# Cunniff Dixon Foundation > The Art of Medicine Near the End of Life ## Posts ### Palliative Care Perspectives Source: [HTML](https://cunniffdixon.org/books/palliative-care-perspectives/) Markdown: [Markdown](https://cunniffdixon.org/books/palliative-care-perspectives/index.html.md) ###### Synopsis: This book provides excellent perspective on end-of-life care and the purpose and quality one should look for in palliative care. Highlights include detailed descriptions and information regarding symptoms and medication treatment plans. ###### Source: Book ###### Vol/Page/Date: 2003 ###### Resource Type: Book ###### Author/Source: James L. Hallenbeck, M.D. ###### keywords: Palliative care, book, symptoms, medication plans, pharmacology, pain, chronic pain, end of life care ###### Submitter: Andy Peters ###### Date of Resource: 2009-04-19 ### When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families Source: [HTML](https://cunniffdixon.org/books/when-children-die-improving-palliative-and-end-of-life-care-for-children-and-their-families/) Markdown: [Markdown](https://cunniffdixon.org/books/when-children-die-improving-palliative-and-end-of-life-care-for-children-and-their-families/index.html.md) ###### Synopsis: "We are in need of medicine with a heart. . . . The endless physical, emotional, and financial burdens that a family carries when their child dies . . . makes you totally incapable of dealing with incompetence and insensitivity." The full text of this book is free online via the link below. The writing is very personal and heartfelt and the book is broken into several important themes: patterns in pediatric palliative care, communication, ethics and legal issues, financing pediatric palliative care and more. This book has a strong voice for what family and patient centered medicine should be. ###### Source: Institute of Medicine of the National Academies ###### Vol/Page/Date: 2003 ###### Resource Type: Book ###### Author/Source: Marilyn J. Field and Richard E. Behrman, Editors ###### Link URL: [http://www.nap.edu/catalog.php?record\_id=10390]() ###### keywords: pediatric palliative care, financing, ethics, communication ###### Submitter: Peters ### THE LAST GIFTS: Creative Ways to be with the Dying Source: [HTML](https://cunniffdixon.org/books/the-last-gifts-creative-ways-to-be-with-the-dying/) Markdown: [Markdown](https://cunniffdixon.org/books/the-last-gifts-creative-ways-to-be-with-the-dying/index.html.md) ###### Synopsis: Review: This is a remarkable book written by an insightful occupational therapist who works in palliative care in New Mexico. Here are the stories of seventeen patients, filled with compassion and caring and Jillian Brasch’s practical strategies and insights. Anyone who works in palliative care will enjoy reading these stories and they will improve your ‘being with’ skills. ###### Source: Andrews McMeel Publishing ###### Vol/Page/Date: 2008 ###### Resource Type: Book ###### Author/Source: Jillian Brasch ###### keywords: palliative care, dying ###### Submitter: Peters ### PALLIATIVE CARE FOR CARE HOMES: A Practical Handbook Source: [HTML](https://cunniffdixon.org/books/palliative-care-for-care-homes-a-practical-handbook/) Markdown: [Markdown](https://cunniffdixon.org/books/palliative-care-for-care-homes-a-practical-handbook/index.html.md) ###### Synopsis: Review: As the populations in our societies age, there will be more and more individuals in care homes who have life-threatening conditions and are deserving of palliative care. The flow of the principles and practices of palliative care into the nursing home community is entirely logical, but it is a big task when many of the caregivers are non-professionals and few of the professional caregivers have had much in the way of education and training in palliative care. Written by a Macmillan nurse (a nurse who has undertaken special post-graduate training in palliative care in the UK) who has spent many years in care homes. This book sets out all the basic information about palliative care in a very practical, accessible way. It will be a useful resource for professional caregivers, but it is written in a ‘non-medical’ manner and would be easily understood by non-professional or family caregivers. ###### Source: Radcliffe Publishing ###### Vol/Page/Date: 2009, 167 pp ###### Resource Type: Book ###### Author/Source: Christine Reddall ###### keywords: caregivers, support care, homes, palliative care ###### Submitter: Peters ### FAMILY CARERS IN PALLIATIVE CARE: A Guide for Health and Social Care Professionals Source: [HTML](https://cunniffdixon.org/books/family-carers-in-palliative-care-a-guide-for-health-and-social-care-professionals/) Markdown: [Markdown](https://cunniffdixon.org/books/family-carers-in-palliative-care-a-guide-for-health-and-social-care-professionals/index.html.md) ###### Synopsis: Review: Providing care and support for the family of the patient is one of the basic, almost sacred, tenets of palliative care. But how well are we doing? In this book Peter Hudson and Sheila Payne have assembled a distinguished cast of contributors, which is both multidisciplinary and international, to critically assess the evidence. There are chapters on family support in different clinical settings and different economic circumstances, as well as for different disease groups (geriatrics, paediatrics, cancer, advanced organ failure, and neurodegenerative diseases) and it seems to be well referenced. I did not find it a light read, but there is a wealth of information here, application of which can only improve what we do in the way of family support. Anyone responsible for planning or operating a palliative care service should read this book and it will be a valuable resource for people involved in post-graduate courses in palliative care. ###### Source: Oxford University Press ###### Vol/Page/Date: 2009, 309 pp. ###### Resource Type: Book ###### Author/Source: Peter Hudson and Sheila Payne (Eds) ###### keywords: caregivers, palliative care, family support ###### Submitter: Peters ### PAIN MANAGEMENT: Enhancing Your Life to the Fullest Source: [HTML](https://cunniffdixon.org/books/pain-management-enhancing-your-life-to-the-fullest/) Markdown: [Markdown](https://cunniffdixon.org/books/pain-management-enhancing-your-life-to-the-fullest/index.html.md) ###### Synopsis: Review: Here is a book for patients with pain and for parents with children who have pain, written by someone who has dealt with pain for more than 40 years. Trained as a teacher of children with special needs, Renee Goossens suffered horrendous injuries in a car accident when she was 21, which left her in an English hospital for nearly two years. Wheelchair-bound with a lively toddler to raise, she beat the odds and walked again. Returning to Australia in the 1960s, she taught children with disabilities, was lecturer in French at the Conservatorium of Music, and French language coach for the Australian Opera. The book deals with all aspects of pain management, from how to deal with doctors and the health system, to analgesics and the medical management of pain, to complementary and alternative therapies. I was particularly impressed with chapters dealing with the psychological and social factors involved with pain and how to deal with them. Throughout, one gets the feeling ‘Been there, had that. Here’s how you can deal with it.’ The chapter on children with pain will be very useful for troubled parents. ###### Source: Anshan ###### Vol/Page/Date: 2009, 231 pp. ###### Resource Type: Book ###### Author/Source: Renee Goossens ### Jewish Ritual, Reality and Response at the End of Life Source: [HTML](https://cunniffdixon.org/books/jewish-ritual-reality-and-response-at-the-end-of-life/) Markdown: [Markdown](https://cunniffdixon.org/books/jewish-ritual-reality-and-response-at-the-end-of-life/index.html.md) ###### Synopsis: This guide introduces Jewish beliefs and practices around illness, death and loss and provides practical suggestions for responding to the sometimes complicated situations where the clinical, religious and cultural are entwined. Healthcare professionals, chaplains, social workers, funeral directors, family caregivers and others caring for Jewish patients and families through illness, death and bereavement will find this a useful resource. The detailed table of contents helps readers quickly find information on specific topics. Stories included throughout make this guide both a valuable resource for patient care and an interesting exploration of Judaism’s rich traditions. ###### Source: Duke Institute on Care at the End of Life ###### Resource Type: Book ###### Author/Source: Rabbi Mark A. Popovsky ###### Link URL: [http://iweb.nhpco.org/iweb/Purchase/ProductDetail.aspx?Product\_code=821134]() ###### keywords: Jewish beliefs, illness, cultural issues, death, loss ###### Submitter: Peters ###### Date of Resource: 2007 ###### Related Resources: [“Love Your Neighbor Like Yourself”: A Jewish Ethical Approach to the Use of Pain Medication with Potentially Dangerous Side Effects]() ### Test Video Page Source: [HTML](https://cunniffdixon.org/stories/test-video-page/) Markdown: [Markdown](https://cunniffdixon.org/stories/test-video-page/index.html.md) ### Cunniff-Dixon Letter: Andy Baxter Source: [HTML](https://cunniffdixon.org/stories/cunniff-dixon-letter-andy-baxter/) Markdown: [Markdown](https://cunniffdixon.org/stories/cunniff-dixon-letter-andy-baxter/index.html.md) ###### This letter is part of my Healthcare Proxy/Living Will package "To My Health Care Proxy(ies), Anne, Cookie, and Michael: Personal Wishes; Supplemental Thoughts With complete foreknowledge of the consequences of my doing so, I hereby fully relieve and release, and without hesitation or qualification firmly direct and require my Executor(s) to relieve and release each of my personal physicians and each other Health Care Professional, para-professional, administrator, etc. (without limitation) from any and all responsibility and/or liability, blame or accountability for following my wishes as interpreted and expressed by my Health Care Proxy or Agent, even if doing so appears to hasten the moment of my death and/or represent a failure to follow the Hippocratic Oath. I implore you, medical professionals, to hear, heed and honor my wishes. I am writing this to augment the instructions on the attached formal Health Care Proxy. I am fortunate currently to be in excellent health, and I have been fortunate to be healthy for my entire life to date. I have been witness to the terminal illness of my wife Carley, and several dear friends — Don Byers and Balint Vazsonyi — and I have a very clear picture of what I do not want to happen at the end of my life. In the event that I am suffering from any life threatening disease, and should lose consciousness with little hope for regaining consciousness, I expect you to do as little as possible to extend my life. In no case do I want you to extend my life simply for the sake of extending it. This is particularly true to the extent that disease, age or trauma have caused me to be unable to live a reasonably active, independent and joyful life in the event of my recovery. Extension of my life in order to live a dramatically diminished existence, largely dependent on my loved ones, is not something I want. I know that assuming and carrying out responsibilities as my Health Care proxy are burdensome and stressful, but you and I have talked many times about my feelings regarding the end of my life, and I believe that you have a clear sense of what I would want you to do and not do on my behalf. I have complete trust and appreciation for your role in this part of my life, and I thank you." Signed at Essex, Connecticut, this 25th day of January, 2005. ### Cunniff-Dixon Letter: Carley Cunniff Source: [HTML](https://cunniffdixon.org/stories/cunniff-dixon-letter-carley-cunniff/) Markdown: [Markdown](https://cunniffdixon.org/stories/cunniff-dixon-letter-carley-cunniff/index.html.md) Near the end of her life, Carley Cunniff wrote this letter with the assistance of Dr. Peter Dixon and her health care proxies. It is shared here as one example of a health care directive that played a crucial role in guiding caregivers at the end of Carley's life. This letter is part of the Healthcare Proxy/Living Will package: "To My Health Care Proxy, Andy or Marian B.S. Young, and to my wonderful family: With complete foreknowledge of the consequences of my doing so, I hereby fully relieve and release, and without hesitation or qualification firmly direct and require my Executor(s) to relieve and release each of my personal physicians and each other Health Care professional, para-professional, administrator, etc. (without limitation) from any and all responsibility and/or liability, blame or accountability for following my wishes as interpreted and expressed by my Health Care Proxy or Agent, even if doing so appears to hasten the moment of my death and/or represent a failure to follow the Hippocratic Oath. I implore you,medical professionals, to hear, heed and honor my wishes. I am writing this to augment the instructions on the attached formal Health Care Proxy. I have been very fortunate in my life to have been blessed, until recently, with excellent health and a strong physical constitution. As a result, I have enjoyed substantial independence of thought and action for most of my adult years. I abhor the idea of becoming a long-term drain and physical and/or psychological burden to my wonderful family and friends, despite my confidence that this is a burden they would likely accept willingly or at least stoically. It is not the way I would choose to finish out my life, and it is not the way I would choose to be remembered. The idea of total helplessness and dependence depresses me as I think about it today, still in fairly good health and personal control despite my cancer diagnosis. I love life, but it is life as I have known it, with substantial independence of thought and action, with the capacity for joy. The nature of my cancer has been such that I have already had several years to contemplate the idea of "untimely" death. There are worse things! A graceless, protracted and burdensome demise is one of them. Thank you for assuming and executing this responsibility on my behalf. To my wonderful siblings: While I love and trust all of you, I wish to spare each and all of you the responsibility which my appointing one or more of you would or might subject you to, and I fervently insist that each of you support the directives which Marian issues as my Health Care proxy. Thank you so much. Signed at Essex, Connecticut, this 29th day of December 2004." ###### Related Resources: [Cunniff-Dixon Letter: Andy Baxter]() ### Epilogue: A written piece by the late Lydia Prescott Thayer Source: [HTML](https://cunniffdixon.org/stories/epilogue-a-written-piece-by-the-late-lydia-prescott-thayer/) Markdown: [Markdown](https://cunniffdixon.org/stories/epilogue-a-written-piece-by-the-late-lydia-prescott-thayer/index.html.md) ###### Description: Epilogue by Lydia Prescott Thayer What is it in us, especially when we are young, that makes most of us fight for life with such dogged and desperate and passionate persistence? Life is a future we cannot see, mysterious and unpredictable. Yet we choose it, if choice is really ours, even with all its suffering and sorrow because it is there, a challenge like a mountain to be climbed. The mountain’s peak is hidden in the clouds. We cannot see it, but we must reach it at all costs. We are curious, determined, courageous and fool hardy. No alternative appeals to us. So, slowly and painstakingly we struggle to make our way to the top. Who knows the ultimate length of our journey? Ninety-seven years for one, fifty-sixfor another, eighteen for another. Who measure out our time? Someone walks a little way with us along the path, and we are grateful for the touch of his or her hand in ours. For a time the sun is just a little warmer and the stars a little brighter. As we grow older, one by one our companions along the way drop out and disappear, taking pieces of our hearts with them. They are no longer there to remember the special, the unique moments we shared together, and so we are diminished and impoverished by their going. We are all things to all men and women. We are less than what they imagine, and more. We are many persons even to ourselves. Which is the real one? Somewhere deep inside of us is our own very secret self which we may never choose to fully disclose. How adept are we at camouflage? How many penetrate our careful and deliberate disguise? If we pretend too long, do we become our own pretense? Do we lose ourselves in the smoke screen that we ourselves have thrownup? We can only conjecture about those whom we purport to know. Can we ever really know ourselves? The first time we hear our recorded voice, we are shocked and do not claim that voice is ours. Pictures only tell half truths. They are never complete. We have to live withourselves as best we can. We have to die with ourselves as well. We spend our lives trying to find answers to unanswerable questions, to find reason where perhaps no reason exist. Few claim to have solved the riddle of their existence. None of us can foresee its exact end. We come to terms with what the gods have seen fit to bestow on us and hope that in some small way we have used those gifts to bring a measure of comfort and understanding to those who have accompanied us on our way, and so, temporarily at least, to have helped us assuage the essential loneliness which is the human condition. ###### Link: Visit Site ### Excerpt from "In Blackwater Woods"; a poem by Mary Oliver Source: [HTML](https://cunniffdixon.org/stories/excerpt-from-in-blackwater-woods-a-poem-by-mary-oliver/) Markdown: [Markdown](https://cunniffdixon.org/stories/excerpt-from-in-blackwater-woods-a-poem-by-mary-oliver/index.html.md) ###### Synopsis: Mary Oliver is a poet from Province Town, MA and writes mostly about nature. Oliver was awarded the Pulitzer Prize (1984) and the National Book Award (1992). Her most recent collection is Evidence (2009). The following is an excerpt from her poem In Blackwater Woods that was recently published in the New York Times. To live in this world you must be able to do three things: to love what is mortal; to hold it against your bones knowing your own life depends on it; and, when the time comes to let it go, to let it go. ###### Source: Newspaper ###### Vol/Page/Date: NY Times July 5, 2009 ###### Resource Type: Other ###### Author/Source: Mary Oliver ###### keywords: Mary Oliver, Poetry ###### Submitter: A. Peters ###### Date of Resource: 2009-07-09 ### A Surgeon's Blog: The Microcosm Source: [HTML](https://cunniffdixon.org/stories/a-surgeons-blog-the-microcosm/) Markdown: [Markdown](https://cunniffdixon.org/stories/a-surgeons-blog-the-microcosm/index.html.md) ###### Description: The following is a blog posting from Jeffry Parks MD, a general surgeon from Cleveland, OH. It's a case about an elderly patient he successfully cared for using his palliative medical instincts: "I received a consult one morning on an old guy, ostensibly for "abdominal pain". It was early, before 7:30 and no one had seen him yet. The internist had admitted him over the phone from the ER. I walked into the room and I saw a ninety year old, 100 pound guy who glowed yellow. He looked skeletal. His skin was paper thin, like cellophane wrapped around a chicken breast. He was affable enough. He knew where he was. He said his stomach had been hurting him for months. He'd lost close to fifty pounds since Christmas. He lived alone in an assisted living facility. He had a son in Alabama, but that was it. I read through the chart. His bilirubin was 8 and the rest of his liver function tests were wildly abnormal. His Ca19-9 was over 20,000. A CT scan had been done at 3AM but there wasn't a read on it yet. I looked at it myself and easily identified a giant mid body pancreatic mass with multiple liver mets. I wrote a note about the findings and recommended a hospice consult. The next day, I didn't make rounds on him until late, close to 7pm. In the interval, an astounding amount of medicine had been practiced. Consults had gone out to GI, oncology, and nephrology (creatinine 1.9). The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests. I stared at the chart for a while. I was a little tired and foggy brained. But I couldn't believe it. The poor guy was zonked out in his bed, exhausted from all the tests and procedures that had been administered that day. I wrote in the chart something along the lines of "further invasive procedures/chemotherapy would be ill-advised" and I strongly encouraged a hospice consult. (I may or may not have capitalized and triple underlined the word hospice.) The next day, the dogs were called off. The son arrived from Alabama. They had decided to forego any further treatment. He would take his Dad home...." ###### Link: Visit Site ### Palliative Care Grand Rounds: August 2009 Source: [HTML](https://cunniffdixon.org/stories/palliative-care-grand-rounds-august-2009/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-grand-rounds-august-2009/index.html.md) ###### Description: This link is to the August issue of "Palliative Care Grand Rounds", a monthy round-up of insightful and often emotional palliative care blogs from around the web. This months host, Risa's Pieces, is a palliative care Nurse Practitioner and writes her own personal blog at [www.risaden.blogspot.com/](). Blogs are a freeform online journaling that allow authors to write in thier own voice that encourage open discussion and comments on current issues. ###### Link: [Visit Site]() ### Palliative Care Grand Rounds: July 2009 Source: [HTML](https://cunniffdixon.org/stories/palliative-care-grand-rounds-july-2009/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-grand-rounds-july-2009/index.html.md) ###### Description: This link is to the 6th issue of Palliative Care Grand Rounds. This issue's blogger, Tim Cousounis, is managing director of DAI Palliative Care Group, which is a consulting firm that partners with palliative care teams to boost their success. His personal blog, Palliative Care Success, can be found at [www.palliativemedicine.blogspot.com/](). Blogs are a free-form online journaling that allow authors to write in their own voice that encourages open discussion and comments on current issues. ###### Link: [Visit Site]() ### Palliative Care Grand Rounds: October 2009 Source: [HTML](https://cunniffdixon.org/stories/palliative-care-grand-rounds-october-2009/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-grand-rounds-october-2009/index.html.md) ###### Description: The link below will take you to "Palliative Care Grand Rounds"; a monthy review of palliative care blogs throughout the internet. This weeks host is geripal [(www.geripal.org]()) a geriatrics and palliative care blog. Geripal starts the review with a lot of interesting links to blog posts that are focused on the death panel and health care reform debate. There are some must reads! ###### Link: [Visit Site]() ### Urbana NPR Station Features 'A Life Worth Living' with Dr. Robert Martensen Source: [HTML](https://cunniffdixon.org/stories/urbana-npr-station-features-a-life-worth-living-with-dr-robert-martensen/) Markdown: [Markdown](https://cunniffdixon.org/stories/urbana-npr-station-features-a-life-worth-living-with-dr-robert-martensen/index.html.md) ###### Description: Illinois Media's "Afternoon Magazine with Celeste Quinn" featured an interview with Dr. Robert Martensen (Cunniff-Dixon Foundation Senior Advisor) in November 2008. Dr. Martensen discusses his book A Life Worth Living: A Doctor's Reflection On Illness In A High-Tech Era. ###### Link: Visit Site Media ###### Provided By: Illinois Public Media:[The Afternoon Magazine with Celeste Quinn]() ###### Audio: ###### Related Resources: [NPR Audio Podcast: End Of Life Care in America, A Doctor's Diagnosis]() ### Video: Dr. Bridget Duffy from the Cleveland Clinic Speaks about the Patient Experience Source: [HTML](https://cunniffdixon.org/stories/video-dr-bridget-duffy-from-the-cleveland-clinic-speaks-about-the-patient-experience/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-dr-bridget-duffy-from-the-cleveland-clinic-speaks-about-the-patient-experience/index.html.md) ###### Synopsis: This is a great video of Dr. Bridget Duffy speaking at a [Gel]() conference in 2008. At the time Dr. Duffy was the Chief Experience Officer at the Cleveland Clinic and her 30 minute talk is all about the patient experience. She introduces a new patient gown that embodies the changes she was trying to make at the Cleveland Clinic to make patients feel more comfortable, empowered and satisfied during their weakest moments of illness. She includes many engaging stories and facts that make this video a must see for anyone working in health care or experiencing it from the outside in. ###### Source: Gel Health ###### Vol/Page/Date: 2008 ###### Resource Type: Video or Podcast ###### Author/Source: Dr. Bridget Duffy/Gel (Good Experience Live) ###### Link URL: [http://gelconference.com/videos/2008/bridget\_duffy/]() ###### keywords: patient experience, Bridget Duffy, Cleveland clinic ###### Submitter: Peters Media ###### Video: ###### Related Resources: [Bridget Duffy on the Patient Experience: Gel Health Conference 2009]() [Gel Health Conference 2009]() ### StoryCorps Audio Podcast: Sarafina Viviano asks her mother, Dana, about her work as a cancer nurse. Source: [HTML](https://cunniffdixon.org/stories/storycorps-audio-podcast-sarafina-viviano-asks-her-mother-dana-about-her-work-as-a-cancer-nurse/) Markdown: [Markdown](https://cunniffdixon.org/stories/storycorps-audio-podcast-sarafina-viviano-asks-her-mother-dana-about-her-work-as-a-cancer-nurse/index.html.md) ###### Description: This is an audio podcast from StoryCorps, a non-profit organization devoted to honoring one another's lives through the art of listening. In this heartfelt clip, a child asks her mother about her experiences as a cancer nurse... “How's it feel...telling someone they're going to die?” ###### Link: [Visit Site]() ### StoryCorps Audio Podcast: Andrea St. John remembers her fiance. Source: [HTML](https://cunniffdixon.org/stories/storycorps-audio-podcast-andrea-st-john-remembers-her-fiance/) Markdown: [Markdown](https://cunniffdixon.org/stories/storycorps-audio-podcast-andrea-st-john-remembers-her-fiance/index.html.md) ###### Description: In this audio podcast from [StoryCorps](), Andrea St. John remembers being with her fiance when he found out his cancer had returned. Her story is heart heavy but also scattered with a lightness and humor that is inspirational to all. ###### Link: [Visit Site]() ###### Related Resources: [StoryCorps Audio Podcast: Danielle and Gabrielle Hall remember their mother Martha, who died of breast cancer in 2003.]() [StoryCorps Audio Podcast: “The saddest day of my life was the day my father died.”]() ### StoryCorps Audio Podcast: Danielle and Gabrielle Hall remember their mother Martha, who died of breast cancer in 2003. Source: [HTML](https://cunniffdixon.org/stories/storycorps-audio-podcast-danielle-and-gabrielle-hall-remember-their-mother-martha-who-died-of-breast-cancer-in-2003/) Markdown: [Markdown](https://cunniffdixon.org/stories/storycorps-audio-podcast-danielle-and-gabrielle-hall-remember-their-mother-martha-who-died-of-breast-cancer-in-2003/index.html.md) ###### Description: This is a nice story of two daughters remembering one of their last meals with their mother. It is a wonderful example of all the little memories that families and caregivers hold on to after a difficult experience. ###### Link: [Visit Site]() ###### Related Resources: [StoryCorps Audio Podcast: Andrea St. John remembers her fiance.]() [StoryCorps Audio Podcast: “The saddest day of my life was the day my father died.”]