthing and being born and, you know... and celebrate every part of somebody's life and not just the very beginning.

And so, again, my teaching background coming through. So these were the objectives. Hopefully, and the format of this didn't allow us to take questions throughout the lecture, so I always... I like to gauge where people are at, and I wasn't able to do that with this. But, hopefully we're able to achieve these. Just to explain palliative care. 

How is it? How does it relate to hospice but, also, how is it distinct? And what are, where is it? You know, what are the commonalities? Why are we hearing about it more lately? And I think part of it is that book that came out, and also there's more and more research. 

We're realizing, like, we went through this amazing time of growth in medical development, all these advances, but we kind of lost sight of why we're doing all this, and that's to help people to hopefully live as long but also as well as they can. And so that's, I think, why it's getting, why it's becoming more prominent. And then, because it is an area of medicine, we like to do research. And so we want to sort of learn more about it and how it can help, and so we went over that a bit. 

And then a little bit about the elements. 

So, in closing, my final quote is another one by Dr. Gawande: "Our ultimate goal, after all, "is not a good death but a good life to the very end." And that's what we hope to help people with. So, and then I just, in closing, I just want to thank a few people that kind of helped me. One was my program director Dr. Campbell, Dr. Toby Campbell, who was the one who was listed as the person who was going to give this talk today. He helped me a lot with a lot of the slides. 

Some of the concepts were his. And then, of course, all the faculty I work with and colleagues. Patients and families, they have been wonderful. And my family for letting me run this by them a few times. And that's it. Thank you. 
(audience applause)