() ### StoryCorps Audio Podcast: “The saddest day of my life was the day my father died.” Source: [HTML](https://cunniffdixon.org/stories/storycorps-audio-podcast-the-saddest-day-of-my-life-was-the-day-my-father-died/) Markdown: [Markdown](https://cunniffdixon.org/stories/storycorps-audio-podcast-the-saddest-day-of-my-life-was-the-day-my-father-died/index.html.md) ###### Description: In this audio podcast from [StoryCorps](), Tom Morgan talks to his friend Tracy Ross about his father's death and the decision to take him off life sustaining treatments. Morgan, who himself suffered from emphysema, died on April 26, 2007. ###### Link: [Visit Site]() ### StoryCorps Audio Podcast: Dr. John Bancroft, a pediatrician, tells his daughter Carolyn about a memorable patient. Source: [HTML](https://cunniffdixon.org/stories/storycorps-audio-podcast-dr-john-bancroft-a-pediatrician-tells-his-daughter-carolyn-about-a-memorable-patient/) Markdown: [Markdown](https://cunniffdixon.org/stories/storycorps-audio-podcast-dr-john-bancroft-a-pediatrician-tells-his-daughter-carolyn-about-a-memorable-patient/index.html.md) ###### Description: In this audio podcast from [StoryCorps](), a father recounts to his daughter one of his most memorable days as a Doctor when a young patient's family decides to give knowing that all they truly want is a donor. ###### Link: [Visit Site]() ### Audio Podcast: Spiritual and Religious Care of the Hospice Palliative Care Client. Source: [HTML](https://cunniffdixon.org/stories/audio-podcast-spiritual-and-religious-care-of-the-hospice-palliative-care-client/) Markdown: [Markdown](https://cunniffdixon.org/stories/audio-podcast-spiritual-and-religious-care-of-the-hospice-palliative-care-client/index.html.md) ###### Description: This is an audio podcast from [Hospice Palliative Care Insights](), a monthly palliative care podcast based in Canada. In this discussion Jacquie Peden, an Advanced Practice Nurse in Hospice Palliative Care, interviews Rev. Dan Cooper, Spiritual Care Development Consultant for the Regina Qu'Appelle Health Region. The audio is not the highest quality but it is good enough to listen to some of the good distinctions and definitions that Rev. Cooper offers regarding spritual care. Duration: 52 minutes \* PDF written transcript of the podcast provided in the attachment below ###### Link: Visit Site Attachment Size [Cooper\_24Mar05(2).pdf]() 159.45 KB Media ###### Provided By: [Hospice Palliative Care Insights](). ###### Audio: ### Audio Podcast: End-of-Life Care For Children: Adding Life to a Child's Time Source: [HTML](https://cunniffdixon.org/stories/audio-podcast-end-of-life-care-for-children-adding-life-to-a-childs-time/) Markdown: [Markdown](https://cunniffdixon.org/stories/audio-podcast-end-of-life-care-for-children-adding-life-to-a-childs-time/index.html.md) ###### Description: This is an audio podcast from [Hospice Palliative Care Insights](), a monthly palliative care podcast based in Canada. In this discussion, Jacquie Peden, an Advanced Practice Nurse interviews Ms. Maria Rugg, Clinical Nurse Specialist of the Hospital for Sick Children (Toronto, Canada), Palliative and Bereavement Care Program. The Audio is not the highest quality but it is good enough to benefit from Maria's perspective on managing pain in children, medication treatment plans and even handling the simple yet complicated questions that children ask such as, "What does a dead person look like?" Duration: 60 minutes \* PDF written transcript of this podcast is provided in the attachment below ###### Link: Visit Site Attachment Size [Rugg\_25Aug05.pdf]() 155.28 KB Media ###### Provided By: [Hospice Palliative Care Insights](). ###### Audio: ### Audio Podcast: Patients Choose Complementary and Alternative Medicine Source: [HTML](https://cunniffdixon.org/stories/audio-podcast-patients-choose-complementary-and-alternative-medicine/) Markdown: [Markdown](https://cunniffdixon.org/stories/audio-podcast-patients-choose-complementary-and-alternative-medicine/index.html.md) ###### Description: This is an audio podcast from [Hospice Palliative Care Insights](), a monthly palliative care podcast based in Canada. In this discussion, Jacquie Peden, an Advanced Practice Nurse interviews Barbara Findlay, a Canadian nurse leader in Integrative Medicine program development (now at the Samueli Institute in Alexandria, Virginia). This podcast offers one of the most descriptive, in depth and easy to follow discussions on complementary and alternative medicine (CAM). It covers a wide range of topics beginning with basic and current definitions of CAM, current uses and education of CAM in hospitals, private settings and universites and important distinctions such as: most patients that are using CAM are using it for symptom management not as a curative treatment. Duration: 56 minutes \* PDF written transcript of this podcast is provided in the attachment below ###### Link: Visit Site Attachment Size [Findlay\_26Jan06.pdf]() 157.98 KB Media ###### Provided By: [Hospice Palliative Care Insights](). ###### Audio: ### Video: Palliative Care in Action Source: [HTML](https://cunniffdixon.org/stories/video-palliative-care-in-action/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-palliative-care-in-action/index.html.md) ###### Description: This video posted on [getpalliativecare.org]()gives a short, basic introduction to Palliative Care and how it is used. It includes interviews with Diane Meier, MD, FACP who is the director of the Center to Advance Palliative Care and the director of the Hertzberg Palliative Care Institute at the Mount Sinai School of Medicine. If you are looking to learn about the definition of palliative care and how and when it is applied during the disease trajectory, this video will be useful. Duration: 3min 8sec ###### Link: [Visit Site]() ### The Tibetan Book of Living and Dying Source: [HTML](https://cunniffdixon.org/books/the-tibetan-book-of-living-and-dying/) Markdown: [Markdown](https://cunniffdixon.org/books/the-tibetan-book-of-living-and-dying/index.html.md) ###### Synopsis: Often in times of serious illness and disease one turns to a deeper level of spirituality-- something greater than the problems and challenges that have been brought about. The Tibetan Book of Living and Dying is a wonderful resource and read for anyone who is trying to put living and dying in greater perspective. "This book offers readers not just a theoretical account of death and dying , but also practical measures for understanding, and preparing themselves and others in a calm and fulfilling way." - The Dalai Lama ###### Source: Book ###### Vol/Page/Date: revised and updated 2002 ###### Resource Type: Book ###### Author/Source: Sogyal Rinpoche ###### keywords: Book, spirituality, buddhism, living and dying ###### Submitter: Andy Peters ###### Date of Resource: 2009-05-05 ### "Living Old" - Frontline's 2006 documentary on aging Source: [HTML](https://cunniffdixon.org/stories/living-old-frontlines-2006-documentary-on-aging/) Markdown: [Markdown](https://cunniffdixon.org/stories/living-old-frontlines-2006-documentary-on-aging/index.html.md) ###### Description: "A powerful and intimate journey into the uncharted territory of Americans living longer than ever -- and what it means for them, their loved ones and our society." PBS's award winning documentary team explores the topic of "living old" and the rapidly growing population of people age 85 and older. Top notch film making and reporting make this a must see video for those experiencing (first or second hand) the journey into old age. To view this high quality streaming online video click the following link: ["Living Old"]() ###### Link: Visit Site ### Palliative Care Grand Rounds: November 2009 Source: [HTML](https://cunniffdixon.org/stories/palliative-care-grand-rounds-november-2009/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-grand-rounds-november-2009/index.html.md) ###### Description: This months Palliative Care Grand Rounds is out and hosted by [Pallimed]() -- a Hospice and Palliative Medicine blog-- if you aren't familiar with Pallimed check it out, they always have great posts. The format of this months blog review is a creative one- Pallimed designated awards to various palliative care blogs that they found worthy. Get reading! [http://www.arts.pallimed.org/]() ###### Link: [Visit Site]() ### Video Clip: What is Palliative Care? Source: [HTML](https://cunniffdixon.org/stories/video-clip-what-is-palliative-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-clip-what-is-palliative-care/index.html.md) ###### Description: This is a short video with Diane Meier, MD, FACP from [getpallaitivecare.org]() offering her views on what palliative care is and what type of patients and situations could benefit from it. Duration: 1min 38sec ###### Link: [Visit Site]() ### Video Clip: People Who Need Palliative Care Source: [HTML](https://cunniffdixon.org/stories/video-clip-people-who-need-palliative-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-clip-people-who-need-palliative-care/index.html.md) ###### Description: This is a short clip of Diane Meier, MD, FACP posted on [getpalliativecare.org]() talking about who might be eligible for palliative care and for what reasons. Duration: 1min 6sec ###### Link: [Visit Site]() ### Video Clip: A Profile of Hospital Palliative Care Source: [HTML](https://cunniffdixon.org/stories/video-clip-a-profile-of-hospital-palliative-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-clip-a-profile-of-hospital-palliative-care/index.html.md) ###### Description: This is a short video of Diane Meier, MD, FACP posted on [getpalliativecare.org]() talking about hospital palliative care teams. She speaks about the unique communication skills they provide within the healthcare system and specific symptoms that palliative care teams can treat best. ###### Link: [Visit Site]() ### Video Clip: Palliative Care is Different from Hospice Source: [HTML](https://cunniffdixon.org/stories/video-clip-palliative-care-is-different-from-hospice/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-clip-palliative-care-is-different-from-hospice/index.html.md) ###### Description: This is a short clip of Diane Meier, MD, FACP posted on [getpalliativecare.org]()talking about the differences between hospice and palliative care. She emphasizes the barriers that exist with certain Hospice requirements given that doctors are not all that accurate at predicting when a patient has only six months to live. Duration: 2min ###### Link: [Visit Site]() ### Geripal: Nelson Mandela and Imagery of Aging Source: [HTML](https://cunniffdixon.org/stories/geripal-nelson-mandela-and-imagery-of-aging/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-nelson-mandela-and-imagery-of-aging/index.html.md) ###### Description: This is a November 12th blog from [Geripal]() about a [New York Times article]() written by Celia Dugger. The article is about the aging of Nelson Mandela and Geripal offers some nice thoughts on people's perception of aging. ###### Link: [Visit Site]() ### NPR Audio Podcast: Why This Wisconsin City Is The Best Place To Die Source: [HTML](https://cunniffdixon.org/stories/npr-audio-podcast-why-this-wisconsin-city-is-the-best-place-to-die/) Markdown: [Markdown](https://cunniffdixon.org/stories/npr-audio-podcast-why-this-wisconsin-city-is-the-best-place-to-die/index.html.md) ###### Description: This audio podcast from NPR's [All Things Considered]()on November 17, 2009 is about the quality of dying at the Lutheran Hospital in La Crosse, Wisconsin. Their success is based on the number of patients who have completed advanced directives-- a task that is aided by specially trained nurses who spend up to an hour with each patient working through the often confusing and daunting paperwork. This has increased the operating costs at Lutheran Hospital, but they view it as the cost of doing business and believe it is crucial to good patient care. Towards the end of the podcast the discussion turns to the health care bill in which there is an item that would help to cover the costs of what Lutheran Hospital is providing on a daily basis. ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog Post from November 18, 2009: "The Best Town to Die In"]() [End of Life - thoughts from an MD: Where's the Best City to Die?]() ### Hospice and Caregiver Blog: MedPAC Discusses Analysis of Hospice Visit Patterns Source: [HTML](https://cunniffdixon.org/stories/hospice-and-caregiver-blog-medpac-discusses-analysis-of-hospice-visit-patterns/) Markdown: [Markdown](https://cunniffdixon.org/stories/hospice-and-caregiver-blog-medpac-discusses-analysis-of-hospice-visit-patterns/index.html.md) ###### Description: November 12, 2009: At their November 5 public meeting, MedPAC (Medicare Payment Advisory Commission), discussed an analysis of hospice visit patterns. The data was collected to assist them in making recommendations for changes to the Medicare payment system for hospice services. Previously, [MedPAC recommended]() changing the current flat per diem system of hospice payments to a system that is more U-shaped, allowing for higher payments at the beginning and end of service. You can find the [brief and presentation on this page](), as well as a link to send MedPAC your comments. (Pallimed has posted [some more background here]().) ###### Link: [Visit Site]() ### Hospice and Caregiving Blog: Veterans in Hospice Care Source: [HTML](https://cunniffdixon.org/stories/hospice-and-caregiving-blog-veterans-in-hospice-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/hospice-and-caregiving-blog-veterans-in-hospice-care/index.html.md) ###### Description: November 10, 2009: Hospices across the country care for terminally ill veterans during the final weeks and months of their lives. In honor of Veterans Day, we want to share the story of Cpl. Adam Austin and Staff Sgt. Deuntae Preston, both members of the United States Marine Corps. They serve as volunteers through a unique partnership with Heartland Home Health and Hospice in Kansas City. Stacy Higgins, Volunteer Coordinator at Heartland, matches Marines in the Single Marine Program with veterans in hospice care. HFA featured Cpl. Austin, Staff Sgt. Preston and Ms. Higgins on our Diversity and End-of-Life Care teleconference. (Read the full interview below the video.) Link to Video: [Veterans Hospice Program]() Tell us about your work with the Single Marine Program and Heartland Hospice.AUSTIN: A big facet of the Single Marine Program is volunteer work. And the hospice just seemed like a very great idea, to deal with veterans. As military members we are people that can actually give something back a lot more to these veterans. Because, these veterans don't talk a lot with their families. A big thing that this program has accomplished so far is actually looking at Marines as more than just a fighting force. We are compassionate people and we are actually able to give back to the community. What motivated you to become involved in the volunteer program with Heartland Hospice?PRESTON: I would say what motivated me more or less was my background with the military. My grandfather was in the army. My uncle was in the navy. And I said it could me one day -- it could be a young corporal when I'm ill and they come out to visit me and it's just the right thing to do. You know these are not only Marines, but Army, you know, sailors who laid their life on the line and just did the right thing from different wars back in the day and it was just the right thing to do. AUSTIN: My family is not very military oriented. I'm actually the first. But I always loved hearing stories. I loved to know any type of history about anybody. And this is the perfect way for me to actually get to sit down with people and hear so many things that happened back in their time. I love volunteering and this is a perfect opportunity for me. What have been some of your most meaningful experiences volunteering with fellow veterans?AUSTIN: I have not found one that really didn’t want to share anything. They've been more than welcoming -- the whole family has been more than welcoming, the veterans and their spouses. I love the stories, the fact that there's still such camaraderie between military services, whether it was Marines, Air Force, Navy, Army. Like that fact when we are on the battlefield -- all that matters is that you all are brothers in a way. I love that. My most meaningful experience was with one of our veterans -- he was a music lover and just me sitting down and playing the piano just meant the world to him, because that's something he couldn't necessarily do himself anymore. Just to give something as small as that, just to really move him; it got to me, it got to my heart. PRESTON: My most meaningful experience was with a veteran who didn't really want us to come in the beginning but changed his mind. And we get there and the conversation was wonderful. He was upbeat. He had a lot to talk about and he didn't want us to leave. And it just left me with a smile on my face knowing that in the beginning he didn't want us to be there. We came, we had a nice conversation, enjoyed his company and it just meant a lot to me and I saw that it meant a lot to him as a veteran. What have been some of the more difficult experiences for you?AUSTIN: Some veterans, you know, they’ve had to go through a lot and they don't want to deal with a lot of it anymore. I remember one; he actually just grabbed right a hold of me and said I just don't want to have to deal with this anymore. I don't want to -- I really don't want to necessarily deal with life. And I told him, “Well, you know, you're still here for a reason. I think you're still here for a reason, sir.” PRESTON: I would say it's difficult and it's easy. It's difficult in that you don't know what you're getting into. It's easy in the mind set where when you get there, you're learning from veterans, their different experiences, their background. So, you know, it's difficult and easy at the same time. What about being a Marine has helped you to work with fellow veterans facing the end of life?PRESTON: I would say mainly as a Marine, we have to know -- you know, to deal with any type of death and dying; and just being able to cope with stuff like that, it does make it a little easier to be able to talk with the veterans. AUSTIN: What I take from this program is hope, hope that when I am much older and I'm a veteran -- that a program like this will still be around, in which I can share my stories. I think the biggest thing with this partnership is really getting to give back to these veterans that have already done so much, for how they've already served their country. And the fact that we can at least show them that yes, you are here, you're still part of that brotherhood. You still mean so much to us as present day military. ###### Link: Visit Site ### Geripal November 6, 2009 Blog Post: $50,000 for your favorite Palliative Care Leader in Idaho, Oregon, Utah, and Washington Source: [HTML](https://cunniffdixon.org/stories/geripal-november-6-2009-blog-post-50000-for-your-favorite-palliative-care-leader-in-idaho-oregon-utah-and-washington/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-november-6-2009-blog-post-50000-for-your-favorite-palliative-care-leader-in-idaho-oregon-utah-and-washington/index.html.md) ###### Description: Who can pass up the chance to give $50K to their favorite palliative care leader or organization if it turns out that it won't cost you a dime? The Regence Foundation has established a new program, the Sojourns Award, aimed to promote palliative and end-of-life care in Idaho, Oregon, Utah, and Washington. It is meant to recognize individuals or non-profits that provide exemplary leadership and innovation in palliative care. One winner from each state will receive the Sojourns Award along with $50,000 (keep in mind before you go out and buy that new flat screen TV that individual awardees will need to give the money to a non-profit.) The call for nominations is now out at the [Regence Foundation website]() with a deadline of December 4th, 2009. Anyone can nominate, however I would also be happy to put together a nomination for someone we think is deserving of $50K. Just comment on this post or email me with suggestions of people or non-profit organizations that inspire you. ###### Link: [Visit Site]() ### NPR Audio Podcast: End Of Life Care in America, A Doctor's Diagnosis Source: [HTML](https://cunniffdixon.org/stories/npr-audio-podcast-end-of-life-care-in-america-a-doctors-diagnosis/) Markdown: [Markdown](https://cunniffdixon.org/stories/npr-audio-podcast-end-of-life-care-in-america-a-doctors-diagnosis/index.html.md) ###### Description: In this April 2nd, 2009 podcast on NPR's Fresh Air, author, Doctor and bioethicist, Robert Martensen, speaks with Terry Gross about the challenges and complexities of medical care at the end of life; a topic Doctor Martensen explores more deeply in his book, A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era. Duration: 40min ###### Link: [Visit Site]() ###### Related Resources: [Urbana NPR Station Features 'A Life Worth Living' with Dr. Robert Martensen]() ### Geripal Blog: "Hospice Upheaval" Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-hospice-upheaval/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-hospice-upheaval/index.html.md) ###### Description: Thursday November 19, 2009: It never occurred to me until today that enrolling my patients in hospice could cause them harm and distress. What unfolded is what happens all the time but which I hadn't recognized could have such a negative effect. My patient had been receiving home health through one agency for chronic ulcers and short term home rehabilitation. She has been largely bed and chair-bound and I have seen her frequently on housecalls. Her condition had plateaued and with her strong desire not to ever return to the hospital and to live as comfortably as she could in her home until she died, we agreed it was time to transition to hospice. The previous home health agency did not have a 'sister'-hospice as part of their organization. So I enrolled her with one of the agencies I work closely with.[http://3.bp.blogspot.com/\_g6b7lckX2zE/SwYmM4\_jDVI/AAAAAAAABKA/oia85ToQiCY/s1600/movers.JPG]() The intake by the hospice case manager was uneventful. All seemed well until I heard from her family that yesterday several men from several different DME (durable medical equipment) companies came in and out of her home to change ALL of her equipment: hospital bed, pressure pad, wheelchair, shower bench, oxygen and humidifier, etc. She was overwhelmed, distraught and felt she had lost all control of her life and her home. Hearing this I felt immense remorse and guilt. I already knew that many agencies have contracts with different DME companies. But I had never recognized that, of course, when hospice uses different companies from pre-hospice days, the equipment is changed over--necessitating a tremendous upheaval (physically and emotionally) for the client. I wish I'd had the foresight to discuss the DME issues with the hospice case manager before this had occurred. Might we have been able to spread the visits so they didn't coalesce in a torrential downpour in one day? Or would there still have been an urgency by the DME companies and hospice to have everything set up promptly per their contracts? I don't know. I intend to discuss the case with the hospice. While patients in closed systems such as the VA or HMOs may not experience this, it's worth discussing for those of us who practice in the community and partner with different home health and hospice agencies. Who would have thought that something as 'mundane' as DME contracts could so significantly influence a patient's quality of life? Well, now I know better. Posted by Helen Kao ###### Link: [Visit Site]() ### CancerDoc Blog: "Goodbye Mr. B" Source: [HTML](https://cunniffdixon.org/stories/cancerdoc-blog-goodbye-mr-b/) Markdown: [Markdown](https://cunniffdixon.org/stories/cancerdoc-blog-goodbye-mr-b/index.html.md) ###### Description: This is a link to a blog entry by CancerDoc, "a budding oncologist trying to make sense of the world." It is a brutally honest post about an experience CancerDoc had watching a patient die in front of his daughter. It's a bit gruesome, but is incredibly compelling. It is an example of a compassionate physician/patient relationship and of the stress that can grow out of these relationships when a patient dies. ###### Link: [Visit Site]() ### Palliative Care Success Blog: "Future of Palliative Medicine Practices" Source: [HTML](https://cunniffdixon.org/stories/palliative-care-success-blog-future-of-palliative-medicine-practices/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-success-blog-future-of-palliative-medicine-practices/index.html.md) ###### Description: Thursday October 29, 2009: Will reform help or hinder the practice of Hospice and Palliative Medicine(HPM)? Help, if HPM physicians reconfigure themselves into "sought-after practices". The reconfiguration must be willful and carefully planned, and in advance of implementation of national health reform. In other words, bets must be placed now that the health care delivery system will be restructured, and payment for health services will be revamped. In upcoming blog posts, we'll take a close look at likely scenarios, and how the organizational alignment we've identified as Advanced Palliative Care Organizations will evolve into Accountable Palliative Care Organizations (APCOs). And, we'll examine the likely role of HPM physicians in APCOs, or what we refer to as the emerging role of the Chief Palliative Care Officer. This blog will be one forum for this discussion, so your comments and experiences are invited. Also, we plan a regular publication (HPM Practitioner) that will offer you insights into "bellwether" practices. An upcoming issue will feature the HPM practice in Grand Junction, Colorado, about which I have [posted]() previously. From our study and research into best practices of palliative care, we've developed theories of what differentiates exemplar palliative care communities from others. How HPM physicians are utilized is one distinguishing feature. How they are organized is another. And under health reform, how they are paid will likely be another. Think bundling, and the value of a "network of HPM physicians" tightly organized to increase negotiating (with both payors and providers) clout. ###### Link: [Visit Site]() ### Palliative Care Success Blog: Building a Hospice and Palliative Medicine \(HPM\) Medical Staff Source: [HTML](https://cunniffdixon.org/stories/palliative-care-success-blog-building-a-hospice-and-palliative-medicine-hpm-medical-staff/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-success-blog-building-a-hospice-and-palliative-medicine-hpm-medical-staff/index.html.md) ###### Description: Thursday October 29, 2009: A former colleague with many years of hospital executive experience recently accepted a position as the chief executive of a mid-sized, not-for-profit hospice (115 ADC). Upon review of employee staffing, she noticed that the hospice had half-dozen "arrangements" with physicians (with varying commitments but all under 15 hours per week) to provide largely unspecified clinical and administrative services. She asked if medical staff planning customary in hospitals had applicability and relevance for hospices. Of course, I replied, the "planning process" has great relevance, although there are several differences in scope and scale. To prepare a Hospice Medical Staff Development Plan, we follow a systematic five-step process: Step1 – analyze HPM professional fee billings and Activity/Effort reports and job descriptions for physician roles, Step2 – conduct interviews with key stakeholders (including all physicians practicing HPM in any capacity and commitment), Step3- compile Hospital and Community Palliative Performance Profiles using Dartmouth Medical Atlas, Step4 – review Hospice strategic plan and contracts/agreements between the Hospice and physicians, Step5 – using Responsibility Charting process, define professional expectations, metrics, and accountability. Through this five-step process, we gain insights that address the most common questions posed by hospice executives (administrators and physicians) about medical staff development: To what extent may nonphysician providers be used to meet additional clinical demands?When will additional physician staff be needed, and what are the anticipated time requirements to recruit these individuals?When should recruitment occur given practice ramp-up time and total recruitment budgets?Are there sufficient resources and the political will to build a hospice-sponsored HPM physician group?In what communities and health provider sites do we place physicians to meet our organization’s strategic objectives? Are there other questions regarding building of a medical staff on your minds? I invite your comments on what challenges each of you face in building a hospice medical staff? ###### Link: [Visit Site]() ### Video: Diane E. Meier, MD, FACP and Geoffery P. Dunn, MD, FACS "How to Have the Hard Conversation" Source: [HTML](https://cunniffdixon.org/stories/video-diane-e-meier-md-facp-and-geoffery-p-dunn-md-facs-how-to-have-the-hard-conversation/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-diane-e-meier-md-facp-and-geoffery-p-dunn-md-facs-how-to-have-the-hard-conversation/index.html.md) ###### Synopsis: This video is a short segment taken from the Cunniff-Dixon Foundation 2009 Symposium on the 'Art of Medicine at the End of Life' held at the New York Academy of Medicine. In this clip Diane Meier talks candidly about "having the hard conversation" when a Doctor has to inform a patient that he or she is nearing the end of life. ###### Source: Cunniff-Dixon Foundation 2009 Symposium ###### Vol/Page/Date: May 8, 2009. ###### Resource Type: Video or Podcast ###### Author/Source: Diane Meier ###### keywords: breaking bad news, communication, family meetings ###### Submitter: Peters Media ###### Video: ###### Related Resources: [Spring 2009 CME Symposium: 'The Art of Medicine at the End of Life.']() ### About.com Pallliative Care Blog: Moments with Baxter: the Hospice Angel Source: [HTML](https://cunniffdixon.org/stories/about-com-pallliative-care-blog-moments-with-baxter-the-hospice-angel/) Markdown: [Markdown](https://cunniffdixon.org/stories/about-com-pallliative-care-blog-moments-with-baxter-the-hospice-angel/index.html.md) ###### Description: The most recent (November 18) blog entry from Angela Morrow, RN about a hospice dog, Baxter, who brought cheer to dozens of human beings as they approached the end of life. ###### Link: [Visit Site]() ### The New Health Dialogue Blog: "Health Care: Time for a Serious Discussion Source: [HTML](https://cunniffdixon.org/stories/the-new-health-dialogue-blog-health-care-time-for-a-serious-discussion/) Markdown: [Markdown](https://cunniffdixon.org/stories/the-new-health-dialogue-blog-health-care-time-for-a-serious-discussion/index.html.md) ###### Description: This link is to a guest blog post (November 6, 2009) by Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. In this post, Dr. Byock talks about the House's Affordable Health Care for America Act and the recent section that has been resurrected; reimbursing doctor's for having voluntary discussions with their patients on how they would like to receive end-of-life care. From this subject of health care reform he segues into a few candid stories about advanced directive discussions with his patients, medical school students and his own daughters. ###### Link: [Visit Site]() Media ###### Provided By: ### New Health Dialogue Blog: Dying Well Beats Dying Badly. And Expensively Source: [HTML](https://cunniffdixon.org/stories/new-health-dialogue-blog-dying-well-beats-dying-badly-and-expensively/) Markdown: [Markdown](https://cunniffdixon.org/stories/new-health-dialogue-blog-dying-well-beats-dying-badly-and-expensively/index.html.md) ###### Description: This post from Joanne Kenen on November 20, 2009 reviews some recent news in palliative care including NPR's report on the Gunderson Lutheran Hospital in La Crosse, Wisonsin. Joannes writing is very clear and includes some nice reflections. ###### Link: [Visit Site]() ###### Related Resources: [NPR Audio Podcast: Why This Wisconsin City Is The Best Place To Die]() [End of Life - thoughts from an MD: Where's the Best City to Die?]() [Geripal Blog Post from November 18, 2009: "The Best Town to Die In"]() ### Video: CBS 60 Minutes, "The Cost of Dying" Source: [HTML](https://cunniffdixon.org/stories/video-cbs-60-minutes-the-cost-of-dying/) Markdown: [Markdown](https://cunniffdixon.org/stories/video-cbs-60-minutes-the-cost-of-dying/index.html.md) ###### Description: CBS's 60 minutes recently spent time with the Palliative Care Team at Dartmouth-Hitchcock Hospital in Hanover, NH filming part of a segment that aired on sunday November 22nd called The Cost of Dying. ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: Dying in 14 Minutes of 60 Minutes]() [Geripal Blog: "How should costs fit into the conversation about end-of-life care?"]() ### Bridget Duffy on the Patient Experience: Gel Health Conference 2009 Source: [HTML](https://cunniffdixon.org/stories/bridget-duffy-on-the-patient-experience-gel-health-conference-2009/) Markdown: [Markdown](https://cunniffdixon.org/stories/bridget-duffy-on-the-patient-experience-gel-health-conference-2009/index.html.md) ###### Description: This Gel Video is of Bridget Duffy speaking at the 2009 Gel Health conference. She talks about her recent experience as a patient with a broken leg and how that has continued to inspire her work improving the patient experience. ###### Link: [Visit Site]() Media ###### Video: ###### Related Resources: [Gel Health Conference 2009]() [Video: Dr. Bridget Duffy from the Cleveland Clinic Speaks about the Patient Experience]() ### Terminally Ill and Suicide Source: [HTML](https://cunniffdixon.org/stories/terminally-ill-and-suicide/) Markdown: [Markdown](https://cunniffdixon.org/stories/terminally-ill-and-suicide/index.html.md) ###### Synopsis: Joan Bakewell discusses the real-life case of Mary, a terminally-ill woman in her 80s. She has considered her condition and has decided that she wants to die. ###### Source: The BBC ###### Vol/Page/Date: August 6, 2009 ###### Resource Type: Video or Podcast ###### Author/Source: BBC: Inside the Ethics Committee ###### Link URL: [http://www.bbc.co.uk/iplayer/console/b00lvgwj]() ###### keywords: ethics, suicide, refusing palliative care ###### Submitter: Peters ### Geripal Blog: Dying in 14 Minutes of 60 Minutes Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-dying-in-14-minutes-of-60-minutes/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-dying-in-14-minutes-of-60-minutes/index.html.md) ###### Description: November 22, 2009: CBS did a segment entitled "The Cost Of Dying" on tonight's 60 Minutes.Considering the title of the segment and the short amount of time alloted to it, CBS's coverage was accurate and thought provoking.I'd have done some things differently.....for example: Point made: Patients most often don't pay their medical bills out-of-pocket. In fact, they hardly look at their bill. My addendum: CBS should have provided actual price tags for costly EOL-in- ICU procedures, like CRRT, TPN, and mechanical ventilation, as well as data to show the percentage of time these procedures are in place but do not prolong life. Point made: Most people want to die at home or in hospice, but instead die in hospitals. My addendum: Discuss the fact that patients have a choice; that a living will is easy to complete, does not require a lawyer/fees (in most states), and that patients have a right to make their own healthcare decisions, especially at EOL. Point made: Technology is available to prolong life. My addendum: despite this technology, a terminal disease is just that - terminal - and patients have the right to determine how and where they want to die. Point made: Hospitals are incented to admit patients, and doctors are paid by the number of patients they treat. My addendum: State that terminally ill patients have a right to limit their treatments and days in the hospital, especially at EOL. I want insurance providers and Medicare to require terminally ill patients to prepare for EOL as a condition of treatment reimbursement. Point Made: Dorothy Glas, RN, stated that her mother saw many (read: 25) consultants in her final hospital stay before her death. She and the CBS interviewer Kroft agreed these were basically CYA consults. My addendum: CBS missed a good opportunity to (1.) discuss how malpractice litigation has a direct effect on skyrocketing healthcare costs, and (2.) ask Dorothy Glas RN why she didn't question the attending MD about the many consults. Did Ms. Glas have good reason to believe the consults were necessary, or had the patient herself stated she wanted 'everything done', hence all the specialists? Did the patient have a living will? I can't stop myself from thinking that the referenced psych consult might have been most appropriate, considering there were 24 others. My bet is the Palliative Care consult came last. Imagine the savings of money and complaints if PC had been consulted, say, within the first 6. Point made: The $43,000 defibrillator implant in a 90-something year old. Dr. Byock referred to age and medical condition as reasons to question this procedure. My addendum: explore a patient's individual quality of life before we reference age. I've met a few robust 92 year olds that could run circles around a bunch of sedentary 72 year-old smokers. This was another missed opportunity; Geriatric Medicine would have fit very nicely here. Point made: Dr. Fisher stated the reason patients are admitted to hospitals is because it's the "path of least resistance" since physicians don't have time to treat these patients in their offices. My addendum to that would be"why are we discussing this?". Yes, hospitals get 'direct admits' from the MD offices, but don't the majority of ICU patients come in through the ED? Then again, I'm no Dartmouth researcher. This was valuable time wasted on a curious finding. It's unfortunate that Mr. Kroft asked Dr.Byock the So Yesterday question about pulling the plug on Granny. Dr. B did a decent job of defending himself, albeit in a brusque sort of way. His intensity on camera is probably balanced by an endearing, sincere bedside manner. Too bad CBS didn't interview one of the many patients who are undoubtably grateful for his interventions. I admire his passion. I'm grateful to the CBS Fates for not airing the words 'Palliative Care' without a full explanation.....and there’s no telling what that explanation might have been ……phew... ###### Link: [Visit Site]() ###### Related Resources: [Video: CBS 60 Minutes, "The Cost of Dying"]() ### Geripal Blog: "How should costs fit into the conversation about end-of-life care?" Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-how-should-costs-fit-into-the-conversation-about-end-of-life-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-how-should-costs-fit-into-the-conversation-about-end-of-life-care/index.html.md) ###### Description: [http://3.bp.blogspot.com/\_cB8\_Eo3hX9Q/Swx2RODosoI/AAAAAAAAADg/KFH2FunJjuk/s1600/save+money.bmp]()November 23, 2009: Diane Meier just [tweeted](): "60 minutes misses the point- palliative care is about matching treatment to patient goals, NOT stopping it." The central question raised by the [60 minute episode]() and [subsequent discussion](): how should costs fit into the conversation about end-of-life care? Various positions: 1. We should focus on reducing costs at the end of life. Costs of care at the end of life are outrageously high. We should limit spending on "unnecessary" expenditures that do little to prolong life. As a side effect, we will reduce suffering. 2. We should focus on reducing suffering. Many of the life-prolonging interventions at the end of life (e.g. mechanical ventilation, ICU stays, ED visits) cause suffering. As a side effect of reducing suffering, we will reduce costs. 3. We should focus on informed choices: matching patients care to their goals and values. Many patients do not realize alternatives exist to high intensity life-prolonging care, such as care focused on maximizing quality of life. If more patients were informed, more people would opt for care focused on quality rather than quantity of life. As secondary effects, greater emphasis on informed decision making would reduce costs and suffering. Costs are central to the argument in position 1. Reduced costs are ancillary benefits to positions 2 and 3. These are not necessarily mutually exclusive positions. Someone could argue that the three goals of reduced costs, reduced suffering, and promoting patient choice are equally important. That said, each argument has a different policy implication. For example, an argument based on costs leads to a policy of rationing. An argument based on promoting informed choices leads to funding for [advance care planning]() (I like this term better than “end-of-life” counseling). Furthermore, each argument arises from a different ethical principle, and there may be reasons for arguing that one principle should take precedence over the other. The argument for reducing costs arises from the ethical principle of justice. By paying such high costs at the end of life, we reduce our ability as a society to pay for other potentially beneficial treatments. For example, if even half of the $50 billion dollars (number from 60 minutes) spent on care in the last month of life were spent on reducing social determinants of disease (e.g. smoking and obesity), this money could conceivably lead to a tremendous improvement in the overall health of our society. More realistically, if we do not contain spiraling costs, we will not be able to pay for other needed government programs, like schools. The central challenge to this issue is that rationing must be accomplished on a societal/political level, not the bedside, yet well publicized personal stories of denied coverage often trump reasoned arguments in social/political debate. The argument for reducing suffering arises from the ethical principle of beneficence and nonmaleficence. Health care systems and individual providers should refrain from providing care that is known to be ineffective or cause harm. The challenge here is that what constitutes “suffering” or “quality of life” is highly subjective. Older adults who survived ICU admissions [rate their quality of life higher]()than their family members do. Making judgments at a physician or even health policy level about what constitutes “suffering” smacks of paternalism, and many will be uncomfortable with this argument. The argument for promoting informed decision making arises from the principle of respect for patient autonomy. Patients have a right to be informed of the potential for suffering with high intensity life-prolonging care, limited potential life-prolonging benefit, and alternatives such as care that focuses to a greater extent on quality of life. The challenge here is that while patients have an established right to refuse unwanted treatments (a negative right), some patients claim the positive right to receive specific drugs or interventions. In part, this has led some (such as Andy Billings) to say that “[autonomy \[has\] run amok]().” If I have to take a stand on what I see as an essentially normative ethical issue, I would argue that promoting informed patient choices should be the objective of the palliative care community (one could make a similar argument about the geriatrics community). While reducing costs and reducing suffering are laudable goals, for both ethical and pragmatic reasons, they are unlikely to be successful in today’s political climate. I also believe that these issues are inextricably intertwined. How we (we meaning the palliative care community in this case) promote ourselves and address the cost issue depends on our audience. Hospitals and health systems see palliative care clinicians as cost reducers and referring providers see us as reducers of suffering. Costs savings mean little to referring providers, and reducing suffering means little to health systems (I’ve heard Diane Meier say of reduced suffering as a goal in and of itself, "that and 50 cents will get you a cup of coffee”). We need to demonstrate cost savings to grow outside of the inpatient and hospice settings. We need to demonstrate reduced suffering so providers will refer patients to us. And for ourselves, for our patients and their families, we need to say honestly that we are helping them navigate serious illness with the goal of promoting their best interests. Thanks to Barbara Brown for her [excellent post]() and stimulating discussion that lead to this post. I also recommend reading this seminal article about the [high costs of care at the end of life](); I re-read it recently and found it fascinating and thoughtfully written. Finally, thanks to Bernie Lo for his book [Resolving Ethical Dilemmas](), which I used today as a reference. Posted by Alex Smith ###### Link: [Visit Site]() ###### Related Resources: [Video: CBS 60 Minutes, "The Cost of Dying"]() [Geripal Blog: Dying in 14 Minutes of 60 Minutes]() ### Palliative Care Success Blog: "Engage with Grace-- Communicating End-of-Life Wishes" Source: [HTML](https://cunniffdixon.org/stories/palliative-care-success-blog-engage-with-grace-communicating-end-of-life-wishes/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-success-blog-engage-with-grace-communicating-end-of-life-wishes/index.html.md) ###### Description: Some conversations are easier than others Last Thanksgiving weekend, many of us bloggers participated in the first documented “[blog rally]()” to promote [Engage With Grace]() – a movement aimed at having all of us understand and communicate our end-of-life wishes. It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family. Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different. A bit of levity. At the heart of Engage With Grace are [five questions]() designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important. To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer: Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion. So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them. Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation. One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge. Wishing you and yours a holiday that’s fulfilling in all the right ways. (To learn more please go to [www.engagewithgrace.org](). This post was written by Alexandra Drane and the Engage With Grace team. ) ###### Link: [Visit Site]() ###### Related Resources: [Palliative Care Success Blog: "Future of Palliative Medicine Practices"]() [Palliative Care Success Blog: Building a Hospice and Palliative Medicine (HPM) Medical Staff]() [Why Intellectual Capital Matters to Growth of Palliative Care Programs]() ### Geripal Blog: "Penalizing Hospitals for Readmissions: Unintended Consequences?" Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-penalizing-hospitals-for-readmissions-unintended-consequences/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-penalizing-hospitals-for-readmissions-unintended-consequences/index.html.md) ###### Description: Tuesday December 1, 2009: Medicare recently started publicly reporting hospital readmission rates as a measure of quality, and there are proposals to financially penalize hospitals with high rates of readmission. A recent [article]() in the Annals of Internal Medicine makes a compelling case that an unintended consequence of such a proposal could be to worsen health inequalities by inappropriately penalizing hospitals that care for our most vulnerable underserved patients. I found the article convincing. I don't think Medicare should implement any plans to penalize hospitals based on readmission rates without answering the concerns of this article. Further, the article raises serious questions about viewing readmission rates as a measure of quality. The authors of the article were Drs. [Rohit Bhalla]()and [Gary Kalkut]()of Montefiore Medical Center in the Bronx, NY and the Albert Einstein College of Medicine. It is certainly true that encouraging hospitals to reduce readmission rates in older patients is a good thing. There is a strong basis for viewing readmission rates in the elderly as a measure of quality. While Medicare may be primarily concerned with the cost of rehospitalization, it is also the case that repeated hospitalizations in older persons can have very deletious complications, including exacerbating disability and accelerating cognitive decline. The need for readmission can be an indicator that coordination of care was poor. However, there are many things beyond the hospitals control that may impact rates of readmission. Independent of the quality of care, patients in poor communities are probably at higher risk of readmission. Factors that contribute to this include lower levels of social support, less access to outpatient care, and lower education. While Medicare readmission models adjust for disease diagnoses, they don't currently adjust for any of these other factors that may also be important determinants of readmission. Therefore, comparing readmission rates may unjustly make hospitals caring for vulnerable patients look bad. It would certainly be even more unjust if our safety net hospitals suffer inappropriate financial penalties for readmissions related soley to their higher risk populations. In addition to these concerns that were raised in the article, it should also be noted that readmission models do not adjust for factors like frailty, disabilty, and cogntive impairment. As a result, hospitals that care for large numbers of frail elders are also at risk of being unjustly labelled as having worse quality based on readmission rates. Hopefully, Medicare will take the issues raised by Bhalla and Kalkut seriously. Posted by ken covinsky ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: "Hospice Upheaval"]() [Geripal Blog Post from November 18, 2009: "The Best Town to Die In"]() ### Geripal Blog: "Thoughts on Preventative Medicine" Source: [HTML](https://cunniffdixon.org/blogs/geripal-blog-thoughts-on-preventative-medicine/) Markdown: [Markdown](https://cunniffdixon.org/blogs/geripal-blog-thoughts-on-preventative-medicine/index.html.md) ###### Description: Tuesday December 1, 2009: You can prevent Heart Attacks You can prevent Strokes You can prevent Colon Cancer You can prevent Cervical Cancer You can prevent Breast Cancer You can prevent Prostate Cancer Really? Well perhaps You can prevent Syphilis You can prevent the Friends of Syphilis You can prevent smallpox, polio, measles, mumps, rubella, tetanus, chicken pox, meningitis, influenza, hepatitis, diphtheria, whooping cough You can prevent Diabetes You can prevent Complications of Diabetes You can prevent Hip fractures You can prevent Diarrheal Illness You can prevent Nosocomial Infections Really? Really, just wash your hands But you cannot prevent death. Saying that we can prevent death is preposterous. Indeed, the word “prevention” doesn’t even apply to death You can delay death You can stall death You can prolong life But it just doesn’t make sense to say that you can prevent death. Posted by Dan Matlock ###### Link: [Visit Site]() ###### Related Resources: [Excerpt from "In Blackwater Woods"; a poem by Mary Oliver]() ### Dean Ornish on Healing Source: [HTML](https://cunniffdixon.org/stories/dean-ornish-on-healing/) Markdown: [Markdown](https://cunniffdixon.org/stories/dean-ornish-on-healing/index.html.md) ###### Synopsis: Dean Ornish talks about simple, low-tech and low-cost ways to take advantage of the body's natural desire to heal itself. This talk is very entertaining, interesting and packed with information that supports the healing wonders of the body-- even when illness and disease have already set in. ###### Source: Website: TED ideas worth spreading ###### Vol/Page/Date: February 2004 ###### Resource Type: Video or Podcast ###### Author/Source: Dean Ornish ###### Link URL: [http://www.ted.com/talks/lang/eng/dean\_ornish\_on\_healing.html]() ###### keywords: healing, illness, depression, cancer treatment ###### Submitter: Peters Media ###### Video: ### Michael Christensen: Co-founder, Big Apple Circus; founder, Clown Care Source: [HTML](https://cunniffdixon.org/stories/michael-christensen-co-founder-big-apple-circus-founder-clown-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/michael-christensen-co-founder-big-apple-circus-founder-clown-care/index.html.md) ###### Synopsis: Visiting children and their families in the hospital, Clown Care founder Michael Christensen has learned to focus on "what's going right" in the room. Speaking at the first [Gel Health]() conference, Christensen describes how his clown rounds got started, and finishes with an on-stage performance as Dr. Stubs. ###### Source: GEL (Good Experience Live) Health Video ###### Vol/Page/Date: October, 2009 ###### Resource Type: Video or Podcast ###### Author/Source: Michael Christensen ###### Link URL: [http://www.gelconference.com]() ###### keywords: clown care, patient connection ###### Submitter: Peters Media ###### Video: ###### Related Resources: [Bridget Duffy on the Patient Experience: Gel Health Conference 2009]() [Gel Health Conference 2009]() ### Two Songs For Hedli Anderson Source: [HTML](https://cunniffdixon.org/stories/two-songs-for-hedli-anderson/) Markdown: [Markdown](https://cunniffdixon.org/stories/two-songs-for-hedli-anderson/index.html.md) ###### Synopsis: Stop all the clocks, cut off the telephone, Prevent the dog from barking with a juicy bone... [Link to Full Poem]() ###### Source: Selected poems by W.H Auden ###### Vol/Page/Date: 1989 ###### Resource Type: Book ###### Author/Source: W. H. Auden ###### keywords: poetry, death, W.H Auden ###### Submitter: Peters ###### Related Resources: [Excerpt from "In Blackwater Woods"; a poem by Mary Oliver]() ### A Meeting Source: [HTML](https://cunniffdixon.org/stories/a-meeting/) Markdown: [Markdown](https://cunniffdixon.org/stories/a-meeting/index.html.md) ###### Synopsis: In a dream I meet my dead friend. He has, I know, gone long and far... [Link to Full Poem]() ###### Source: Poem from "A Part" ###### Vol/Page/Date: 1980 ###### Resource Type: Book ###### Author/Source: Wendell Berry ###### keywords: poetry, wendell berry, death, friend ###### Submitter: Peters ###### Related Resources: [Excerpt from "In Blackwater Woods"; a poem by Mary Oliver]() [Two Songs For Hedli Anderson]() ### Memory of My Father Source: [HTML](https://cunniffdixon.org/stories/memory-of-my-father/) Markdown: [Markdown](https://cunniffdixon.org/stories/memory-of-my-father/index.html.md) ###### Synopsis: Every old man I see Reminds me of my father When he had fallen in love with death One time when sheaves were gathered...[http://www.npr.org/programs/death/readings/poetry/kava.html]()[Link to Full Poem]() ###### Source: Poem from "Collected Poems" ###### Vol/Page/Date: 1947 ###### Resource Type: Book ###### Author/Source: Patrick Kavanagh ###### keywords: father/son, remember, death, poetry, love ###### Submitter: Peters ###### Related Resources: [Excerpt from "In Blackwater Woods"; a poem by Mary Oliver]() [Two Songs For Hedli Anderson]() [A Meeting]() ### Anna Deavere Smith: "Let Me Down Easy" Source: [HTML](https://cunniffdixon.org/stories/anna-deavere-smith-let-me-down-easy/) Markdown: [Markdown](https://cunniffdixon.org/stories/anna-deavere-smith-let-me-down-easy/index.html.md) ###### Description: The link below is to a November 6, 2009 episode of democracy now where Amy Goodman interviews Anna Deavere Smith who researched, wrote and perfoms "Let Me Down Easy" -- a solo act about various trials and tribulations within the U.S health care system. There is a short article and a great video interview with a mix of question and answer between Amy and Anna along with some great highlight clips from Anna's show. This embedded You Tube video provides highlights and narrative by Anna Deavere Smith on her solo act, "Let Me Down Easy". ###### Link: [Visit Site]() Media ###### Video: Sorry, you need to install flash to see this content. ### Advance Care Planning: Role of the Primary Care Physician Source: [HTML](https://cunniffdixon.org/stories/advance-care-planning-role-of-the-primary-care-physician/) Markdown: [Markdown](https://cunniffdixon.org/stories/advance-care-planning-role-of-the-primary-care-physician/index.html.md) ###### Link: Visit Site Media ###### Provided By: This is an informative continuing medical education video (January 8, 2008) from the University of California Davis Medical School on the role of the primary care physician in advanced care planning. Ben A. Rich, J.D., PhD., addresses the importance and role of advanced directives as well as the shortcomings of oral directives. The video includes Dr. Rich speaking with intermittent views of his powerpoint slides. ###### Video: Sorry, you need to install flash to see this content. ### GeriPal: What a nursing assistant will tell us...if we ask Source: [HTML](https://cunniffdixon.org/stories/geripal-what-a-nursing-assistant-will-tell-us-if-we-ask/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-what-a-nursing-assistant-will-tell-us-if-we-ask/index.html.md) ###### Description: Posted: 29 Jan 2010 01:34 PM PST A friend recently forwarded me an update to a story first reported in the Washington Post in May 2009 about a home care nursing assistant, Marilyn Daniel. (Here’s the update). Using quotes and photographs, the author describes a typical day of visits—from transportation challenges to detailed, moving stories of a few of her patients. It caused me to pause and reflect upon the caregivers closest to our geriatric patients. Nursing assistants provide the greatest amount of direct care to our patients whether in hospitals, nursing homes, or homes. For me, this article aptly notes the challenges of the job, the importance of continuity of care, and the difficulty for home health aides when given a next “case” right after a long standing relationship with a patient ends (or perhaps when hospice comes in and negotiations can’t be reached for keeping the same home health aide). The audience here at GeriPal is one that knows these issues well, but when a photographer/writer captures it so movingly, I can’t help but call attention to it. It is projected that there will be a 50% growth in home health aide positions in the next ten years because of the expansion of home care for our geriatric population (US Bureau of Labor Statistics). How will we work with home health aides to increase retention? How can we argue for better compensation for such a demanding (physically and emotionally) position? And for those of us involved in geriatric palliative care, how can we ensure that palliative care education is offered and encouraged for home health aides? In the larger picture, offering continuing education and acknowledging specialized training is a start. I know that programs such as ELNEC-Geriatric include specific content and attention to nursing assistants (self disclosure - I’m part of the team offering this course in Philadelphia in March-link above is for this, but see \* below for more details). And in recognition of additional education and experience in palliative care, HPNA (through NBCHPN) offers certification for nursing assistants. These are a start—as was the public attention given to the role in the Washington Post articles. In my own practice, the same as with most of you I assume, I often elicit opinions and thoughts from the home health aides caring for an individual. But in the smaller, every day picture is this enough? How we can better include nursing assistants in palliative care teams? I don’t have the answer, but I do think that as we continue to consider how geriatric palliative care is delivered, we all need to advocate for nursing assistants as valued members of the interdisciplinary team. \* ELNEC-Geriatric Train the Trainer Course, March 9-10, Philadelphia, PA Nursing CEUs (12) offered and we’re working on the Social Work CEUs Sponsored by University of Pennsylvania School of Nursing, Penn Wissahickon Hospice and NewCourtland.[http://www.pennmedicine.org/homecare/conference/end-of-life-nursing-educ...]() ###### Link: [Visit Site]() ### Geripal Blog: Social Workers Are Awesome Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-social-workers-are-awesome/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-social-workers-are-awesome/index.html.md) ###### Description: Social Workers Are AwesomePosted: 15 Mar 2010 02:00 AM PDT In 1927, Francis Peabody remarked that "The secret of the care of the patient is in caring for the patient." Medicine has made much progress since those days, but some might argue that some of the humanitarian cornerstones of caring that concerned Peabody have been lost. Of course, there are many health professionals that still embody this caring ethic. And in todays era, perhaps the group that best personfies this central caring ethic of medicine are medical social workers. I know we should avoid generalizations, but isn't it the case that all social workers are nice? Perhaps it is this niceness, combined with their knowledge and skills that makes them so indispensable. It is often the social worker on the team that understands what is really going on with the patient and identifies the key details that make it possible to effectively care for them. It is because they know what to ask, and patients and families are comfortable confiding in them. Geriatrics practice would be impossible without social workers. I definitely see this in our Geriatrics clinic. Many patients are referred to Geriatrics because things seem to be falling apart in terms of their ability function independently at home. After I do an initial evaluation, I have to admit that I sometimes feel kind of bewildered. There is almost never a single underlying cause of the patient's problems---as the Fiddler on the Roof song goes, it is a little bit of this, a little bit of that (or perhaps a lot of this and a lot that). There is always a complex interaction of medical, social, and environmental factors that can not be separated from each other. So, after I do my initial evaluation, a politely excuse myself from the exam room and knock on the door of our social worker, Karen. She somehow always has time for my unannounced visit to discuss the patient, often even adding the patient that day to her overbooked schedule. After talking through the issues with her, what was bewildering starts to become clear, and we are able to start formulating a plan for the patient. I end up returning to the exam room more confident we will be able to come up with a plan that will help the patient. Can you believe there are still doctors who will dimissively refer to some patient issues (usually psychosocial issues) with a comment such as, "that's social work." The tone often implies they think the issue is not their problem, or even worse, they think addressing the issue is beneath them. Perhaps we should continue to encourage physicians to remark, "that's social work" but train our students to know that means they are dealing with something of particular importance that will take great skill to manage. I know very little about the structure of social work training. However, it seems efforts to improve medical education could learn something from social work training. Social workers tend to be better than most physicians at communicating with patients, and many patients are more comfortable talking to a social worker than their doctor. The ability of social workers to uncover key elements of the history that physicians fail to identify suggests we can learn some basic skills of physicianship from them. It sure seems we would be better doctors if more elements of social work training were included in our training. Given the importance of the medical social worker, you would think this would be a well paid position. However, according to the Bureau of Labor Statistics, the median salary of medical social workers is only $46,000 per year. Only 10% earn over $70,000 per year. This seems strikingly low for a position that requires extensive education (many social workers have masters degrees), requires very high level skill and judgment, and is so indispensible. I wonder what the reasons for this are. Is this because social work tends to attract individuals committed to helping others and who are therefore less concerned with monetary rewards? Is it because social workers are so focused on others that they are less effective at negotiating their compensation? Or is this the legacy of workplace gender discrimination, as historically, woman have been more likely to enter social work than men? We are currently in the middle of Social Work Month 2010. This year's theme is Social Workers Inspire Community Action. But day in and day out, social workers make things better for our patients. In truth, every month is social work month. ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: "Hospice Upheaval"]() [Geripal Blog Post from November 18, 2009: "The Best Town to Die In"]() [Educational needs of hospice social workers: spiritual assessment and interventions with diverse populations.]() [Social workers' educational needs in end-of-life care.]() ### Geripal Blog: Q&A with Jeff Gordon - Author of "A Death Prolonged" Source: [HTML](https://cunniffdixon.org/books/geripal-blog-qa-with-jeff-gordon-author-of-a-death-prolonged/) Markdown: [Markdown](https://cunniffdixon.org/books/geripal-blog-qa-with-jeff-gordon-author-of-a-death-prolonged/index.html.md) ###### Description: Many terminal patients linger through their final months with a miserable quality of life and too often with extreme levels of suffering. Today’s high-tech medical care can sustain technical life – the beating heart – but utterly fails to restore real quality of life for many. The result: Death Prolonged. This is the introduction from Dr. Jeff Gordon’s new book, A Death Prolonged. Dr. Gordon's agenda is pretty clear in this book - to get people to talk about end-of-life prefereneces. He uses a fictional account of a young physician who learns that high cost end-of-life care may not be synonymous with high quality care. She also learns that in a system with limited resoureces, high cost interventions in terminally ill patients are likely to shift resources away from cheaper preventive care. After reading this book I thought it would be a good idea to ask Dr. Gordon a couple questions about how he decided to approach this subject in his novel. Here are four of the answers he gave me: Q. What motivated you to write this book? A. As a hopitalist, I witness two related tragedies every day: people suffer needlessly at the end of their lives and we waste precious health care dollars on futile care. Unfortunately, the problem is growing, as America ages. We could prevent both tragedies if physicians and patients would discuss matters in advance. People need the truth about EOL care because most are misinformed. That’s because most people get their information from television, and the TV fantasy world has created a level of ignorance that is hard to exaggerate. The dollar and human costs of this gross misinformation are astronomical. This book brings the public into the hospital to learn the facts and empower them to make informed decisions about EOL care. In the end, I hope they will have intelligent and productive discussions with their family and physicians. Q. One lesson I learned during this last summer’s healthcare reform debate is that one should be very careful mentioning improving end-of-life care anywhere near the words cost savings, otherwise it will be labeled as rationing or worse, “pulling the plug on granny”. Your books central premise is that simple interventions, like advance directive discussions, have the potential to both save money and relieve suffering. Are you concerned that you are too closely connecting these issues? A. My greater concern is that we will try to sugar-coat the truth. Most Americans don’t make informed end-of-life decisions and end up receiving care that prolongs their suffering and consumes valuable resources. We must assert this truth frequently and to many audiences. I found that the “death panel” talks from last summer opened doors for meaningful discussions and allowed me to enlighten more people with the facts. We should attack ignorance with facts and thoughtful dialogue. “Spin doctors” underestimate the intellect of the American people. Let’s just tell the truth in a clear, sensitive, and unapologetic way, and frame end-of-life discussion in terms of informed consent: the risks, benefits, and alternatives. "Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence. John Adams" Q. You use a fictional story to lay out your arguments against costly care that only prolongs dying and suffering in terminally ill patients. Why not just describe real events that you have seen in the hospital? A. Fiction is powerful and has been extremely influential in many social and ideological struggles. George Orwell’s 1984 and Animal Farm shaped American understanding of communism. Ayn Rand effectively conveyed her influential existentialist views through Atlas Shrugged and The Fountainhead. When Abraham Lincoln met Harriet Beecher Stowe, author of Uncle Tom’s Cabin, he said, “So you’re the little woman who started this great war.” We need to attack EOL issues from every possible angle and some people will embrace and feel the truth through fiction, like this, in ways that they can’t through non-fiction. Q. You recommend several ways to improve documentation for end-of-life decisions by patients and families? One notable exception is the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm program. What role do you think POLST forms have in improving end-of-life care? A. Unfortunately, we do not use POLST forms in Ohio. The forms are simple, unlike the DNR forms we use. With POLST, patients can make their wishes explicit and clear. I wish I’d included a discussion on the POLST paradigm in the book. ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: Social Workers Are Awesome]() [Geripal Blog Post from November 18, 2009: "The Best Town to Die In"]() ### Television Special with Katie Couric: When Families Grieve Source: [HTML](https://cunniffdixon.org/stories/television-special-with-katie-couric-when-families-grieve/) Markdown: [Markdown](https://cunniffdixon.org/stories/television-special-with-katie-couric-when-families-grieve/index.html.md) ###### Description: This link is to a great television special that aired April 14th, 2010 on PBS. The special is hosted by Katie Couric who does a really nice job communicating between the viewers and some of the Sesame St. characters like "Elmo". Couric and Elmo begin discussing death and grieving when Elmo tells Couric that his uncle died. In between these discussions the show cuts to stories of real families and children that have had to deal with and try to understand death in their family. It is quite heavy at times and very emotional, but very well done. Towards the end of the show the children of these families are interviewed and explain what the grieving process was like for them. This is a must see for health professionals who work with families on a regular basis and for families themselves who have been through the grieving process. One of the most difficult concepts that arose from the show was the idea of permanency, especially for children, trying to grasp the idea that a loved one who dies is not going to be around any more. Press Release: "Sesame Workshop, the nonprofit educational organization behind Sesame Street, in association with Worldwide Pants Incorporated and Lookalike Productions, is producing a new prime-time television special, When Families Grieve featuring Katie Couric and the Sesame Street Muppets. This hour-long HD special, airing in prime-time nationwide in April on PBS, will present families’ personal stories about coping with the death of a parent, as well as strategies that have helped these families move forward..." ###### Link: [Visit Site]() ### "Vesta” Performed Across Country Source: [HTML](https://cunniffdixon.org/stories/vesta-performed-across-country/) Markdown: [Markdown](https://cunniffdixon.org/stories/vesta-performed-across-country/index.html.md) ###### Description: This [Bryan Harnetiaux]() play offers a warm and often funny exploration of a family’s struggle with a variety of end-of-life issues as they come to terms with the eventual loss of their matriarch, Vesta. This 90-minute drama has been used by hospices, churches, divinity schools, medical schools, and other organizations all over the nation as an educational tool and as a vehicle for creating public dialogue about end-of-life issues... Click the link below for the full write-up on the play, "Vesta" ###### Link: [Visit Site]() Media ###### Provided By: Duke Institute on Care at the End of Life ###### Video: Sorry, you need to install flash to see this content. ###### Related Resources: [Duke University School of Medicine Center for Palliative Care]() ### Palliative Care Grand Rounds: April 2010 Source: [HTML](https://cunniffdixon.org/stories/palliative-care-grand-rounds-april-2010/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-grand-rounds-april-2010/index.html.md) ###### Description: [Click here]() for the April edition of Palliative Care Grand Rounds. This month is hosted by blogger [Palliative Care Success]()- he outlines what is happening in the palliative care blogosphere and provides links to all their posts. Topics range from health care reform to futile care and hot discussion topics debating the need for palliative care as a medical specialty. Happy reading. ###### Link: Visit Site ###### Related Resources: [Palliative Care Grand Rounds: December 2009]() [Palliative Care Grand Rounds: November 2009]() ### CancerDoc Blog: "Denmark" Source: [HTML](https://cunniffdixon.org/stories/cancerdoc-blog-denmark/) Markdown: [Markdown](https://cunniffdixon.org/stories/cancerdoc-blog-denmark/index.html.md) ###### Description: Saturday, March 20, 2010"Denmark" R.N. just died. She was my first breast cancer patient out of fellowship and training. My first breast cancer patient where I was the "doctor". No backup. Nobody to turn to for advice. I write the orders, I explain the side effects. I hold the hands. She was only 33 years old when she was diagnosed 4 years ago. She and her husband had just moved from Denmark only months before for his company. Something with maritime equipment that brought him to the mid-Atlantic... [read more]() ###### Link: Visit Site ###### Related Resources: [CancerDoc Blog: "Goodbye Mr. B"]() ### GeriPal Blog: Palliative Care: Transforming the Care of Serious Illness – A Book Review Source: [HTML](https://cunniffdixon.org/uncategorized/geripal-blog-palliative-care-transforming-the-care-of-serious-illness-a-book-review/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/geripal-blog-palliative-care-transforming-the-care-of-serious-illness-a-book-review/index.html.md) ###### Description: On my way out of the hospital this evening I ran into a soon-to-be palliative care fellow. Our conversation quickly turned the topic of what one should read prior to beginning a fellowship in order to hit the ground running. This used to be a tough question for me, considering the myriad of key journals, textbooks, and novels that have helped shape my understanding of the field. The answer, though, has become a lot easier after reading Diane Meier’s new book, Palliative Care: Transforming the Care of Serious Illness. Palliative Care: Transforming the Care of Serious Illness is a whirlwind tour of the history of the hospice and palliative care movement and how it is reshaping the care given to those with serious illnesses. It is edited by Diane Meier, Stephen Isaacs, and Robert Hughes, and incorporates some of the very best works that the field has to offer. The book begins with Dr. Meier's original article on the "Development, Status, and Future of Palliative Care". Dr. Meier gives her readers the grand picture of how a small movement focused on the care of the dying developed into what we now know as palliative care. From the early work of Elisabeth Kubler Ross and Cicely Saunders, to more recent works from the National Consensus Project for Quality Palliative Care, Dr. Meier creates a timeline revealing the influences behind the fields rapid growth. She further describes the current state of the field, both successes and failures, and how it can continue to move forward through her policy recommendations. Dr. Meier's essay is followed by reprints of 25 influential works in the field of Hospice and Palliative Care, ranging from book chapters to journal articles. These seminal works cover a range of topics and serve as a nice complement to Dr. Meier’s overview. Here is a taste of the articles picked for the section titled "Efforts to cope with advanced illness": Hope (by Elisabeth Kübler-Ross) The Nature of Suffering and the Goals of Medicine (by Eric J. Cassell) The Nature of Suffering and the Goals of Nursing (by Betty R. Ferrell and Nessa Coyle) Death: “The Distinguished Thing” (by Daniel Callahan) The Philosophy of Terminal Care (by Cicely Saunders) Access to Hospice Care: Expanding Boundaries, Overcoming Barriers (by Bruce Jennings, True Ryndes, Carol D’Onofrio, and Mary Ann Baily) It was great to read these articles over again, as well as to see works that I previously overlooked. Take, for instance, the inclusion of Timothy Quill and Ira Byock's article Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids . This work focused on the use of palliative sedation to treat intractable suffering. The editors, on a truly brilliant move, also added a letter to the editor from a group of prominent physicians and ethicists expressing strong disagreement with the premise of Quill and Byock's article. This small addition stressed the importance of differing opinions, something that gets seemingly lost in many debates surrounding end-of-life care. If I had one minor criticism of the book, it would be that I was eager to read more content in the editor’s introduction for the reprinted articles. These introductions were generally only a paragraph in length, which I’m guessing made it difficult to fully describe the articles impact. I would have loved to be able to catch a glimpse of the inner thoughts of someone like Dr. Meier and how she viewed the importance of each one of these articles. What made them stand out? How did it change the playing field? Nevertheless, I remain thoroughly impressed by Palliative Care: Transforming the Care of Serious Illness. It makes a terrific read for those practicing in the field, and serves as a great resouce for trainees interested in Hospice and Palliative Medicine. ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: Palliative or Terminal Sedation?]() [Geripal Blog: "How should costs fit into the conversation about end-of-life care?"]() ### GeriPal Blog: Advance directives say “I’m not dead yet” Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-advance-directives-say-im-not-dead-yet/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-advance-directives-say-im-not-dead-yet/index.html.md) ###### Description: “Enough. The living will has failed, and it is time to say so.” So said Angela Fagerlin and Carl Schneider in 2004. “Living wills are still widely and confidently urged on patients, and they retain the allegiance of many. For these loyal advocates, we offer systematic proof that such persistence in error is but the triumph of dogma over inquiry and hope over experience.” Joann Lynn wrote an essay titled Why I Don’t Have a Living Will, saying, “I do not have a living will because I fear that the effects of having one would be worse, in my situation, than not having one. How could this be? A living will of the standard format attends to priorities that are not my own, addresses procedures rather than outcomes, and requires substantial interpretation without guaranteeing a reliable interpreter.” Thomas Pendergast said, “ advance directives are recorded by medical personnel more often but are not completed by patients more frequently. The process of recording them does not enhance patient-physician communication. When available, advance directives do not change care or reduce hospital resources. The most ambitious study of advance care planning, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments \[SUPPORT\], failed to show any change in outcomes after an extensive intervention.” Prominent figures in palliative care decried persistent research and health policy efforts to promote living wills, saying, “when have living wills ever been shown to do anything???!!!” And yet, after being thrashed to within an inch of death, two recent studies breathed life into advance directives. Before getting into the particulars of these studies, it’s important to understand how and why we came to have advance directives in the first place. Driven by the rise of the autonomy standard in medical decision making, two primary events led to the propagation of advance directives: highly publicized legal cases of young women (Karen Ann Quinlan and Nancy Cruzan) in a persistent vegetative state, and the AIDS epidemic among young gay men. The Cruzan case eventually made it to the Supreme Court, where justices affirmed the individual’s right to refuse life-sustaining treatment, but allowed states to set their own evidentiary standards for documentation. In response, patients began advocating for stronger protection of their right to self determination in the form of written or oral advance directives on a state by state basis. In California in the early 1980s, the wards of San Francisco General Hospital were filled with young gay men dying of AIDS. California law stipulated that relatives were the default health care proxy for these men. In many cases these men had become estranged from family members or simply preferred that their partners – who knew them best – guide decision making when they lost capacity. The national response to this movement toward protecting patientss right to self-control culminated in Congress’s passage of the Patient Self Determination Act in 1990, which mandated that hospitals ask all patients if they have an advance directive and offer information about them, but stopped short of mandating that they complete one. Two recently published studies provide a major challenge to the arguments of opponents of advance care planning, as applied specifically to older adults, by finding that: (1) older adults are completing advance directives; (2) many elders lose the ability to make decisions before death and need decisions made, creating a role for advance directives; and (3) advance directives match treatment to patient goals better than usual care. In an article in the New England Journal of Medicine published last month, Silveira and colleagues used after death interviews with next of kin from a national survey to describe the prevalence and use of advance directives around the time of death. Using data from next-of-kin for 3746 subjects age 60 and older who died between 2000 and 2006, they found: 43% of elders who died required a major decision about treatment at the end of life 70% of those patients who needed a decision made lacked the ability to make a decision 68% of patients who lacked the ability to make a decision and needed one made had an advance directive 97% of elders who requested comfort care received it 50% of elders who requested “all care possible ” to sustain life received it In the second article, released online first by the British Medical Journal, Detering and colleagues randomized 309 hospitalized Australian patients aged 80 and older to facilitated use of an advance care planning decision aid followed by completion of an advance directive, or usual care. Notable findings: Of the 154 elders randomized to the advance care planning intervention, only 4 patients declined the intervention. Satisfaction with the hospital stay was higher in the intervention group (93%) compared to the control group (65%). Of the 56 patients who died 6 months after enrollment: 25/29 (86%) in the intervention group had their end-of-life wishes followed, compared to 8/27 (30%) in the control group. This BMJ article by Detering was the subject of journal club in the UCSF Division of Geriatrics last month and the Program in Palliative Care this Thursday. A few of the take home points from our discussion: (1) the effective sample size for assessing the effectiveness of the intervention was small – 56 patients – highlighting the need to replicate this study in larger samples before jumping up and down; (2) the fact that so few Australian elders declined the advance care planning intervention implies it was acceptable to them – would Americans be as open? (3) overall satisfaction with the hospital stay improved dramatically with the advance care planning intervention, and this may be an incentive for hospitals with publicly reported satisfaction measures to incorporate advance care planning discussions into routine care; (4) nurses led the intervention – countering the argument following the failure of the nurse-led SUPPORT intervention that advance care planning must be done by physicians to be effective; and (5) a structured and facilitated decision aid helped people make decisions, and the structured discussion and aid method is better than the usual menu option with a lawyer we have in the US (remember the scene from Seinfeld – paraphrasing - lawyer asking George Costanza, “What if you have one eye, one leg, and you have to eat through a tube?” George, “Pull the plug!”). Do these studies convince you? Have advance directives been resuscitated? Did you ever doubt them? The movement toward advance directives was really spurred by challenges to the autonomy of younger patients (young women in persistent vegetative state, young men with AIDS), not older adults. Perhaps they are not the right mechanism for younger patients, who have not had the opportunity to experience life’s stages, and may have different potential for recovery from serious illness. But for older adults? A quote from the Silveira article: “The fact that so many elderly adults complete advance directives suggests that they find these documents familiar, available, and acceptable. Moreover, it suggests that elderly patients, their families, and perhaps their health care providers think advance directives have value.” Interestingly, Fagerlin (author of the Enough: Failure of the Living Will article) and Silveira (author of the NEJM study finding wide usage of advance directives among elders) are both at the University of Michigan. I wonder what they say to each other. ###### Link: [Visit Site]() ### Surgeon and Hospice Founder Accepts Hastings Center Cunniff-Dixon Physician Award Source: [HTML](https://cunniffdixon.org/stories/surgeon-and-hospice-founder-accepts-hastings-center-cunniff-dixon-physician-award/) Markdown: [Markdown](https://cunniffdixon.org/stories/surgeon-and-hospice-founder-accepts-hastings-center-cunniff-dixon-physician-award/index.html.md) ###### Description: Dr. Milch is the inaugural winner of the Hastings Center Cunniff-Dixon Established Physician Award for excellence in clinical care for patients near the end of life and national leadership in palliative care. In this video provided by The Hastings Center, Andy Baxter (Founder of The Cunniff-Dixon Foundation) and Thomas H. Murray, PhD (CEO of The Hastings Center) sit down with Dr. Milch to talk about his long standing work in palliative care. ###### Link: Visit Site Media ###### Provided By: The Hastings Center ###### Video: Sorry, you need to install flash to see this content. ### Patient Power Webcast: "America’s Problem with Facing End-of-Life Issues" Source: [HTML](https://cunniffdixon.org/uncategorized/patient-power-webcast-americas-problem-with-facing-end-of-life-issues/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/patient-power-webcast-americas-problem-with-facing-end-of-life-issues/index.html.md) ###### Description: The controversy behind end-of-life decisions is ever-present in our health system. Is it ethical to go against the wishes of a dying patient? When is end-of-life counseling necessary? Peter and Andrew probe into some of the unknowns, while addressing the controversy with Dr. Robert Martensen, Director of the Office of the National Institutes of Health. Dr. Martensen is author of “A Life Worth Living”, a guide for patients facing tough questions when confronted with serious illness. Don’t miss this provocative discussion as we explore some of the factors faced by health care professionals when working to help patients' families to make informed and ethical end-of-life decisions. We will also identify some of the complex issues that must be considered by doctors and hospitals adjoining the treatment of terminally-ill patients. ###### Link: [Visit Site]() Media ###### Video: ###### Related Resources: [NPR Audio Podcast: End Of Life Care in America, A Doctor's Diagnosis]() ### GeriPal: The Opposite of Love Source: [HTML](https://cunniffdixon.org/stories/geripal-the-opposite-of-love/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-the-opposite-of-love/index.html.md) ###### Description: The Opposite of Love Posted: 17 May 2010 The Emergency Department phoned my office right before lunch. I was on call for our general IM group, so when I was done with my morning schedule I walked across the street to the hospital. Greg, my partner's 38 year old patient, was a woodworker admitted with fever, chills, cough, a sharp pain in his right side, and a WBC of 18,000. On the chest x-ray, I saw what I expected: a right middle lobe infiltrate. What I didn't expect were the massive lymph nodes bulging between his lungs, pushing them outward into his chest wall. "Has anyone mentioned lymphoma to you?" I asked Greg. His face was gaunt, the pallor of his cheeks contrasting with his red flannel shirt. "Yeah, I’m pretty familiar with lymphoma," he said. "I’ve had all the radiation therapy my chest can take. My oncologist just told me we need to start on another chemotherapy regimen. This’ll be my third. The first two didn't shrink the tumors." "OK," I said. "Are you ready for more chemo?" "I don’t know," Greg said. "If the first two didn’t work, is this one going to do any better?" "Maybe, maybe not," I said. "But it sounds like you've thought about that." "Yes, I have," he said. We looked at each other. "You have a small pneumonia," I said. "I can give you a prescription for antibiotics that will help, assuming your air passages aren’t closed down by the tumors. But curing your lymphoma may not be so easy." "That's what I've been thinking," said Greg. A moment of silence. "How do you feel about that?" I asked. "Not great," he said. "Actually, I’m scared as hell." We talked. As it turned out, Greg realized he was probably going to die. He had not mentioned this to anyone, least of all his doctors. He was frightened, but overshadowing this was his dread of going through more treatment. I told him all the decisions were up to him, and that he should talk them over with his oncologist and his primary care physician, my partner. The whole conversation took about ten minutes. "I have to get back to my office," I said finally. "One thing before you go," said Greg. "I’ve had four different doctors for the last two years, but you’re the first one who’s talked to me about how I feel." "That's a shame," I said. I knew each of his doctors. They were good clinicians. But all of them were more comfortable with the technicalities of diagnosis and treatment than they were with their patients’ emotions. "It's a shame all right," said Greg. "But now that I'm clearer about my feelings, I think it'll be easier to make up my mind about what I want to do. Thanks." "It's a pleasure," I said. The next week my partner told me that Greg had decided on hospice. He lived for three months, then died comfortably at home. Talking with patients about their impending death is never simple. However, it’s easier if it’s done with a certain kind of love. This love is related to compassion, the willingness to suffer along with another human being in pain. A quiet joy can emerge when people suffer together like this. Medical training seems to have little to say about death, and even less to say about this kind of love. Common wisdom tells us that the opposite of love is hate. But that’s only true on the surface. Love and hate are two sides of the same coin, the coin of attachment. Humans are just as attached to the people they hate as to the people they love. Either way, they just can’t stop thinking and talking about each other. Look at the world of politics. In reality, the opposite of love is fear. Whereas love connects us, fear cuts us off from each other. Fear fosters abandonment, which can take many forms. Some are more obvious than others, but all are damaging. At times we abandon our patients by ignoring or rejecting them. More often, paradoxically, we abandon them to further treatment, treatment that may or may not extend their lives, never thinking to ask them how they feel about it. High costs can accrue from this thoughtlessness. These costs are not just economic, but emotional and spiritual as well. We need both delivery system reform and reimbursement reform in the US. Our financial incentives need to be realigned. But when our patients near the end of life, a deeper incentive calls. This call comes from love. This love, if we truly align with it, is strong enough to cancel out fear. This love helps us accept together what we can't overcome alone. We must heed this call, because even though it may summon us to witness terrible grief and loss, when we respond to it everyone has a chance to win. Ultimately, this deeper kind of love really has no opposite. There is nothing in this world that compares to it. It encompasses everything in life, including death. May we listen carefully for its quiet and constant voice. ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: Social Workers Are Awesome]() [Geripal Blog: Q&A with Jeff Gordon - Author of "A Death Prolonged"]() ### Geripal Blog: The breadth of life-sustaining treatment Source: [HTML](https://cunniffdixon.org/uncategorized/geripal-blog-the-breadth-of-life-sustaining-treatment/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/geripal-blog-the-breadth-of-life-sustaining-treatment/index.html.md) ###### Description: In a recent story in the New York Times, Katy Butler described her parents' experiences with illness, the health care system, and the decline of her mother's well-being in-step with her father's physical and cognitive decline. Butler's beautiful account of her parents' lives before the onset of illness and subsequent to her father's stroke, pacemaker placement, and progression to advanced dementia and frailty are moving in the human story alone. But what struck me in reading the story, and some of the hundreds of comments which were posted from readers, was that this story is not just about pacemakers, health care costs, and the age old conflict between the risks and benefits of medical interventions and appropriateness in individuals of a given age or level of frailty. A retired cardiologist commented that the pacemaker was not, as with a defibrillator, keeping Butler's father alive (in what Butler described as his final years in "purgatory") but was regulating a bradycardia which might otherwise have given him significant symptoms (although prior to the pacemaker placement, Butler noted he was asymptomatic). What I learned from this remarkable story was that a focus on pacemakers as something which could be perceived as a 'life-sustaining' intervention is too narrow a view of Butler's story. I have begun to question our medical and cultural perspectives of distinguishing between medical interventions which are procedural (such as device placement, CPR, surgery) and those which are pharmacologic. If one considers 'life-sustaining' treatment, one often encounters the standard list: CPR, mechanical ventilation, pressors, defibrillators, dialysis, etc. When we discuss 'end of life' care and 'advanced directives' we naturally primarily discuss significant interventions such as these. But medical illness, and an individual's experience of illness or decline, will often bring the individual to encounter the less procedural (eg pharmacologic) treatment modalities earlier. We generally don't question Jehovah's Witnesses' choice to avoid blood products. And we generally don't question a preference for 'no-code' in a patient with terminal cancer. The classic tension in choosing pharmacologic treatment or not in a life-death situation is with chemotherapeutics in patients with cancer. But reading Butler's article, I began to see her father's story as one not just about the appropriateness of a pacemaker and the ethics of when and how to turn one off. I began to see the story as the tug and pull between medical science/technology and 'natural death' (however a given individual defines it). As physicians, as practitioners of medicine, we have been trained to try our best to diagnose and treat illness, discomfort, debility. But where do we draw the line (the distinction) between what we think we should do medically for a patient, what medicine can scientifically do for a patient, and what a patient wants for his/her own life and death. Someone choosing to die without life support in the comfort of their home and after stopping extraneous medications which do not promote comfort (the usual hospice picture) can be seen as choosing a 'natural death.' But do we draw that distinction only at the, quote "end of life"? Do we discuss 'natural death' only with those who are 'approaching their final chapters?' What does natural death mean? All illness may not lead to death. But certainly many diseases and conditions, if untreated (or suboptimally treated) will lead to further morbidity and possibly death. Perhaps our patients who avoid medical care and medications for their hypertension and diabetes are telling us they want to live their life 'naturally' (with all the risk and future burdens of these conditions). We are quick to judge these patients as 'non-compliant', or perhaps more empathically 'needing more education, guidance, patient-centered direction.' But I think about my patient with angina and coronary artery disease who is knowledgeable and cognitively competent who chooses to live his life with yoga, herbals and holistic modalities. No aspirin, no beta blocker, no statin. Perhaps he, just like Butler's parents, is choosing his 'natural' course to life and death. And, thus, medications and procedures suddenly become one. How an individual defines life-sustaining could start with carvedilol and atorvastatin. I recognize at this point someone will undoubtedly point out to me that the risks and side effects of procedural interventions far outweigh those of most pharmacologic interventions, and that is why we tend to distinguish between a pacemaker and aspirin. As with all things geriatrics and palliative, there is no right or wrong answer. But the more I care for patients at different stages of their lives (whether a frail 66yo, a robust 85yo, a dying 73yo), the more I realize that I'm generally not the one who defines where living and dying blend and where 'natural death' begins (if 'natural death' is what my patient chooses). by: Helen Kao ###### Link: [Visit Site]() ### The Hastings Center Cunniff-Dixon Physician Awards 2010 Source: [HTML](https://cunniffdixon.org/stories/the-hastings-center-cunniff-dixon-physician-awards-2010/) Markdown: [Markdown](https://cunniffdixon.org/stories/the-hastings-center-cunniff-dixon-physician-awards-2010/index.html.md) ###### Description: Enjoy this short video produced by the Hastings Center, featuring interviews with the 2010 Hastings Center Cunniff-Dixon Physician awardees and information on this years nominations. We are excited for our second year of prizes! ###### Link: Visit Site Media ###### Provided By: The Hastings Center ###### Video: Sorry, you need to install flash to see this content. ###### Related Resources: [Surgeon and Hospice Founder Accepts Hastings Center Cunniff-Dixon Physician Award]() ### Geripal Blog: Atul Gawande New Yorker Article "Letting Go" Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-atul-gawande-new-yorker-article-letting-go/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-atul-gawande-new-yorker-article-letting-go/index.html.md) ###### Description: I want to draw people's attention to a fantastic new piece in the New Yorker by Atul Gawande titled, "Letting Go: What should medicine do when it can't save your life?" The stories told are raw and emotional, and offer glimpses into the struggles of patients with life-threatening illnesses, family caregivers, nurses, and physicians. The hospice nurse in the article is both empathetic and very direct at the same time, in a very Boston sort of way. I was trained by the physicians mentioned in the story (Block, Marcoux, Morris, Nowak, and even Gawande for a day). These are some of the best physicians in the world. And yet these stellar physicians - including Susan Block, perhaps the world's foremost communication specialist - struggle to talk with patients and family members about the one clinical event everyone is 100% going to experience: death. Gawande does an outstanding job weaving patient stories, research findings, and health policy with the inner perspectives of physicians and nurses. He gives the richest and most heartfelt account I have seen of the current state of the national convesation on death, difficult conversations, costs of care at the end-of-life, and quality of life. I recommend that everyone read it. Please share your thoughts in the comments. by: Alex Smith ###### Link: [Visit Site]() ###### Related Resources: [Letting Go: What Should Medicine Do When it Can't Save Your Life? (From The New Yorker)]() ### "I Grieve" - Peter Gabriel Source: [HTML](https://cunniffdixon.org/stories/i-grieve-peter-gabriel/) Markdown: [Markdown](https://cunniffdixon.org/stories/i-grieve-peter-gabriel/index.html.md) ###### Description: The grieving process is incredibly important for anyone trying to cope with and understand loss. This song, by Peter Gabriel, was written after his father died and is a very moving piece of art. Perhaps this kind of art that others have shared during their grieving process can only help us express our own. [(Download I Grieve]() or listen to the song on the you tube video below.) Lyrics: It was only one hour ago It was all so different then There's nothing yet has really sunk in Looks like it always did This flesh and bone It's just the way that you would tied in Now there's no-one home I grieve for you You leave me 'so hard to move on Still loving what's gone They say life carries on Carries on and on and on and on The news that truly shocks is the empty empty page While the final rattle rocks it's empty empty cage And I can't handle this I grieve for you You leave me Let it out and move on Missing what's gone They say life carries on They say life carries on and on and on Life carries on In the people I meet In everyone that's out on the street In all the dogs and cats In the flies and rats In the rot and the rust In the ashes and the dust Life carries on and on and on and on Life carries on and on and on It's just the car that we ride in A home we reside in The face that we hide in The way we are tied in And life carries on and on and on and on Life carries on and on and on Did I dream this belief? Or did I believe this dream? Now I can find relief I grieve ###### Link: Visit Site Media ###### Video: Sorry, you need to install flash to see this content. ### Geripal Blog: Length of Stay in Nursing Homes at the End of Life Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-length-of-stay-in-nursing-homes-at-the-end-of-life/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-length-of-stay-in-nursing-homes-at-the-end-of-life/index.html.md) ###### Description: One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in [JAGS by Kelly and colleagues]() (many of whom are geripal contributors, including Alex Smith and Ken Covinsky). The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital. The length of stay data were striking: the median length of stay in a nursing home before death was 5 months the average length of stay was longer at 14 months due to a small number of study participants who had very long lengths of stay 65% died within 1 year of nursing home admission 53% died within 6 months of nursing home admission [http://1.bp.blogspot.com/\_g6b7lckX2zE/THX7D3XuBpI/AAAAAAAABVI/fk7-z20ukqo/s1600/Screen+shot+2010-08-25+at+10.25.58+PM.png]() The authors also found that length of stay varied based on a number of demographic, social, and clinical factors. For instance: men died sooner after admission than women (men had a median length of stay of around 3 months versus 8 for women) married nursing home residents died sooner after admission than unmarried participants (an average of 4 months sooner) nursing home residents in the highest quartile of net worth died six months sooner than those in the lowest quartile. I had a chance to talk with the lead author, Anne Kelly, about the implications of these findings. Kelly told me "that even though this study doesn’t address why certain demographic and social factors lead to a shorter length of stay, it does look like people with greater social support at home have shorter lengths of stay when admitted to a nursing home." Kelly also explains that the findings of this study reinforce the idea that advance care planning needs to occur upon admission to a nursing home. In her words: "it's best to begin those discussions early on and readdress them frequently during their stay given that so many people are going to be there for only a brief time." I think these findings have broader implications for our community as well. For one thing, I think it should make us re-evaluate our priorities when thinking about where we put our clinical efforts. For instance, most palliative care consultations occur within hospitals, although most patients will die outside of the hospital setting. With the recent NEJM study on the [effectiveness of outpatient palliative care]() ([see here to learn more]()), maybe we should think of more effective ways in partnering with nursing home providers to manage the end-of-life needs of these patients. Sounds like fresh territory for a geriatrics and palliative care collaboration (hmmm, I wonder what we should call such an endeavor???) by: Eric Widera ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: "Hospice Upheaval"]() [Geripal Blog: Atul Gawande New Yorker Article "Letting Go"]() ### Geripal Blog: Advance Care Planning: A Paradigm Shift Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-advance-care-planning-a-paradigm-shift/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-advance-care-planning-a-paradigm-shift/index.html.md) ###### Description: What is the purpose of Advance Care Planning? I have been taught to view the goal as helping patients define what they would want done if they became seriously ill. But there is an important [article]() by [Rebecca Sudore]()and [Terri Fried]()that convinces me I should think about this very differently. Sudore and Fried propose a paradigm shift: Advance care planning is not aimed at prespecifying decisions. Rather it is aimed at helping patients and their families make the best possible in-the-moment decisions. Sudore and Fried note several serious problems with the traditional goals of advance planning. Most importantly, patients goals and preferences change as their health and circumstances change. One reason is that patients have a remarkable ability to adapt to their circumstances. For example, many well elders would say living with disability is unacceptable to them. However, once elders become disabled they find they can adapt, view their quality of life as good, and change their treatment preferences to reflect this. In this context, while advance directives can still be useful, they should be viewed as one of several sources of information that might be useful for in-the-moment decision making. What makes this article particularly useful are specific suggestions for what clinicians can do to help their patients prepare to make the best possible in-the-moment decisions. The two tables in the article are full of useful suggestions of what a clinician might consider saying to a patient. A few selected examples: To help motivate patients to prepare: "When patients talk with me and their loved ones about what would be important to them if they got sick, it helps them to keep a sense of control about their medical care and have piece of mind." To help clarify values: "Some patients say if they become so sick that they could not recognize or talk to their loved ones, they would want all possible treatments to prolong their life. Other patients say they would rather have care focused on comfort. What kind of person are you?" To clarify whether values have changed: "Your health has changed over time. Sometimes patients can get used to these changes and sometimes they can not. In the past you told me that ......" To establish whether the patient wants to give the surrogate leeway in decision making: "Having told me what is important to you, what if your surrogate finds it difficult to provide this for you?" or "What if, based on changes in your health, the doctors recommend something different from what you have told your loved one?" This is definitely a must read article. by: Ken Covinsky ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: Palliative or Terminal Sedation?]() [Geripal Blog: Q&A with Jeff Gordon - Author of "A Death Prolonged"]() ### 2011 Cunniff-Dixon Hastings Center Physician Awards Video Source: [HTML](https://cunniffdixon.org/uncategorized/2011-cunniff-dixon-hastings-center-physician-awards-video/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/2011-cunniff-dixon-hastings-center-physician-awards-video/index.html.md) ###### Description: Care for patients at the end of life has long troubled American medicine, not only in its failure to provide good palliative care, but also in the relationship between doctors and patients. Many efforts to remedy this situation have emerged: a growing and strengthening palliative care movement, better understanding of the situation of patients at the end of life, a sharper focus on the values and behavior of physicians in their care of the dying, and a more general effort to gain medical recognition that end-of-life care is just as important as care during all other phases of life. Great progress has been made, but there is still a distance to go. As the number and percentage of people who die from chronic and degenerative diseases increase, the physician skills and virtues necessary to provide good end-of-life care also increase. The aim of The Hastings Center Cunniff-Dixon Physician Awards is to foster those skills and virtues by providing financial prizes to those physicians, young and old, who have shown their care of patients to be exemplary, a model of good medicine for other physicians, and a great benefit in advancing the centrality of end-of-life care as a basic part of the doctor-patient relationship. ###### Link: Visit Site Media ###### Provided By: [The Hastings Center]() ###### Video: Sorry, you need to install flash to see this content. ###### Related Resources: [The Hastings Center Cunniff-Dixon Physician Awards 2010]() [2012 Hastings Center Cunniff-Dixon Physician Awards: Video highlighting the 2012 Awardees (4:31min)]() ### 2012 Hastings Center Cunniff-Dixon Physician Awards: Video highlighting the 2012 Awardees \(4:31min\) Source: [HTML](https://cunniffdixon.org/uncategorized/2012-hastings-center-cunniff-dixon-physician-awards-video-highlighting-the-2012-awardees-431min/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/2012-hastings-center-cunniff-dixon-physician-awards-video-highlighting-the-2012-awardees-431min/index.html.md) ###### Description: ![]() A pioneer in establishing best practices for palliative medicine and a specialist in pain management and spiritual care of cancer patients are among the five American physicians honored for improving the care of patients near the end of life. They were named recipients of the third annual Hastings Center Cunniff-Dixon Physician Awards. The awards were given by the Cunniff-Dixon Foundation, whose mission is to enrich the doctor-patient relationship near the end of life, in partnership with The Hastings Center. The awards were made in three categories: a senior physician category for leadership in end-of-life care, a mid-career physician category for longstanding commitment to serving patients and for leadership in palliative care, and an early-career physician category for serious commitment to the field and contribution through practical research or clinical work. The recipients, drawn from a national group of nominated candidates are, from left to right: Janet Bull, Michael Rabow, Justin N. Baker, Jason Morrow, and Theresa A. Soriano. Janet Bull, MD, chief medical director and principal investigator of Four Seasons, a nonprofit hospice and palliative care organization that serves the Hendersonville and Asheville regions of western North Carolina, received the senior physician award of $25,000. She has served as principal investigator of more than 30 clinical trials to establish best practices in hospice and palliative care. She has also designed an experimental course to train palliative care physicians and provides consulting programs in hospice, palliative care, and research. In addition, she has worked closely with the Palliative Care Association of Zambia to advance policy, education, and clinician training to promote palliative care throughout that country. Michael Rabow, MD, Professor of Clinical Medicine, University of California‐San Francisco; Director, Symptom Management Service, UCSF Helen Diller Family Comprehensive Cancer Care Center, received the mid-career physician award of $25,000. He developed the service, which is one of the first outpatient palliative care services in a comprehensive cancer center in the U.S. It includes an interdisciplinary team of clinicians from medicine, oncology, surgery, nursing, social work, psychology, pharmacy, and chaplaincy. Early-career awards of $15,000 each were given to three physicians: Justin N. Baker, MD, FAAP, FAAHPM, director, Division of Palliative and End-of-Life Care, an attending physician, Quality of Life Service, and director of the Hematology/Oncology Fellowship Program at St. Jude Children’s Research Hospital in Memphis, for outstanding leadership and research on palliative care for children. Jason Morrow, MD, PhD, medical director, inpatient palliative care, University of Texas Health Science Center at San Antonio, for his advocacy in expanding palliative care services and his passion for educating medical students, residents, and other physicians in clinical practices and ethics. Theresa A. Soriano, MD, MPH, director, Mount Sinai Visiting Doctor’s Program, Mount Sinai School of Medicine in New York, for her advocacy and leadership in caring for underserved patients and bringing primary and palliative care to those who are homebound.  “We commend the winners for their exceptional skill in palliative care and their leadership in bringing this care to diverse groups of patients,” said Thomas Murray, president of The Hastings Center. “They are making a difference to these patients and their families.” [Click here to view the full biographies of all the 2012 award recipients]() [Click here to view the nominations page for the 2013 Hastings Center Cunniff-Dixon Physician Awards]() Click Below to play the 2012 Awards Video ###### Link: Visit Site Media ###### Video: Sorry, you need to install flash to see this content. ###### Related Resources: [2011 Cunniff-Dixon Hastings Center Physician Awards Video]() [The Hastings Center Cunniff-Dixon Physician Awards 2010]() ### Geripal Blog: The Shortsighted Argument in Limiting Hospice Access Source: [HTML](https://cunniffdixon.org/stories/geripal-blog-the-shortsighted-argument-in-limiting-hospice-access/) Markdown: [Markdown](https://cunniffdixon.org/stories/geripal-blog-the-shortsighted-argument-in-limiting-hospice-access/index.html.md) ###### Description: It feels like every passing day brings with it more news of an aggressive campaign to reign in the cost of Medicare hospice spending. For instance, federal government investigations of hospices that enroll patients who live longer than 6 months have resulted in the death of one of the most important organizations in our field, San Diego Hospice ([as covered by Pallimed here]()). There have also been threats from those like the governor of Louisiana, Bobby Jindal, who attempted to make a case that eliminating Medicaid hospice care would save the state over a million dollars... ###### Link: [Visit Site]() ###### Related Resources: [Geripal Blog: "How should costs fit into the conversation about end-of-life care?"]() [Geripal Blog: "Hospice Upheaval"]() ### Geripal: The Long Term Care Insurance Con Game Source: [HTML](https://cunniffdixon.org/uncategorized/geripal-the-long-term-care-insurance-con-game/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/geripal-the-long-term-care-insurance-con-game/index.html.md) ![]()"You are getting older, and are concerned about the costs of nursing homes and long term care. So, you decide to get expensive long term care insurance to protect your family from these costs. The policy will pay some of the cost of long term care if you develop cognitive or physical disability. All you have to do is keep making payments on the policy until you have a need for services. But make sure you make the payments. If you don't, your policy gets cancelled, you lose all the money you put into premiums, and you get nothing when you need the services you thought you were paying for." ###### Link: [Visit Site]() ### Treating C.O.P.D. in the Elderly \(New York Times Health\) Source: [HTML](https://cunniffdixon.org/new-york-times-health/treating-c-o-p-d-in-the-elderly-new-york-times-health/) Markdown: [Markdown](https://cunniffdixon.org/new-york-times-health/treating-c-o-p-d-in-the-elderly-new-york-times-health/index.html.md) ![nytlogo152x23]() Which medications work best for older adults with chronic obstructive pulmonary disease? Doctors aren’t entirely sure: Despite the fact that C.O.P.D. is the third-leading cause of death, there is scant research on the comparative effectiveness of treatment options in seniors. But a study recently published in The Journal of the American Medical Association provides valuable new information. C.O.P.D. refers primarily to two conditions that compromise breathing: emphysema and chronic bronchitis. Nearly four million seniors have been diagnosed with the condition. For their new study, researchers in Ontario combed through records of all adults ages 66 and older with C.O.P.D. who had started taking two types of medications: long-acting beta agonists and inhaled corticosteroids. Long-acting beta agonists (sold under brand names like Foradil, Oxis, Serevent) help relax muscles around the airways in the lungs, allowing air to flow more freely. Inhaled corticosteroids (Flovent, Azmacort, Asmanex and others) act against inflammation and swelling in airways, making breathing easier. Clinical guidelines recommend that doctors begin treatment for C.O.P.D. with long-acting beta agonists (or another set of medications called long-acting anticholinergics, not studied in this report), then add other medications if necessary. But it has never been clear if this is optimal for older adults. Click here to [Read More]() ### Beth Israel pilot to let patients add notes to medical records Source: [HTML](https://cunniffdixon.org/articles/beth-israel-pilot-to-let-patients-add-notes-to-medical-records/) Markdown: [Markdown](https://cunniffdixon.org/articles/beth-israel-pilot-to-let-patients-add-notes-to-medical-records/index.html.md) [![Female-Doctor-with-Tablet]()]() Boston’s Beth Israel Deaconess Medical Center [**received a $450,000 grant**]() from The Commonwealth Fund this week to develop a program called OurNotes that allows patients to contribute to their medical records. The program is an extension of the well-known OpenNotes initiative and will include collaboration with a handful of other providers across the country. “This is really building for the future,” BIDMC Principal Investigator Jan Walker said in a statement. “We envision the potential capability of OurNotes to range from allowing patients to, for example, add a list of topics or questions they’d like to cover during an upcoming visit, creating efficiency in that visit, to inviting patient to review and sign off on notes after a visit as way to ensure that patients and clinicians are on the same page.” [Read More Here...]() ### Know the Hard Choices Prolonging Life Entails Source: [HTML](https://cunniffdixon.org/new-york-times-health/know-the-hard-choices-prolonging-life-entails/) Markdown: [Markdown](https://cunniffdixon.org/new-york-times-health/know-the-hard-choices-prolonging-life-entails/index.html.md) Virgie Divinigracia had the kind of death last month that most Americans say they want: at home, relieved of physical and mental pain, surrounded by those she loved, “a beautiful death” as those present described it. Alas, this is true for too few Americans. Most still die in costly medical facilities tethered to machines, often unable to communicate, in a futile attempt to prolong their lives. [Dr. Angelo E. Volandes](), the author of an enlightening new book, “The Conversation,” said that although Americans received some of the best health care money could buy, “they also experience some of the worst deaths in the developed world,” mainly because people failed to articulate what they wished for at the end of life, and doctors failed “to recognize that fixing specific problems may not fix the whole patient.” Mrs. Divinigracia’s experience is illustrative. At 88 and in need of full-time care after 10 years with Alzheimer’s disease, she developed acute kidney failure. Her doctor suggested dialysis. But after a clearheaded review of her prospects, her devoted husband and primary caregiver, Paul, and their son and daughter acknowledged that, had she been able to say so, she would not have chosen aggressive medical treatment that would only further diminish the quality of her remaining days. And so she lived to have an 89th birthday celebration with her family before deteriorating health prompted a call to hospice for help. By now, most people are aware of advance directives — living wills that detail the treatments wanted or not wanted when life hangs in the balance, and assignment of health care agents to speak for patients when they cannot speak for themselves. But as of 2010, only 26.3 percent of American adults had prepared such a document, according to a nationally representative [survey]() of 7,946 participants. Even those who have done so don’t necessarily understand what they have signed up for, nor have they discussed these matters with their doctors and had the document included in their health record. “An advance directive is just a piece of paper — that’s not enough,” said [Dr. Joan M. Teno](), a health policy expert at Brown University School of Public Health. “The doctor or nurse practitioner should talk with the patient and family about the goals of care and the patient’s wishes and preferences, then put a plan of care in place to insure that those preferences will be honored.” Doctors should be sure patients understand their prognosis, and should anticipate the problems likely to arise and “have the right medications and services in place” so patients nearing the end of life are not automatically shipped off to an intensive care unit and placed on ventilators, feeding tubes or dialysis, Dr. Teno said. As Dr. Atul Gawande put it in [his new book](), “Being Mortal,” “We pay doctors to give chemotherapy and to do surgery but not to take the time required to sort out when to do so is unwise.” Dr. Volandes, a staff physician at Massachusetts General Hospital in Boston, noted that “in the abstract, fighting every second of the way and pursuing aggressive life-prolonging interventions sounds admirable.” But he wants doctors, patients and families to consider the likely outcome of the fight and how much suffering it will involve. He recognizes that “there are no right and wrong decisions about medical care at the end of life” but insists that all decisions should be fully informed. To ensure that patients and families understand the options, he has developed a video tour of what medical interventions like ventilation, CPR or placement of a feeding tube look like, which often prompts a change of heart. As one patient put it, “It looks so different on television.” [The video,]() produced by [ACP Decisions](), a nonprofit group devoted to advanced-care planning, is licensed to health care providers and insurers who can show it to patients and families to facilitate shared decision making in planning for care at the end of life. In a randomized trial of the video’s effectiveness among 50 patients with advanced brain cancer, a quarter of patients in the control group who had only a verbal discussion about end-of-life care with their doctors chose life-prolonging care, half opted for limited medical care and only one-quarter chose comfort care. But none of those who saw the video opted for life-prolonging care, a handful chose limited medical care, and 92 percent decided on comfort care, Dr. Volandes reported. After watching the video, patients said they had a better understanding of their choices. However, even just a discussion with their doctors about goals for end-of-life care can often make a huge difference. The one-third of patients in a 2008 national Coping With Cancer [study]() who had such a discussion were less likely to undergo CPR, be put on a ventilator or be placed in an intensive care unit. Most enrolled in hospice, suffered less and were in better physical shape and better able to interact with others and for a longer time. Their survivors, too, fared better; six months after the deaths, they were markedly less likely to experience major depression. Options regarding end-of-life care should be discussed well before an emergency — or for those with dementia, during the early stages of mental decline. “The absolute worst time to contemplate decisions about medical care is when one is critically ill and in the hospital,” Dr. Volandes writes. The kinds of questions doctors should be asking: ■ What gives your life meaning and joy? ■ What are your biggest fears and concerns? ■ What are you looking forward to? ■ What goals are most important to you now? ■ What trade-offs or sacrifices are you willing to make to achieve those goals? Whoever is chosen as health care agent must understand the patient’s priorities and agree to honor them, regardless of what that person might want for himself. A strong backbone is needed to assure that the agent will advocate the patient’s wishes even if doctors or family members disagree. [Visit New York Times Health for the Complete Post]() ### The Trouble With Advance Directives Source: [HTML](https://cunniffdixon.org/new-york-times-health/the-trouble-with-advance-directives/) Markdown: [Markdown](https://cunniffdixon.org/new-york-times-health/the-trouble-with-advance-directives/index.html.md) The man had w![17span-master675]()ritten an advance directive four years ago, before his advancing [dementia]() had made communication difficult. He had been very specific. In case of a life-threatening condition, “he wanted comfort care only, no heroics,” said Dr. [Rebecca Aslakson](), a critical care anesthesiologist at Johns Hopkins Hospital in Baltimore. But last month an uncontrollable [nosebleed]() caused the 79-year-old to begin [vomiting blood](). The nursing home that cared for him sent him to a hospital, where doctors put him on a ventilator. They slowed the bleeding, but couldn’t stop it. After a week and two surgical procedures, the patient was transferred to Johns Hopkins. There, physicians stopped the nosebleed, performed a [tracheostomy]() (a procedure to create an opening in the throat that would permit long-term ventilator use) and placed a feeding tube in his stomach. Two weeks after that, a surgeon happened to find the patient’s advance directive in his medical chart. None of the other health care providers had noticed it, which meant they had all inadvertently violated it. Such missteps occur more commonly than most of us, with our carefully composed documents stored in drawers somewhere, would like to think. They help explain why researchers and medical staff working with patients near the end of life have grown increasingly disenchanted with advance directives, including living wills and powers of attorney for health care. [Read More]() ### Many seriously ill Americans lack access to palliative care Source: [HTML](https://cunniffdixon.org/articles/many-seriously-ill-americans-lack-access-to-palliative-care/) Markdown: [Markdown](https://cunniffdixon.org/articles/many-seriously-ill-americans-lack-access-to-palliative-care/index.html.md) Millions of Americans suffering from serious [illness]() lack access to care that could improve their quality of life by relieving [pain]() and other symptoms, a study finds. Access to so-called palliative care is greatest in the New England, Pacific and mid-Atlantic regions of the U.S., researchers report in the Journal of Palliative Medicine. Far fewer hospitals have palliative care programs in the Southern states. People who live near larger hospitals are also more likely to have access to palliative care - it's offered in 90 percent of hospitals with at least 300 beds but just 56 percent of hospitals with fewer beds. While variation in access to palliative care isn't surprising and mirrors what happens in many areas of medicine, the study findings help identify gaps in care that could be improved, said senior author Dr. Sean Morrison, a researcher in geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai in New York. "Considerable data now demonstrates that when patients receive palliative care in addition to traditional medical care, they have improved quality of life, greater satisfaction with their medical care, are less likely to be re-admitted to the hospital or have to visit an emergency department, and in certain diseases (i.e. cancer) have greater survival," Morrison said by email. Morrison and colleagues analyzed data from a variety of sources including the U.S. census and the American Hospital Association as well as from interviews with hospital administrators and program directors. In addition to hospital size, they found institutions' tax status was also a significant predictor of access to palliative care. [Read More]() ### Our View: End-of-life care talks key part of health picture Source: [HTML](https://cunniffdixon.org/articles/our-view-end-of-life-care-talks-key-part-of-health-picture/) Markdown: [Markdown](https://cunniffdixon.org/articles/our-view-end-of-life-care-talks-key-part-of-health-picture/index.html.md) Six years ago, a proposal to compensate physicians for talking to patients about their treatment in their last days was stripped from the Affordable Care Act after critics made dark predictions about “death panels” and government rationing of care to senior citizens. Last week, with little fanfare, the federal government announced that as of Jan. 1, it would begin paying doctors for these counseling sessions – giving millions the say in their own end-of-life treatment that they want and deserve. Nothing is currently stopping physicians from offering end-of-life consultations, of course. Some doctors provide the service without getting paid for the counseling time, and some private insurers already reimburse for it. But because Medicare covers 55 million people, making it the largest insurer at the end of life in the U.S., its decision to cover advance care planning is significant – and not just because private companies often follow Medicare’s lead. The move recognizes that people need to be involved in treatment decisions before they become seriously ill or unable to make their wishes known. Patients aren’t getting the care they want, according to a landmark 2014 Institute of Medicine report, [“Dying in America”](): Instead of dying at home, with measures to ease pain, Americans are receiving unwanted interventions and not enough comfort care. That said, there are also people who would want doctors to pursue more aggressive steps. And the new Medicare rule wouldn’t keep patients from expressing, in advance, their preference in favor of life-prolonging procedures. Read more here: http://www.pressherald.com/2015/11/05/our-view-end-of-life-care-talks-key-part-of-health-picture/ ### Choosing to make the most of every moment: An intimate view of hospice care Source: [HTML](https://cunniffdixon.org/uncategorized/choosing-to-make-the-most-of-every-moment-an-intimate-view-of-hospice-care/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/choosing-to-make-the-most-of-every-moment-an-intimate-view-of-hospice-care/index.html.md) [![iStock\_000038472342\_Large]()]() It’s Wednesday afternoon at Hospice Atlanta Center, and nurse Wendy Gleason works from a desk covered in jolly Disney paraphernalia, her Mickey Mouse earrings sparkling. Above her desk, a Walt Disney quote: “If you can dream it, you can do it.” Across the hall, inside an elegant library, a volunteer plays a beautiful*Pie Jesu* on a grand piano. Laughter rings out in the in-patient facility’s halls, as a cook delivers custom-ordered meals to patients. Minutes later, a doctor rushes to help ease a very ill patient’s pain. A chaplain helps a family grapple with devastating news. In the acute care wing, a young patient spends what may be their last days with family and friends. This is a place where life and death intersect in ways most of us have never seen. Because in hospice care, the aim is not to cure disease, but to help patients through the process of dying. “In most facilities and hospitals, the mindset is curative. Where in hospice it’s not curative, it’s palliative,” says Gleason. “Palliative means you’re not trying to cure the disease. You’re trying to manage the symptoms and improve quality of life.” For most of us, the thought of death and dying is difficult — even the idea of contemplating end-of-life care can be daunting. But November is National Hospice month, a good opportunity to bring awareness about hospice care to family and friends. Read more here: http://www.ajc.com/news/lifestyles/health/comfort-final-days-hospice-professionals-share-pow/nn3Ft/ ### Quebec to invest extra $10-million a year in palliative care Source: [HTML](https://cunniffdixon.org/articles/quebec-to-invest-extra-10-million-a-year-in-palliative-care/) Markdown: [Markdown](https://cunniffdixon.org/articles/quebec-to-invest-extra-10-million-a-year-in-palliative-care/index.html.md) Quebec is investing an additional $10-million a year to improve palliative care. One measure that will kick in next April will see the families of caregivers receive $1,000 to help look after their loved ones. Currently, 11 per cent of Quebecers who have chronic diseases such as cancer die at home surrounded by their loved ones. Health Minister Gaetan Barrette said he wants that number to jump to 20 per cent within five years. Read More: http://www.theglobeandmail.com/news/national/quebec-to-invest-extra-10-million-a-year-to-improve-palliative-care/article27286598/ ### New rule gives Medicare beneficiaries more control in end-of-life care Source: [HTML](https://cunniffdixon.org/stories/new-rule-gives-medicare-beneficiaries-more-control-in-end-of-life-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/new-rule-gives-medicare-beneficiaries-more-control-in-end-of-life-care/index.html.md) The [Centers for Medicare and Medicaid Services]()(CMS) has announced that Medicare will begin paying physicians and other practitioners to discuss advance care planning, effective Jan. 1, 2016. Advance care planning marks a critical step forward in ensuring that care delivery aligns with individual goals, values and preferences, resulting in better care, higher patient and family satisfaction and fewer undesired hospitalizations. In 2013, [nearly 70 percent]() of people who died in Tennessee were age 65 and older, making Medicare the largest insurer of health care provided during the last year of life. In fact, almost 30 percent of all Medicare dollars nationwide are paid during the last year of life, with more than 50 percent of that amount going to acute care hospitals. This money is often spent to keep a patient alive far past the hope of recovery. With physician involvement in advanced care planning allowed in the CMS final physician payment rule, seniors and their families will be able to control the type of care they receive and when they receive it. Read More: http://www.tennessean.com/story/opinion/contributors/2015/11/17/new-rule-gives-medicare-beneficiaries-more-control-end--life-care/75946390/ ### Caregivers recognized during hospice, palliative care month Source: [HTML](https://cunniffdixon.org/stories/caregivers-recognized-during-hospice-palliative-care-month/) Markdown: [Markdown](https://cunniffdixon.org/stories/caregivers-recognized-during-hospice-palliative-care-month/index.html.md) Golden LivingCenter-Columbus are joining other hospice care organizations across the nation in celebrating National Hospice and Palliative Care Month during November. The holiday recognizes the compassion and dedication of the caregivers who provide these important services. This year’s theme is Hospice. Helps. Everyone. With this theme, we are reminded of how hospice helps patients and family caregivers live as fully as possible bringing compassion, hope and dignity when they are needed most. Beyond the physical relief, hospice strives to help patients and families find emotional and spiritual comfort during this time. Every year, nearly 1.6 million patients receive hospice and palliative care in the United States. Hospice is a comprehensive, medically directed, team-oriented program that emphasizes pain control and symptom management rather than curative treatment for patients who no longer respond to routine medical care. Palliative medicine comes from the word palliation, which means “relieving or soothing the symptoms of a disease or disorder." Palliative care is for people of any age, and at any stage in an illness, and may help a patient to recover from an illness by relieving symptoms such as pain, anxiety, or loss of appetite during medical treatments or procedures. “Hospice treats the person, not the disease; focuses on the family, not the individual; and emphasizes the quality of life, not duration,” said Doug Williams, executive cirector of Golden LivingCenter-Columbus “Palliative medicine complements the hospice discipline as it allows the medical team to address physical, emotional, spiritual and social concerns that arise with advanced illness.” “With hospice and palliative care, many times a skilled nursing facility becomes a patient’s home, and our staff and volunteers become close members of the family,” he said. Read More: http://columbustelegram.com/print\_specific/columnists/caregivers-recognized-during-hospice-palliative-care-month/article\_3c603c1c-0c4c-589a-a397-64add3377ac9.html ### Hospice or palliative care volunteers find work rewarding Source: [HTML](https://cunniffdixon.org/stories/hospice-or-palliative-care-volunteers-find-work-rewarding/) Markdown: [Markdown](https://cunniffdixon.org/stories/hospice-or-palliative-care-volunteers-find-work-rewarding/index.html.md) Bill Brunstad was interested in becoming a hospice volunteer for years. He read a book about the highs and lows of working on the front lines. He even took a class offered by HSHS St. Joseph’s Hospital’s Hospice team. But seeing his friend Jim Dimock in the grocery store gave him added incentive. Dimock told Brunstad that being a hospice volunteer was like no other job. “He just looked at me and said, ‘It’s the best thing I ever did,’ ” Brunstad recalled. A year later, Brunstad was requested to be by Dimock’s bedside as an HSHS St. Joseph’s Hospital Hospice volunteer. Dimock’s health was failing and his family requested Brunstad’s presence. “I told Jim, ‘I don’t feel worthy,’ ” Brunstad said. “But it was just like him to put me at ease.” November is National Hospice and Palliative Care Month, and is an opportunity to honor the millions of nurses, home care aides, therapists, social workers and volunteers who make a remarkable difference for the patients and families they serve. It’s also an opportunity for education. Read More: http://chippewa.com/news/local/hospice-or-palliative-care-volunteers-find-work-rewarding/article\_f59ca73f-1740-5a09-9b09-df6e2f225ca7.html ### Impact of Early Palliative Care Varies Depending on Patient Age, Gender Source: [HTML](https://cunniffdixon.org/stories/impact-of-early-palliative-care-varies-depending-on-patient-age-gender/) Markdown: [Markdown](https://cunniffdixon.org/stories/impact-of-early-palliative-care-varies-depending-on-patient-age-gender/index.html.md) A recent study examined the impact of early palliative care (EPC) on quality of life for patients with advanced cancer. The researchers wished to determine the effectiveness of EPC for the various advanced cancer demographic groups, such as age and gender. The investigators, based at Massachusetts General Hospital and Harvard Medical School, Boston, compared patients in a metastatic non-small cell lung cancer (NSCLC) trial receiving EPC vs. those receiving traditional oncology care only. Data from 107 patients (57 female and 50 male) with metastatic NSCLC diagnosed from 2006 through 2009 were reviewed. Quality of life was measured via a record of patient mood after 12 weeks (utilizing Hospital Anxiety and Depression Scale \[HADS\] and Patient Health Questionnaire 9) and also the Trial Outcome Index (TOI). The researchers saw little difference in outcomes for older and female patient groups, but younger patients who received EPC as a complement to their oncology care reported a lower rate of depression (TOI mean of 49.43 vs. 62.04). Read More: http://www.oncologynurseadvisor.com/daily-oncology-news/early-palliative-care-impact-patient-age-gender-risk/article/457050/ ### How to ensure people get end-of-life health care they want Source: [HTML](https://cunniffdixon.org/stories/how-to-ensure-people-get-end-of-life-health-care-they-want/) Markdown: [Markdown](https://cunniffdixon.org/stories/how-to-ensure-people-get-end-of-life-health-care-they-want/index.html.md) My mom paid a painful price for not completing an advance directive about her preferences for end-of-life medical care. She was an intelligent and organized woman who had everything in her and my dad’s life planned out and written down. She even drafted her own obituary. Ironically, she never discussed her end-of-life care goals with my father or her physician son (me), preferring to talk about “more pleasant subjects.” As a result, after she developed colon cancer at age 86, my dad and I had to figure out how to treat her post-surgical medical complications of heart and renal failure. She died in hospice care after prolonged, unbearable and unnecessary suffering. It broke both my dad’s heart and mine. Unfortunately, my mother’s story is all too common. Nearly one out of four older Americans (24 percent) say that either they or a family member have experienced excessive or unwanted medical treatment, the equivalent of about 25 million people, according to a poll conducted last year by Purple Strategies. A key reason for this problem is only about one out of six Americans (17 percent) say they’ve had discussions about their end-of-life health care goals, preferences and values with a doctor or other health care provider, according to a recent Kaiser Health Tracking Poll. Evidence-based research overwhelmingly shows the need for more and higher-quality doctor-patient conversations about the patient’s health care goals, preferences and values. The report “Dying in America,” by the Institute of Medicine noted that: “Most people nearing the end of life are not physically, mentally, or cognitively able to make their own decisions about care … The majority of these patients will receive acute hospital care from physicians who do not know them. As a result, advance care planning is essential to ensure that patients receive care reflecting their values, goals, and preferences.” Read More: http://www.eastvalleytribune.com/active\_adults/article\_b2e97a44-9e06-11e5-bbb5-2bc1bf3f64a8.html ### A Palliative Care Fellow’s Perspective on Physician-Assisted Death Source: [HTML](https://cunniffdixon.org/stories/a-palliative-care-fellows-perspective-on-physician-assisted-death/) Markdown: [Markdown](https://cunniffdixon.org/stories/a-palliative-care-fellows-perspective-on-physician-assisted-death/index.html.md) I’ll be honest. When I started my fellowship in palliative care 4 short months ago, I had not seriously considered the possibility that one day I would have a patient ask me whether I would prescribe them a medication to end their life. Of course I was aware of the Oregon experience, but living in California where I completed both medical school and residency had sufficiently inured me to this idea. But with the signing into law in California last month of the End of Life Option Act, I have started to feel troubled by this question: would I or would I not prescribe? I recently spoke with my old babysitter who cared for me early on in childhood, a wonderful elderly Honduran woman now living in Maryland who I had not spoken with in over a decade. When I updated her on my career plans in palliative care, assuming she would have no context, I was surprised to hear her quickly respond about a recently watched TV program about doctors helping terminally ill patients die in Europe and Oregon. In clinic last week, when I asked a new patient what his plans would be if his health were to deteriorate from his metastatic cancer, he said, “Oh, that new physician-assisted suicide law.” I have already had 5 patients ask me for information on physician-assisted death in California. Anecdotally, people are talking about this new law and they are associating it with palliative care. As a new face in palliative care, I have found myself deeply affected by these initial requests for more information about assistance with death. But what I have noticed in the field is that before this law was in place, we were comfortable looking the other way, as there were many issues that were considered a bigger priority. And I have also sensed a real unease with physician-assisted death. As I’ve come to understand, many palliative care practitioners have been afraid that any association with this law would further cement the misconception that palliative care is only about death -- even as the field has fought so hard to change its image in the national conscience as a focus on life and living well at any stage of a serious illness. With our aging population and higher burden of chronic diseases, the need for palliative care has never been greater, and yet we have all had patients decline our services because of the death stigma. As one palliative care MD I spoke with put it, “We are already thought of as the death squad. If we start prescribing a lethal pill, will we be?” In [Oregon](), only 0.3% of people that die are utilizing physician-assisted death. Another worry is that we have expended a significant amount of political will on an end-of-life option for the 1% when there is still so much need to expand inpatient and outpatient palliative care services for the 99%. Read More: http://www.geripal.org/2015/12/palcare-fellows-perspective-assisted-death.html ### Untitled Source: [HTML](https://cunniffdixon.org/stories/1246/) Markdown: [Markdown](https://cunniffdixon.org/stories/1246/index.html.md) Scotland is recognised as providing world-leading palliative care. Children’s Hospice Association Scotland (CHAS), as the only hospice service in Scotland for babies, children and young people, is committed to providing the best standard of care to those who need it. The need for holistic palliative care for under-25s, that supports their health, social and emotional needs, was strengthened earlier this month when health secretary Shona Robison launched the findings from the Children in Scotland requiring Palliative Care report (ChiSP). The study was undertaken by the University of York on behalf of the Managed Service Network for Children and Young People with Cancer and CHAS, and gives vital figures on the number of babies, children and young people in Scotland with palliative care needs, and also their needs and those of their families. It is the first time such an in-depth research project of this nature has been carried out in Scotland and the results are fundamental in helping to ensure every affected family across the country has access to care as and when it is needed. The report shows that in 2013-14 there were 6,661 under-25s with a life-shortening condition, compared with 4,334 in 2003-4. The increase is due to a number of factors including advances in medicine, with many children now living longer than previously expected. The study also highlights the need for improved awareness, access to and availability of palliative care services for under-25’s. Our experiences and those gathered from our integrated working with the NHS, local authorities and other health and social care providers have indicated that more needs to be done to reach a growing number of families whose children may benefit from more accessible palliative and end of life care. Read More: http://www.scotsman.com/news/pat-carragher-palliative-care-needed-more-than-ever-1-3972582 ### Concurrent Hospice Care With Chemotherapy, Radiation Therapy Increasing Among Veterans Source: [HTML](https://cunniffdixon.org/news/concurrent-hospice-care-with-chemotherapy-radiation-therapy-increasing-among-veterans/) Markdown: [Markdown](https://cunniffdixon.org/news/concurrent-hospice-care-with-chemotherapy-radiation-therapy-increasing-among-veterans/index.html.md) Receipt of hospice care concurrently with chemotherapy or radiation therapy has increased among veterans dying from cancer without reduction in receipt of [cancer]() therapy, according to a recent study published online ahead of print in *Cancer*.1 Researchers led by Vincent Mor, PhD, of the Providence Veterans Affairs (VA) Health Administration Medical Center in Rhode Island conducted a retrospective cohort study of veteran decedents with cancer from 2006 to 2012, analyzing for hospice and cancer treatment through VA and Medicare administrative data. “Unlike Medicare, the VA health care system does not require veterans with cancer to make the ‘terrible choice' between receipt of hospice services or disease-modifying chemotherapy/radiation therapy,” the authors noted. They defined concurrent care as days in the last 6 months of life during which veterans received both hospice and chemotherapy/radiation therapy. They found that receipt of concurrent care increased from 16.2% to 24.5%, with the proportion of veterans receiving chemotherapy or radiation therapy remaining stable at about 45% and the proportion of those who received hospice increasing from 55% to 68%. Read More Here: http://www.cancertherapyadvisor.com/general-oncology/veteran-cancer-concurrent-hospice-chemotherapy-radiation-treatment-risk/article/460068/ ### Every Pediatric Hospital Should Offer A Palliative Care Program Source: [HTML](https://cunniffdixon.org/uncategorized/every-pediatric-hospital-should-offer-a-palliative-care-program/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/every-pediatric-hospital-should-offer-a-palliative-care-program/index.html.md) When I tell people that I study palliative care for children, I usually hear something like, "You mean taking care of children who die?" It is hard for most people to fathom palliative care for children. The term palliative care often brings to mind images of sick and dying adults. It IS sad to see any child sick, and it is devastating to see a child die. But what many people may not know is that palliative care is really about making the most of life. Palliative care is as much about supporting life as it is about ensuring the best possible death. So what does palliative care really mean? The [National Hospice and Palliative Care Organization]() proclaims that [palliative care]()helps people "facing serious or life-limiting illness to live as fully as possible, surrounded and supported by family and loved ones." This sentiment is echoed by the World Health Organization's definition which [starts](), "Palliative care is an approach that improves the quality of life of patients and their families..." In my work, palliative care means focusing on relieving the physical, psychological, social and spiritual impact of illness. For a child with cancer, that could mean having a doctor with expertise in controlling pain who prioritizes minimizing her terrible bone pain. Or it could mean having regular home visits from a nurse so that parents of four children can spend more time with their family and less time traveling to and from the hospital. Palliative care provides counseling to the depressed and anxious sibling of a child dependent on a breathing machine. Palliative care acknowledges and supports religious, spiritual, and non-western approaches to enhancing health. Some people may equate palliative care with dying patients because the terms hospice and palliative care are often used together. These two terms have important differences. Hospice is an insurance-driven term used with people predicted to live less than six months. Palliative care describes a holistic approach to care for anyone with serious illness. Read More: http://www.huffingtonpost.com/kelly-michelson/every-pediatric-hospital\_b\_8822230.html ### Blue Cross expands benefits for end-of-life care Source: [HTML](https://cunniffdixon.org/news/blue-cross-expands-benefits-for-end-of-life-care/) Markdown: [Markdown](https://cunniffdixon.org/news/blue-cross-expands-benefits-for-end-of-life-care/index.html.md) The state’s largest health insurer this week will begin offering some of the newest and most comprehensive end-of-life benefits in the nation, aiming to prod patients and health care providers to discuss death openly and expand services to help people live out their last days. The move by Blue Cross Blue Shield of Massachusetts comes as a growing number of health organizations put more emphasis on how patients are treated at the end of life by providing and paying for care that is more in line with patient wishes. Most Americans, for example, say they want to die at home, but most still die in hospitals and other institutions, according to several studies. And while the primary goal is not cost control, the effort also has the potential to lower health care spending by giving patients more options to replace hospital care with less expensive — and often preferable — alternatives, such as hospice and home care. Medical care at the end of life can be expensive; a 2010 study found that 25 percent of all Medicare payments go toward the 5 percent of people in the last year of their lives. “The industry is now starting to take this seriously,” said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center. “The industry now not only understands the issues , but understands there are concrete things they can and need to do, and Blue Cross is showing us how to get started.” As of Jan. 1, Blue Cross Blue Shield of Massachusetts, with 2.8 million members, will pay for more counseling sessions between providers and patients to discuss end-of-life care and expand access to hospice services. It is also developing a home care program that will be launched later in 2016. Read More Here: https://www.bostonglobe.com/business/2015/12/27/blue-cross-expands-benefits-for-end-life-care/5Uduttll3fG3ARVZkktP8I/story.html ### Palliative care improves care quality, reduces costs for advanced cancer patients with comorbidities Source: [HTML](https://cunniffdixon.org/stories/palliative-care-improves-care-quality-reduces-costs-for-advanced-cancer-patients-with-comorbidities/) Markdown: [Markdown](https://cunniffdixon.org/stories/palliative-care-improves-care-quality-reduces-costs-for-advanced-cancer-patients-with-comorbidities/index.html.md) Patients with incurable cancer and numerous other serious health conditions who consulted with a palliative care team within two days of hospitalization had significant savings in hospital costs, according to a new study led by researchers at the Icahn School of Medicine at Mount Sinai. Published today in the January issue of the journal *Health Affairs*, the study also determined that the higher number of serious coexisting conditions patients had, the greater reduction in direct hospital costs. While previous studies have shown the link between palliative care and lower costs, this is the first study to examine whether the effect of palliative care consultation varies by the number of co-existing chronic conditions. Researchers compared a treatment group of advanced cancer patients with numerous serious health conditions (also known as comorbidities) from six hospitals who were seen by a palliative care team with a separate group who received usual care. Findings indicated that patients from the treatment group on average had a 22 percent reduction in costs compared to the group that did not receive palliative consultation. Data showed that patients with the highest number of comorbidities had up to a 32 percent reduction in costs. The study's findings suggest that early palliative consultations with the sickest patients may decrease unwanted aggressive end-of-life care, as well as shorten length of stays in hospital. Palliative care is a team-based specialty (incorporating medicine, nursing, social work and chaplaincy) focused on improving quality of life for people with serious illnesses by adding a layer of support for patients, their families, and health care providers. It is provided in conjunction with all other appropriate medical treatments, including curative and life-prolonging therapies. Programs using palliative care consultation teams have rapidly expanded in recent years. Today, over 90 percent of medium-size to large U.S. hospitals now have palliative care teams. "We already know that coordinated, patient-centered palliative care improves care quality, enhances survival, and reduces costs for persons with cancer," said R. Sean Morrison, MD, Director of the National Palliative Care Research Center and Professor of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai and lead author of the study. "Our latest research now shows the strong association between cost and the number of co-occurring conditions. Among patients with advanced cancer and other serious illnesses, aggressive treatments are often inconsistent with patients' wishes and are associated with worse quality of life compared to other treatments. It is imperative that policymakers act to expand access to palliative care." Read More Here: http://www.news-medical.net/news/20160107/Palliative-care-improves-care-quality-reduces-costs-for-advanced-cancer-patients-with-comorbidities.aspx ### New year brings chance to have tough conversations Source: [HTML](https://cunniffdixon.org/uncategorized/new-year-brings-chance-to-have-tough-conversations/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/new-year-brings-chance-to-have-tough-conversations/index.html.md) Approximately 2.5 million people will die in the United States in the new year. Of that number, over three-fourths will very likely be over the age of 65. This makes Medicare the largest insurer of health care during the last year of life for an extremely large number of individuals. In 2015, Medicare proposed payment to physicians and other qualified providers who engage in face-to-face, end-of-life care discussions. Readers may recall that a similar proposal was first made before the passage of the Affordable Care Act although it was shot down at that time after being described as allowing for the establishment of “death panels.” After many attempts to implement this measure, it appears that the final new Medicare rules will include this provision and will take this month. Although dollar amounts for reimbursement have not yet been established, this development is encouraging. It reflects a growing recognition that having difficult end-of-life discussions with medical providers and loved ones can provide many important benefits and should be encouraged. All adults are encouraged to execute estate planning documents, which includes advanced directives. Advanced directives identify a decision-maker to make decisions about what kind of medical care you will receive if you are unable to make your own decisions. Read More Here: http://www.nhbr.com/January-8-2016/New-year-brings-chance-to-have-tough-conversations/ ### Ascension, University of Pennsylvania study EHR algorithms for palliative care Source: [HTML](https://cunniffdixon.org/uncategorized/ascension-university-of-pennsylvania-study-ehr-algorithms-for-palliative-care/) Markdown: [Markdown](https://cunniffdixon.org/uncategorized/ascension-university-of-pennsylvania-study-ehr-algorithms-for-palliative-care/index.html.md) To help clinicians understand when palliative care orders might be most appropriate, Ascension Health is participating in an National Institutes of Health-funded study run by University of Pennsylvania researchers to evaluate electronic health record-prompted automation of palliative care consult orders in the acute care setting. The partnership will enable the Penn researchers and care teams at 11 Ascension facilities to ascertain when, based upon criteria in the EHR, palliative care consult orders can be considered the default. The study will look at patients with end-stage renal disease who are on dialysis; patients with COPD who are either oxygen-dependent or who have been hospitalized two or more times in a 12-month span; and patients with advanced dementia admitted from a long-term care facility or prior placement of a surgical feeding tube or two or more additional hospitalizations in the past 12 months. Lynn Hollar, senior clinical analyst lead for Ascension Information Services Clinical Information Systems and Ascension data architect Suzanne Parra will present the goals of the study, Palliative Care: Using the EHR for Patient Care, at HIMSS16 in Las Vegas next month. "When we started looking at this, there was really nothing in an EHR that was an algorithm like we developed that said 'Identify this patient as being eligible for palliative care,'" she said. Yet, quantifying some of the factors that may determine whether palliative care is indicated can be particularly vexing for clinicians and, what’s more, palliative care is often mistakenly overlooked entirely. Read More Here: http://www.healthcareitnews.com/news/ascension-university-pennsylvania-study-ehr-algorithms-palliative-care ### In India, Dispensers of Balm Travel to Death’s Door Source: [HTML](https://cunniffdixon.org/new-york-times-health/in-india-dispensers-of-balm-travel-to-deaths-door/) Markdown: [Markdown](https://cunniffdixon.org/new-york-times-health/in-india-dispensers-of-balm-travel-to-deaths-door/index.html.md) A white van coursed through narrow roads along the monsoon-soaked coastline of Kerala, a state in southwestern India. Inside, Radha Upasarna, a volunteer, and two nurses looked over the roster of patients they would visit, most of whom had cancer or heart disease or were paraplegic. As they bumped along through the area’s villages, the women shared snacks, stopped for roadside chai, and sang film songs in Malayalam, Kerala’s official language. Around midday the van parked outside a whitewashed home where four out of the five members of the family there were chronically or terminally ill. As they did at each home, Upasarna and the nurses quickly got to work: they checked for bedsores, filled prescriptions, delivered kits of lentils and rice, and often just listened to stories. Bolstered by pillows on a daybed in the living room, Alikoya Karathattya, a snowy-haired 62-year-old was in high spirits, despite recovering from a recent chemotherapy treatment. Karathattya supported the family by driving a motorized rickshaw until he suffered a stroke in 2008; shortly afterward, his bladder cancer was diagnosed. His daughter Semina, a 34-year-old single mother, was receiving chemotherapy for cancer of the cheek, and his wife, Ayshabhi, was trying to control her diabetes, a widespread [problem]() in Kerala. Upasarna, a tiny woman wrapped in a cotton sari, sat at Karathattya’s bedside, holding his hand and assessing his pain. Working with a nonprofit in the Ernakulum district called Apium, she is one of 15,000 volunteers in Kerala who assist a network of physicians and nurses in extending palliative care to tens of thousands of people who are incurably ill, bedridden or nearing the end of their lives. Upasarna said this work was not only a service to her community, but a way to overcome the loneliness she experienced after her husband died last year. “It doesn’t feel like work,” she said. “It’s just something I want to do.” Volunteers like Upasarna are the linchpin in Kerala’s palliative care system — one that was singled out as “a [beacon of hope]()” in The Economist’s “Quality of Death” study in 2010. Kerala’s achievement is especially significant at a time when richer Indian states and wealthy countries like the United States are struggling with the same challenge: How can health systems offer the possibility of a dignified death to everyone? Most people want to die the same way — pain-free and [at home](), surrounded by family. But in reality, most people in high-income countries die in a hospital, while in many lower-income countries they suffer in pain without medicine or facilities. Countries take different approaches to their chronically or terminally ill. In Britain, ranked highest [this year]() in The Economist’s “Quality of Death Index,” the government has invested $703 million on palliative care. In the United States, starting this year under the Affordable Care Act, doctors [will]()be paid for time spent in conversations with patients about end-of-life care. And in Uganda, the health system[has invested]() in nurses, instead of doctors, for pain management and hospice care. “It’s the universal experience,” said Ellen Goodman, co-founder of [The Conversation Project](), an organization that guides people to talk about end-of-life decisions and pain management ([pdf]()). “When you get this right, you get something big right.” Read More Here: http://opinionator.blogs.nytimes.com/2016/01/12/in-india-travelling-dispensers-of-balm-at-deaths-door/ ### Hospice Care, Rather Than Aggressive Treatment, Found Better for End-of-Life Source: [HTML](https://cunniffdixon.org/news/hospice-care-rather-than-aggressive-treatment-found-better-for-end-of-life/) Markdown: [Markdown](https://cunniffdixon.org/news/hospice-care-rather-than-aggressive-treatment-found-better-for-end-of-life/index.html.md) Families may be more satisfied with end-of-life care for loved ones dying of cancer when treatment is focused on comfort rather than aggressive treatment and provided outside of a hospital, a U.S. study suggests. When patients received at least three days of hospice care focused on comfort and quality of life, 59 percent of their loved ones thought their treatment was excellent, compared with just 43 percent when patients received little or no hospice care, the study found. At the same time, family members of cancer patients admitted to an intensive care unit (ICU) in the last month of life reported excellent care just 45 percent of the time, compared with 52 percent when patients didn’t receive this type of aggressive treatment. “Interventions should focus more on increasing early hospice enrollment and decreasing ICU admissions and hospital deaths,” said lead study author Dr. Alexi Wright of Harvard Medical School and Dana-Farber Cancer Institute in Boston. “The best way to do this is to encourage patients, physicians and family members to talk about their end-of-life wishes,” Wright added by email. Many patients with advanced cancer receive aggressive medical care during their dying days even though growing evidence suggests that high-intensity treatments may not be associated with better quality of life or outcomes for patients, or an easier bereavement for the loved ones they leave behind, Wright and colleagues report in JAMA. For the current study, researchers interviewed family members and close friends of 1,146 patients aged 65 and older who died of lung or colorectal cancers. In most patients, the cancer had spread beyond the original location to other tissue and organs. Read More Here: https://www.yahoo.com/health/hospice-care-rather-than-aggressive-treatment-170358118.html ### ED-Initiated Palliative Care Can Improve Quality of Life Source: [HTML](https://cunniffdixon.org/articles/ed-initiated-palliative-care-can-improve-quality-of-life/) Markdown: [Markdown](https://cunniffdixon.org/articles/ed-initiated-palliative-care-can-improve-quality-of-life/index.html.md) Despite the fact that visits to the emergency department (ED) are common for patients with advanced cancer, delivery of palliative care is not standard within most EDs. A new study published in JAMA Oncology, suggests that ED-initiated palliative care consultation improved quality of life (QOL) for patients with advanced cancer and does not appear to shorten survival. The impact of ED-initiated palliative care on depression and healthcare utilization is not as clear and deserves further study. Corita R. Grudzen, MD, MSHS, of New York University, and colleagues conducted the single-blind, randomized clinical trial of ED-initiated palliative care consultation in 136 patients with advanced cancer versus usual care from June 2011 to April 2014 at an urban academic ED at a quaternary care referral center. “Although the availability of palliative care services continues to increase, consultation typically does not occur until a week into a patient’s hospital stay,” the authors wrote. “Thus, the ED presents a key decision point at which physicians set the subsequent care trajectory during a hospitalization.” Study subjects were adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by a palliative care provider, and spoke English or Spanish. They were randomized to palliative care consultations intervention (69 patients), and usual care (67 patients). Among the patients in the intervention, 41 died by the 1-year mark, as did 44 of the 67 patients who received usual care. The palliative care consultation intervention was associated with increased QOL scores from study enrollment to week 12 (average increase of 5.91 points in the intervention group versus an increase of 1.08 in the usual care group). Median survival was longer for patients in the intervention group (289 days) compared with the usual care group (132 days), but the difference was not significant, most likely because of the highly variable length of survival in the study groups. Read More Here: http://www.ajmc.com/newsroom/ed-initiated-palliative-care-can-improve-quality-of-life ### How to Talk to Your Children about End-of-Life Care Source: [HTML](https://cunniffdixon.org/stories/how-to-talk-to-your-children-about-end-of-life-care/) Markdown: [Markdown](https://cunniffdixon.org/stories/how-to-talk-to-your-children-about-end-of-life-care/index.html.md) This period of time can be uncomfortable for all – which is why many families choose not to have the “[tough conversation]()” about what the next steps are for a parent’s care. But, now is the time to talk to your children about end-of-life care. Learn more about how to get your children involved in this conversation. ##### Talking to Your Children about End-of-Life Care There are numerous resources available to adult children who are looking to have the [tough conversation with their parents about end-of-life care](), but there aren’t many resources available to proactive parents who want to have that conversation with their children. So, what should you do if you’re having difficulty speaking with your children about end-of-life care? Tim Prosch, author of “[The Other Talk: A Guide to Talking with Your Adult Children about the Rest of Your Life](),” recommends [focusing on the following](), to get the conversation started with your family: ###### 1. Finances Let your children know about the costs of – and how you’re [preparing to pay for – long-term senior care](). ###### 2. Health Talk with your family about [any health issues you’re having]() and whether or not you plan on designating your child an advocate for your health and medical care in the future. ###### 3. Housing Let your children know about whether or not you [plan on moving out of or staying in your home](), and if so, which type of senior care or housing you are most interested in at this time. ###### 4. Planning Talk with your family about your end-of-life plans and [prepare them with the necessary healthcare and financial documents]() that they will need to carry out your plan. Read More Here: http://www.aplaceformom.com/blog/1-26-16-talk-to-children-about-end-of-life-care/ ### When Your Loved One Is Ready for Hospice Care - and You Aren't Source: [HTML](https://cunniffdixon.org/stories/when-your-loved-one-is-ready-for-hospice-care-and-you-arent/) Markdown: [Markdown](https://cunniffdixon.org/stories/when-your-loved-one-is-ready-for-hospice-care-and-you-arent/index.html.md) Many painful emotional issues face family members and friends when a loved one becomes terminally ill. These include communicating the diagnosis to others; overcoming denial that the person is, in fact, near death; feeling the need to "be strong" and hide their sadness for the benefit of the patient and others; dealing with anticipatory grief; handling the physical and emotional exhaustion of intensive caregiving; and deciding when or whether to engage hospice care services. I want to share the experiences I had near the end of my beloved Romanian soulmate's life. First of all, I was in denial. Even though Ed's medical team at his long-term care facility told me it was likely that he would pass away within six months, I continued behaving as though he would live another year or two, or even more. I even did extensive long-term financial planning to make sure he wouldn't run out of money if he lived another three to five years. I did eventually overcome my denial and decided to call in a hospice organization. But the very word "hospice" scared me. I was frightened just to look at the marketing materials from the hospice director. I felt as if ordering hospice care for Ed would be tantamount to signing his death warrant. I knew that was ridiculous, but that's how I felt. I delayed the call for weeks, telling myself he didn't need it quite yet. The truth was that I wasn't able to deal with it quite yet. Seeing how weak and frail Ed was, I finally felt compelled to take action. I consulted Dr. Doug Smucker, a colleague who was a family physician at the University of Cincinnati and who was specialized in end-of-life care. I had a million questions about how he expected Ed's decline to progress and I needed advice regarding the multitude of issues involved in end-of-life care. I wanted to know about ventilators, antibiotics, DNR (do not resuscitate) orders, living wills and so many other things. Read More Here: http://www.huffingtonpost.com/marie-marley/when-your-loved-one-is-re\_b\_9119364.html ### A New Vision for Dreams of the Dying Source: [HTML](https://cunniffdixon.org/news/a-new-vision-for-dreams-of-the-dying/) Markdown: [Markdown](https://cunniffdixon.org/news/a-new-vision-for-dreams-of-the-dying/index.html.md) One evening in the late fall, Lucien Majors, 84, sat at his kitchen table, his wife Jan by his side, as he described a recent dream. Mr. Majors had end-stage bladder cancer and was in renal failure. As he spoke with a doctor from [Hospice Buffalo]() , he was alert but faltering. In the dream, he said, he was in his car with his great pal, Carmen. His three sons, teenagers, were in the back seat, joking around. “We’re driving down Clinton Street,” said Mr. Majors, his watery, pale blue eyes widening with delight at the thought of the road trip. “We were looking for the Grand Canyon.” And then they saw it. “We talked about how amazing, because there it was — all this time, the Grand Canyon was just at the end of Clinton Street!” Mr. Majors had not spoken with Carmen in more than 20 years. His sons are in their late 50s and early 60s. “My sons are the greatest accomplishment of my life,” Mr. Majors said. He died three weeks later. For thousands of years, the dreams and visions of the dying have captivated cultures, which imbued them with sacred import. Anthropologists, theologians and sociologists have studied these so-called[deathbed phenomena](). They appear in medieval writings and [Renaissance paintings](), in Shakespearean works and set pieces from 19th-century[American]()and British novels, particularly by[Dickens.]()One of the most famous moments in film is the mysterious deathbed murmur in “Citizen Kane”: [“Rosebud]()!” Even the law reveres a dying person’s final words, allowing them to be admitted as evidence in an unusual exception to hearsay rules. In the modern medical world, [such experiences]() have been noted by[psychologists](), [social workers]() and [nurses.]()But doctors tend to give them a wide berth because “we don’t know what the hell they are,” said[Dr. Timothy E. Quill,]() an expert on palliative care medicine at the University of Rochester Medical Center. Some [researchers]() have surmised that patients and doctors avoid reporting these phenomena for fear of ridicule. Read More Here: http://www.nytimes.com/2016/02/02/health/dreams-dying-deathbed-interpretation-delirium.html?ref=health&\_r=0 ### End-Of-Life Care For Cancer Patients Can Help Bring More Value To Life Source: [HTML](https://cunniffdixon.org/news/end-of-life-care-for-cancer-patients-can-help-bring-more-value-to-life/) Markdown: [Markdown](https://cunniffdixon.org/news/end-of-life-care-for-cancer-patients-can-help-bring-more-value-to-life/index.html.md) Today, on World Cancer Day, the goal is to raise awareness of the disease in order to hopefully prevent as many cases as possible in the future. But the reality is, cancer continues to pervade people's lives, with statistics putting[cancer deaths at 8.2 million people per year around the world]() — four million of which are people aged 30 to 69 years old. Death is an important part of the conversation when it comes to cancer, which is why specialists have become focused on ensuring patients know their options when it comes to palliative care. For Dr. James Downar, a critical care and palliative care staff physician at Toronto General Hospital, he's seen an increased recognition in the value of palliative care, and better adoption of it earlier on in the disease course. "Palliative care is often thought of as speciality of medicine that is only given to people at the very end, and that’s not true anymore," he explains to The Huffington Post Canada. "Our intention is to help with symptoms and decision making, and that's often relevant much earlier than people realize." Dr. Pippa Hawley, the palliative care program medical leader at the BC Cancer Agency, would prefer the conversations that can help these notions start even before you get sick. That's why she's started holding [Bucket List Festivals]() across B.C., fundraising events to help people figure out how to make the most out of their lives when their time is limited. As former patient Ian Dunlop Reid [wrote on his blog about one of the events](), "The best thing I took away was a reconnection with my own life — a reconnection that happened because I was forced to consider in a very practical way, my death." While difficult to approach, advanced care planning is what can make the difference between patients feeling like they have some autonomy over their plan, and losing control. Decisions that have to be made include everything from which life-saving measures they will allow to who makes the decisions for them, if they're not able to themselves. Read More Here: http://www.huffingtonpost.ca/2016/02/04/end-of-life-care-cancer\_n\_9151774.html ### In Palliative Care, Comfort Is the Top Priority Source: [HTML](https://cunniffdixon.org/new-york-times-health/in-palliative-care-comfort-is-the-top-priority/) Markdown: [Markdown](https://cunniffdixon.org/new-york-times-health/in-palliative-care-comfort-is-the-top-priority/index.html.md) Last year, when an oncologist advised that Betty Chin might benefit from[palliative care](), her son Kevin balked. Mrs. Chin, a retired nurse’s aide who lives in Manhattan’s Chinatown, was undergoing treatment for a recurrence of [colorectal cancer](). Her family understood that radiation and [chemotherapy]() wouldn’t cure her, but they hoped doctors could keep the [cancer]() at bay, perhaps shrinking her tumor enough to allow surgery or simply buying her more time. Mrs. Chin, 84, was in pain, fatigued and depressed. The radiation had led to [diarrhea](), and she needed a urinary catheter; her chemotherapy drugs caused nausea, [vomiting]() and appetite loss. Palliative care, which focuses on relieving the discomfort and distress of serious illness, might have helped. But Mr. Chin, 50, his mother’s primary caregiver, initially resisted the suggestion. “The word ‘palliative,’ I thought of it as synonymous with [hospice](),” he said, echoing a common misperception. “I didn’t want to face that possibility. I didn’t think it was time yet.” In the ensuing months, however, two more physicians recommended palliative care, so the Chins agreed to see the team at Mount Sinai Hospital. They have become converts. “It was quite a relief,” Mr. Chin said. “Our doctor listened to everything: the pain, the catheter, the vomiting, the tiredness. You can’t bring up issues like this with an oncologist.” Multiple prescriptions have made his mother more comfortable. A social worker helps the family grapple with home care schedules and insurance. Mr. Chin, who frequently translates for his Cantonese-speaking mother, can call nurses with questions at any hour. Read More Here: http://www.nytimes.com/2016/02/16/health/in-palliative-care-comfort-is-the-top-priority.html?\_r=0 ### ‘It’s About Living Better’” Repositioning Palliative Care in Hematologic Cancer Source: [HTML](https://cunniffdixon.org/articles/its-about-living-better-repositioning-palliative-care-in-hematologic-cancer/) Markdown: [Markdown](https://cunniffdixon.org/articles/its-about-living-better-repositioning-palliative-care-in-hematologic-cancer/index.html.md) The role of palliative care is widely misperceived as a strategy reserved for patients with limited options in advanced stages of disease. This misperception has been standing in the way of broader application of treatments that can improve quality of life (QOL) of patients with serious disease even when the prognosis is good, according to experts at a symposium devoted to this topic during the 2015 annual meeting of the American Society of Hematology. "Palliative care has moved further upstream in the 21st century. It's really about supporting people through a serious illness. It is more about living better rather than about the issues that arise only at the end of life," reported Thomas W. LeBlanc, MD, Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina. Several subgroups of patients with hematologic cancers, including many of those scheduled for hematopoietic stem cell transplant (HSCT), are reasonable candidates for palliative care. However, Dr LeBlanc [cited data]() indicating that palliative care is less likely to be offered to patients with hematologic cancer than those with solid tumors, even at the end of life.\[1\] Palliative care, which is directed at symptom control and the stress imposed by symptoms, is already fundamental to hospice and end-of-life management, but it is a strategy that can be initiated at any stage of disease, including at the time of diagnosis. Although palliative care is not a treatment for the disease, it can be delivered alongside forms of treatment with curative intent in order to improve QOL. --- Read More Here: [http://www.medscape.com/viewarticle/859034]() --- ### Influencer Interview with Dr. Lynn Hallarman Source: [HTML](https://cunniffdixon.org/influencer-interviews/influencer-interview-with-dr-lynn-hallarman/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/influencer-interview-with-dr-lynn-hallarman/index.html.md) [![]()]() ###### **In 2007, a year after Palliative Medicine became an approved medical subspecialty, you started an award-winning palliative care program at Stony Brook University Hospital. Can you walk us through that experience as an innovator?** During the first six months of starting Stony Brook's first palliative care consultation service, I sometimes had to spell the word "palliative" for my colleagues who had never heard of the concept: "Pall what?" they would ask. “P-a-l-l-i-a-t-i-v-e Care” I would respond with a gentle tone. I would then recite a 30-second "elevator" speech about how palliative care aims to support patients throughout a serious illness, regardless of the prognosis. Then came the silence, sometimes more questions, and then, sometimes, this would lead a colleague asking me to see their patient. It was a slow build, patient by patient, in gaining trust. About 20 years of national foundational work in palliative care program development had been accomplished before the official 2007 subspecialty designation. This work (by many people) provided me with a blueprint for building palliative care infrastructure at Stony Brook Hospital. I wrote policies, collaborated on creating templates and protocols for our medical ICU and other essential programs. Patient education and brochures were distributed. I gave out hundreds of pocket cards to staff on the criteria for calling a palliative consult. I delivered many medical grand rounds, ran teaching sessions for nurses and social workers, and developed curriculum for trainees. Then there were numerous meetings with the "C" suite administrators making the case for palliative care expansion. There were many programmatic successes along the way and initiatives that didn't work or resonate with patients and families. During the 13 years I was the Palliative Care Director at Stony Brook; my audacious hope was for every patient and family who needed it to have access to palliative care assessment. Symptom management, social support, spiritual care, and family care should be included in the medical plan of every seriously ill patient. My goal was to build a sustainable approach to palliative care programming that would last beyond my tenure at the institution. I wanted Stony Brook Hospital to own palliative care as a mission and mandate. ###### **Since 2019 you have been a Palliative Care educator and consultant - how far have we come in educating clinicians in the concepts of palliative care across the spectrum of their careers? Is there a career stage that you focus on or believe is most important?** I currently work as an educational and programmatic consultant for the National Center for the Equitable Care for Elders (NCECE) based at Harvard University. Their focus is on assisting federally funded community health centers in implementing health programs for community-dwelling older adults. The work, for me, has been an education on how critical community-based health programs are in serving older adults. Reflecting on my career path to becoming a palliative care physician and educator, I turn to a formative experience I had as a student rotator during medical school at a community-based inpatient hospice. My days at the inpatient unit were mostly spent sitting at the bedside of someone dying. I was taught how to listen with intention and presence. I learned how the impacts of people's lives, beyond the illness, affect how they process death and dying. The clinical staff demonstrated interdisciplinary care. This frame of care has stayed with me throughout my career. The experiences and role models we have at the beginning of our careers are critical. While most of my early training was in internal medicine and primary care, I am sure that the hospice experience as a medical student allowed me to have the courage to shift into palliative care when the opportunity presented itself. Palliative care educational programming nationally has focused chiefly on building curriculum infrastructure for medical trainees in hospitals since the training gaps have been so stark in inpatient settings. More recently, palliative care education has focused more on clinical providers in outpatient settings such as in Community Health Centers. My goal in working with health providers in mid-career and beyond in outpatient settings is to help them develop their sense of role modeling and educational leadership, like I had as a trainee years ago. ###### **How has mentorship played a role in your career and life both as a mentee and mentor?** I credit fantastic mentorship throughout my career as helping me to navigate the medical profession's twists, turns, and stresses. It is crucial, I believe, to actively seek out formal mentorship and develop informal collegial relationships that can serve to inform professional growth. Most importantly, to interact and learn from colleagues outside our professional silos. My most significant period of growth as a new palliative care physician, for instance, came from sitting through countless family meetings with our team social worker and chaplain. They were masters at receiving and responding to family concerns. They used humor, empathy, and their training to usher families through difficult conversations that seemed intractably stuck in anger or pain to my inexperienced self. These informal mentors shaped my approach for my whole career. However, this kind of mentorship can only be received and internalized when the mentee has an attitude of openness, respect, and wonder. Cultivating my role as a mentor for my colleagues has been a gratifying part of being an experienced palliative care doctor. I believe giving back in mentorship relationships is an obligation of the profession. It can also help, I think, others and oneself navigate burnout and the general challenges of being a health provider. Laughing together also really helps. ###### **As an educator, how important do you feel it is to discuss and mentor students and residents on issues and matters related to Advance Care Planning?** Very important. The biggest mistake made by providers about advance care planning is that the discussions about the "what ifs" occur after treatment failures: when "nothing more can be done". Advance Care Planning, when delivered expertly, recognizes shifting goals as serious illness evolves. Every juncture: beginning, middle, and end of a serious illness should include discussing patient/family wishes and values. These discussions should be normalized as part of routine care and not left to be done in a crisis by an emergency room doctor. Of course, this requires skills and knowledge on how to discuss advance care planning well. It should be part of every medical curriculum. #### **You spent a yearlong residence as a congressional fellow working for the U.S. Senate Committee on Finance developing opioid legislation. What did that experience teach you?** I was lucky to receive a grant to be a Health & Aging Policy Fellow in 2017. The fellowship facilitated a position as a congressional fellow in D.C. under the auspices of Senator Ron Wyden on the Senate Committee on Finance. My experience as a congressional health fellow helped me understand the extent that frontline health care is impacted by policy, especially related the of lack of connectivity across the continuum of care; often mirrored at these highest levels of health care policy-making. My interest in working in health policy was related the years I spent as the “Physician Champion” in a Palliative Care - Medical Legal Partnership (or PC-MLP). PC-MLP work focuses on addressing major sources of financial-legal-social problems surrounding legacy planning, guardianships, future planning, access to care, next step in care and shoring up of resources for patients with serious illness. As a palliative care physician, I was already acutely aware of the intense suffering and adverse impact that unresolved non-medical issues can have on patients and families who are confronting serious illness. The implementation model for a hospital based MLP consists of real time legal work that addresses non-medical issues that complicate the patient’s medical treatment plan. Patients receive a free bedside consultation with an MLP attorney who has no connection to the hospital’s legal counsel. When complicated health related legal-financial problems are addressed, the medical care team can more effectively tackle exigent health problems. My work implementing an PC-MLP reflects my approach to health advocacy, which starts with insights from direct patient care experiences that are applied to build a model for system change (not the reverse, as is often the case). I have learned to see patterns of problems in frontline care that I know can only truly be solved by system-level solutions that change health policy and health law both locally and nationally. #### **Do you think legislation and policy going forward will make Palliative Care more accessible? Do you have thoughts on what that model should look like?** I would like to see more palliative care policies constructed to support the invisible, unacknowledged work of paid (and unpaid) home care professionals. While medical care is essential, keeping someone in their lives and communities throughout a debilitating serious or chronic illness is often about supporting the work of caregivers. Excellent health policy can change the paradigm of how we think about home health professionals' essential work by designing payment structures and educational standards that support networks of highly trained, respected, and well-paid home care workers. #### **How has your work as an educator in this field changed and evolved because of the COVID pandemic?** Perhaps as a silver lining during an otherwise tragic time, the COVID pandemic has opened opportunities to develop quality online programming to reach providers that may otherwise not be able to participate in educational offerings. Online education may also be key, going forward, in educating home care workers and unpaid family caregivers. #### **Recently you published an exquisite piece for JAMA Neurology on the backstory of your mother and caregiving during COVID. Will you share a little bit about the impact of that story here?** The piece is mainly about my experience in navigating the COVID pandemic as the doctor-daughter of my 92-year-old mother with dementia. It tracks a roller coaster ride of good intentions and unintended consequences. I hope that the piece resonates with all the family members and caregivers who tried to protect their loved ones during the pandemic. The article can be free accessed online at: Hallarman L. The Great Escape—A Physician Confronts Family Caregiving During the COVID-19 Pandemic. *JAMA Neurol.* 2021;78(7):791–792. doi:10.1001/jamaneurol.2021.1170 #### **You followed that up with a guest essay for the *New York Times*on what you've learned over a lifetime of caring for the dying. How has writing in your own voice helped you process, integrate, and access your career work?** My recent experience as a family caregiver has informed my desire to write about doctoring from a personal perspective. Writing, journaling, and storytelling is an excellent way to connect with others and process life experience. I encourage everyone to do it. #### **Are you working on any research, projects, or legislation** **currently that you'd like us to know about?** I would like to remind everyone of the power of being a constituent. Write and meet with your local and state congressman about your ideas, concerns, and priorities about health care in your community. It has more power than you may realize. I learned that when I worked as a congressional health fellow. #### **If people would like to reach you directly for additional information or assistance, how would they do so?** I can be contacted by email at [lynn.hallarman@stonybrookmedicine.edu](). ### Influencer Interview With Dr. Lydia Dugdale Source: [HTML](https://cunniffdixon.org/influencer-interviews/influencer-interview-with-dr-lydia-dugdale/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/influencer-interview-with-dr-lydia-dugdale/index.html.md) ### Remembering Andy: Letter From Dr. Peter Dixon Source: [HTML](https://cunniffdixon.org/homepage/remembering-andy-letter-from-dr-peter-dixon/) Markdown: [Markdown](https://cunniffdixon.org/homepage/remembering-andy-letter-from-dr-peter-dixon/index.html.md) ### Physician Awards: 2022 Hastings Center Cunniff-Dixon Awards Source: [HTML](https://cunniffdixon.org/foundation-news/physician-awards-2022-hastings-center-cunniff-dixon-awards/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/physician-awards-2022-hastings-center-cunniff-dixon-awards/index.html.md) ![]() #### Physicians and Nurses Recognized for Providing Exceptional End of Life Care The Hastings Center and The Cunniff-Dixon Foundation are pleased to announce nine recipients of awards that honor clinicians for outstanding care provided to patients nearing the end of life. The awards are based on technical competence, personal integrity, empathic dialogue with patients, active engagement with the family and loved ones, practical and heartfelt communication regarding advance directives, and compassionate alleviation of suffering. Read more at https://www.thehastingscenter.org/news/physicians-and-nurses-recognized-for-providing-exceptional-end-of-life-care/ ### Featured Video: CDF 2018 Awards Video Source: [HTML](https://cunniffdixon.org/foundation-news/featured-video-cdf-2018-awards-video/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/featured-video-cdf-2018-awards-video/index.html.md) ### CDF Influencer Interview: Dr. Catherine Deamant, M.D. Source: [HTML](https://cunniffdixon.org/news/cdf-influencer-interview-dr-catherine-deamant-m-d/) Markdown: [Markdown](https://cunniffdixon.org/news/cdf-influencer-interview-dr-catherine-deamant-m-d/index.html.md) ![]()What did you see at Cook County Hospital when you were an attending physician specializing in patients with HIV and homeless that inspired you to devote your career to Palliative Care? My interest in caring for patients experiencing homelessness and patients with HIV infection began in the late 1980s when I was a medicine resident and continued when I started working at Cook County in 1990. At that time, many people were first diagnosed with HIV infection when they presented with AIDS related opportunistic infections. In those early years, anti-retroviral therapy was not as effective as it is now. As an attending physician on the AIDS Unit at Cook County Hospital, much of the care was primarily palliative care. Some of those patients were homeless or estranged from family and the care team played a significant role in supporting them through the end of life. Across the country, quite a few physicians and nurses who cared for patients with AIDS in those early years then moved into the field of palliative medicine. However, I was asked a single question by Maurice Lemon, Program Director for Internal Medicine Residency, to create an end of life curriculum for the residents that I learned about the field of palliative medicine. To feel credible in teaching this, I decided I needed to immerse myself more fully into this new field. You became the hospital’s sole Palliative Care practitioner in 2001. What was that like trying to pioneer a new service and team within a hospital? The Division of General Internal Medicine at Cook County Health has a long history of supporting providers who saw an unmet need and created opportunities for program development to address that need. Pioneers in primary care established the first HIV clinic for men, women and children (Ron Sable, Renslow Sherer and Mardge Cohen), while others established programs to address the disparities in primary care (Gordon Schiff) and breast and cervical cancer screening and treatment (David Ansell). Still others developed programs in preventive medicine (Arthur Hoffman and David Goldberg) and the creation of the division of hospital medicine (Avery Hart and Brian Lucas). These pioneers modeled and provided mentorship to me in creating the Section of Palliative Medicine. In addition to the encouragement and guidance from the division, the program was also supported by the Department of Medicine leadership (Brendan Reilly and Robert Weinstein) and hospital administration. How has the Palliative Care Program at Cook County Hospital grown since then? Although I retired from Cook County Health at the end of 2014, I continue to work part-time covering the inpatient palliative care consultation service. Several physicians who were with the program for many years also retired or moved to other states for family reasons (and all remain active in palliative medicine). Yet, the Palliative Care Program continues to thrive and is now led by Orlanda Mackie, MD, who has been with the program since the early years. Through her leadership, the palliative care program has further expanded outpatient clinics in oncology. Lisa Gobbi, MD, a psychiatrist and a recent fellow graduate, is expanding the reach of the program into outpatient nephrology and cardiology. Ancy Jacob, nurse practitioner, with a background in critical care, has increased our presence in the intensive care unit through automatic triggers. Ruhi Shariff, MD, has enhanced and expanded the educational program with a palliative care elective for medical students and required rotation for internal medicine, family medicine and pediatric residents. How did you and your team evolve during the COVID pandemic? Are there important takeaways that you can share? At the beginning of the pandemic, we learned from the experience of our colleagues across the country that were impacted early on, particularly in Washington and New York. As processes and protocols were developed, we offered communication skills education utilizing the resources provided by VitalTalk. Members of our team had to learn and adapt to providing telehealth visits, which can be particularly challenging as 30% of our patients have Limited English Proficiency. Palliative care programs in safety net institutions care for patients from communities of color who are dying due to disparities in access to care. This was further magnified during the pandemic as these communities were disproportionately impacted by COVID. Some team members were involved with providing support and structure around wellness and resilience for the institution. One important takeaway is that attention to wellness and strategies to foster resilience are core to sustaining us in this work. We have built some activities into our workday to foster resilience and not as an extra activity done “after hours.” More broadly, how do you think the COVID pandemic has impacted the access and delivery of palliative medicine in general? The pandemic required all providers to practice primary palliative care skills, including providing empathic communication, communicating prognosis, guiding family meetings and ensuring intensive symptom management in the setting of worsening symptoms of COVID. Our role often involved coaching and guidance when we were not involved in direct care. Do you think legislation and policy going forward will better support Palliative Care? Do you have thoughts on what that model should look like? We saw in the pandemic that the United States did not provide the leadership and response at a federal level that occurred in many other countries. And we are the only developed nation that does not have universal healthcare coverage or view healthcare as a human right. Many other countries recognize and support the high value care provided by palliative care and offer these comprehensive services within the context of a universal healthcare plan. If you could have one conversation with someone making end-of-life decisions whether healthy, just receiving a terminal diagnosis or dying, what would be important for you to convey? I would encourage the person to talk about what matters most to them and what they value with those who matter most to them. Have those conversations early and often. My parents had talked with me for years about their priorities and wishes and so a foundation was already laid when we came to points of decision making, even as those decisions may change over time. Yet, having multiple conversations can increase the comfort in bringing up difficult topics. My children are all young adults and they have heard me discuss my values and wishes frequently (and more than they really wanted to hear)! Do you have research or educational projects you are currently working on that you would like to tell us about? In addition to the clinical work at Cook County, which includes teaching residents and fellows, I am the Education Lead for Palliative Care and Opioid Education at Chicago Medical School-Rosalind Franklin University. It is exciting to create and modify developmentally appropriate curriculum across the four years and have it received so enthusiastically by the learners and wholeheartedly supported by the administration. I received an e-mail from a recent graduate who described how he used the communication skills he learned during medical school with a patient shortly after starting internship. He was appreciative for the training and felt prepared and confident in supporting the patient with difficult news. It is gratifying to be able to influence the next generation of physicians. If people would like to reach you directly for additional information or assistance, how would they do so? I am still working part-time at Cook County Health, and I can best be reached by e-mail: cdeamant@cookcountyhhs.org ### Physicians Recognized for Providing Exceptional End-of-Life Care Source: [HTML](https://cunniffdixon.org/homepage/physicians-recognized-for-providing-exceptional-end-of-life-care/) Markdown: [Markdown](https://cunniffdixon.org/homepage/physicians-recognized-for-providing-exceptional-end-of-life-care/index.html.md) ![]()The Hastings Center and The Cunniff-Dixon Foundation are pleased to announce six recipients of awards that honor physicians for exemplary care provided to patients nearing the end of life. The awards are based on technical competence, personal integrity, empathic dialogue with patients, active engagement with the family and loved ones, practical and heartfelt communication regarding advance directives, and compassionate alleviation of suffering. The [Cunniff-Dixon Foundation](), whose mission is to enrich the provider-patient relationship near the end of life through education, collaboration and recognition, created and funded the awards, which are from $15,000 to $25,000 each. [The Hastings Center](), a bioethics research institute that has done groundbreaking work on end-of-life decision-making, cosponsors the awards. “It’s hard to express how meaningful these awards are,” said Andrew Peters, Executive Director of The Cunniff-Dixon Foundation. “This year’s nominees were so exceptional and reflect the level of exemplary end-of-life care being provided at all career levels throughout the country. The interdisciplinary nature of palliative care is a model of good holistic medicine. We are honored to help recognize those leading this field.” The Hastings Center Cunniff-Dixon Physician Awards have long recognized five outstanding physicians—a senior physician, a mid-career physician, and three early-career physicians. A sixth physician award, the Dr. Richard Payne Leadership Award, was added in 2022 to honor physicians who work with vulnerable and/or underserved populations. Here are the 2024 physician award recipients: **Dr. Richard Payne Leadership Award:** **Hunter Groninger, MD, FAAHPM, Director of the Section of Palliative Care, MedStar Washington Hospital Center; Scientific Director for Palliative Care, MedStar Health Research Institute; and Professor of Medicine, Georgetown University**. For the last 20 years, his clinical practice has focused on providing hospice and palliative care to patients and their families in Washington, DC, across all care settings. Active in clinical education, Dr. Groninger founded the MedStar Health/Washington Hospital Center Interprofessional Palliative Medicine Fellowship and teaches at MedStar Health and Georgetown University School of Medicine. He is also an investigator at the MedStar Health Research Institute. His grant-funded research currently focuses on novel symptom management strategies, innovative palliative care delivery models, and health disparities. **Senior Physician Award**: **Julie Hauer, MD, FAAHPM, Division of General Pediatrics, Boston Children’s Hospital; Assistant Professor, Harvard Medical School**. For nearly three decades, Dr. Hauer’s work as a clinician scientist has focused on children with disorders of the central nervous system who have complex medical care and decision-making needs. Her expertise includes complex symptom treatment, including at the end-of-life. Dr. Hauer has written two books and developed medical content for[NeuroJourney]() at Courageous Parents Network, a team effort that included editing by parent experts. She is committed to education and the support of future clinician scientists. She views relationship-building with parents as her most important work, tapping into their expert knowledge of their child, with commitment to iterative shared decision-making. Dr Hauer’s driving philosophy is that children with medical complexity are not defined by their problems, and that we must strive to see each child’s abilities and what brings meaning to a child’s life. Her work is made possible by being a member of a team that includes nurses, therapists, and social workers. **Mid-Career Physician Award:** **Lynn Flint, MD, Clinical Professor in the Division of Geriatrics, University of California, San Francisco.** Dr. Flint is the medical director of outpatient palliative care at the San Francisco VA Medical Center and the founding director of the UCSF integrated geriatrics and palliative care fellowship, the first such fellowship on the West Coast. The program aims to produce leaders in the care of older adults and those with serious illnesses. In honor of her contributions to education, in 2021 she was inducted into The Haile T. Debas Academy of Medical Educators, which supports people who advance the education mission at UCSF. At the San Francisco VA Medical Center outpatient palliative care clinic, she works with a transdisciplinary team to care for veterans living with serious illness and their loved ones. After more than 10 years of inpatient work, she transitioned to the outpatient setting for the opportunity to impact new and broader populations. **Early-Career Physician Awards:** **Andre M. Cipta, MD, FAAHPM, Assistant Professor of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine.**Dr. Cipta is the program director of the Hospice and Palliative Medicine Fellowship and site director of the innovative mid-career fellowship track at the Kaiser Permanente Los Angeles Medical Center. He also serves as associate medical director of the Kaiser Permanente Los Angeles Hospice Agency and palliative medicine clerkship director at the Tyson School of Medicine. Board certified in Hospice and Palliative Medicine, Dr. Cipta is a recipient of the American Academy of Hospice and Palliative Medicine Leadership Scholar Award. In his multifaceted roles as a leader, educator, and researcher, he strives to enhance the quality of care across the continuum of serious illnesses. His interests lie in exploring novel approaches to medical education, studying the relationship between spirituality and health, and advocating for compassionate, evidence-informed, whole-person-centered care. **Richard Leiter, MD, MA, Assistant Professor of Medicine, Harvard Medical School.** Dr. Leiter is a palliative care physician, writer, and researcher at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital. He serves as the director of the Inpatient Palliative Care Consult Service and founding director of the Psychosocial Oncology and Palliative Care Writing Core, and he sits on the Brigham and Women’s ethics committee. Dr. Leiter writes about the intersection of palliative care and ethics and the emotional experience of working in the field. His writing has appeared in the New York Times, The New England Journal of Medicine, STATNews, the Journal of Clinical Oncology, and Cell, among other publications. Along with Dr. Alexis Drutchas and Rachel Rusch, LCSW, he is a co-founder of[The Palliative Story Exchange](), a storytelling intervention that seeks to enhance connection and foster meaning-making among health care professionals. **Tyler Tate, MD, Assistant Professor of Pediatrics, Oregon Health and Science University (OHSU).** Dr. Tate is a pediatric palliative physician, ethicist, writer, and researcher at OHSU. He serves as an associate director of the OHSU Center for Ethics in Health Care and founding director of the Oregon Bioethics and Humanities Colloquium speaker series. Dr. Tate has written extensively about suffering and decision-making in the palliative context, with a special focus on promoting just and compassionate health care for people with physical and intellectual disabilities. His academic work has been published in numerous journals, including the Hastings Center Report, Pediatrics, and the Journal of Palliative Medicine. Dr. Tate’s favorite thing about palliative medicine is that he often gets to sit down with patients and their families, listen to their stories, and then accompany them along their illness journeys. He deeply values the relationships that he is able to build through his work. Beginning in June 2024, Dr. Tate will be moving to Stanford University where he will be a clinical associate professor in the department of pediatrics in the new Division of Quality of Life and Pediatric Palliative Care. The Physician Awards selection committee is chaired by Kathleen Foley, MD, Memorial Sloan-Kettering Cancer Center, and includes Zara Cooper, MD, MSc, FACS, Brigham and Women’s Hospital; Anthony N. Galanos, MD, Duke University School of Medicine; Diane Meier, MD, Mt. Sinai Hospital and Center to Advance Palliative Care; and Rodney Tucker, MD, UAB Center for Palliative and Supportive Care. The Hastings Center and the Cunniff-Dixon Foundation also give awards to outstanding nurses. Learn more about the physician awards and the nursing awards, including the past recipients, [here](). For information on the Cunniff-Dixon Foundation: [susan@cunniffdixon.org]() For information on The Hastings Center: [gilberts@thehastingscenter.org]() ### Recognizing Good Nursing Source: [HTML](https://cunniffdixon.org/foundation-news/recognizing-good-nursing/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/recognizing-good-nursing/index.html.md) I recently had the opportunity to participate in the launch of an award honoring nurses in end-of-life care. I invited the executive director of the Cunniff-Dixon Foundation, Andy Peters, to share his perspectives on this award. - Betty Ferrell, PhD, FAAN, FPCN, CHPN JHPN Editor-in-chief **RECOGNIZING "GOOD NURSING"** In January of 2005, Andy Baxter, founder of the Cunniff-Dixon Foundation, lost his wife Carley Cunniff to metastatic breast cancer. For 3 years, Andy and Carley were guided impeccably and compassionately by Dr Peter Dixon, a small town family doctor who did not necessarily consider himself to be a practitioner of "palliative medicine." Andy Baxter loved borrowing a phrase from the late Dr Rich Payne who used to say Dr Dixon just practiced "good doctoring." As Andy Baxter reflected on the beautifully guided experience that Dr Dixon gave to him and his wife and began to share his story with friends and strangers, he quickly learned that his experience was not the norm. It was in this light that he created the Cunniff-Dixon Foundation (CDF) to enrich the provider-patient relationship near the end of life. With this mission, it was Andy's hope that more individuals and families would experience a version of the gift that Dr Dixon had given them. I had the privilege of watching CDF begin and grow as I prepared to attend nursing school back in 2008. Working under the late Dr Robert Martensen, I did anything I could to help the foundation build its first websites, aggregate content, and support the beginning of what became the Hastings Center Cunniff-Dixon Physician Awards. Now, as the executive director of the Cunniff-Dixon Foundation, it is a great privilege to share news of our inaugural Hastings Center Cunniff-Dixon Nursing Awards. I often asked Andy Baxter along the way, "Why aren't we recognizing nursing in the same light as the physicians?" Andy would smile confidently, "Because nurses already know how to do this well. They are good communicators and advocates by nature. Physicians are the ones who need to be better at this." This past fall, as the pandemic continued to evolve, we at the Cunniff-Dixon Foundation sat down with The Hastings Center, our partner in these awards, and decided it was time. The pandemic had thrust nurses who were already "doing the work" every day into unimaginable situations. Nurses, like many providers these last 2 years, have been asked to work in unsafe environments, working inhumane hours while desperately trying to provide the quality care they know each person deserves. When I picked up the New York Times one day in the spring of 2020 and saw that one of my classmates at NYU had died from COVID-19 while working as a nurse at the bedside, I was heartbroken. My heart sank for every nurse that showed up each day facing their fears and the risk of death, often without proper safety precautions, in order to care for their fellow humans. Important existential questions that I had already made a point to tackle in my life rippled back through me: What is required of us to be fully present with a fellow human being when challenges surround us? How do we work toward this personally and professionally? Having devoted a large part of my life to learning how to be present with myself through the practice of yoga and meditation, I often examined how the ability to be present with other human beings affects how we live, practice nursing, medicine, or caregiving in general. How do we continue to do work and protect ourselves as we work and care for others? Perhaps being "present" allows for both to happen without push or pull. When present, we do not impose our fears-no matter how strong or unresolved they are. When present, we also receive wisdom from the patient before us who is experiencing some version of pain or life nearing its end. In this sense, the relationship between patient and provider becomes something unconditional. A special and rare space to be in and/or work toward. It is such an honor to celebrate the inaugural Hastings Center Cunniff-Dixon Nursing Awards with three exceptional nurses who have and are working daily toward this masterful space: Barbara Reville, DNP, ANP-BC, ACHPN of Dana Farber Cancer Institute/Brigham and Women's Hospital in Boston, Massachusetts, and Juanita Georges, LVN and Erin Perez, DNP, APRN, ANP-C, AGNP-C, ACHPN of University Health System in San Antonio, Texas. These three nurses were chosen by a prestigious selection committee for their evidenced-based practice, personal ethics, integrity, compassion, empathy, teamwork, and collaboration, as well as application of diversity, equity and inclusion. Much like the care that the recipients of these inaugural nursing awards have given to their patients and their families, these awards are unconditional. It is recognition for the exceptional work they have done-creating and validating a body of work that will hopefully shed light on their future and the team around them. These three recipients are giving the gift of "good nursing" to their patients and families day in and day out. On February 21, 2022, the Cunniff-Dixon Foundation sadly lost its visionary founder and dear friend, Andy Baxter. He died peacefully at home surrounded by his loving sister and daughter. Once again, Dr Peter Dixon was by his side for months, reminding all of us why the Foundation exists. Dr Dixon's care for Andy has reinspired us to propel this work forward, and it is a privilege to do so by recognizing our three inaugural nurses. Andy Baxter reminded us in his final few months: We do not have control over every aspect of our path and process, but we must be present for it. Through this presence, we can begin to create a framework and narrative that helps those close to us, including health care practitioners, act in accordance with our wishes and human values. He would be honored to know the three nurses selected in 2022 who show up fully present for their patients and families every day. As a fellow nurse, I am so excited to see these awards come to fruition. What attracted me to nursing after a short career in education was that it was holistic by nature. Every day, I had to consider the entire well-being of a fellow human being-physically and spiritually, and I learned that no matter where I was in my technical education, I could still practice "good nursing." I feel very fortunate to have been introduced to the world of palliative care while working in home-care and skilled nursing facilities-caring for elders who had few or no advocates. This taught me so much about what I was capable of, regardless of my degree. By listening and being present, I could often pick up on emotional or physical subtleties that colleagues around me were missing. I am grateful to be a nurse and to witness "good nursing" in my colleagues. It is our hope that through these awards, the Cunniff-Dixon Foundation will honor the work of nursing care at the end of life. Andy Peters, RN, BA, BSN ### Andy Baxter's Visionary Tool Source: [HTML](https://cunniffdixon.org/foundation-news/andy-baxters-visionary-tool/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/andy-baxters-visionary-tool/index.html.md) ![]() Andy Baxter, Founder of the Cunniff-Dixon Foundation, was passionate about the planning for end of life care while an individual was healthy. Three principles helped guide him when formulating a plan to create a free tool to help with advanced care directives : - Deciding what treatment and care you want and helping you avoid the ones you don't want. - Empowering your loved ones and reducing their burden by clearly communicating your wishes. - Reducing the risk of a communication conflict between your family members and health care providers. He explained the visionary tool called Planning My Way in this video to help us with an end of life care planning process: https://vimeo.com/373008396 Today Andy Baxter’s visionary free end of life care guide, Planning My Way, continues to serve thousands. If you would to join the Planning My Way Community or would like more information and access to the Planning My Way tools, please visit https://www.planningmyway.org/ ### Influencer Interview: Betty Ferrell, Ph.D., M.S.N., R.N., CHPN, FAAN, FPCN Source: [HTML](https://cunniffdixon.org/influencer-interviews/cdf-influencer-interview-bettyferrell/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/cdf-influencer-interview-bettyferrell/index.html.md) ![]()Excited to share another of our Influencer Interviews featuring Betty Ferrell, Ph.D., M.S.N., R.N., CHPN, FAAN, FPCN, who has focused her clinical expertise and research in pain management, quality of life, and palliative care. One of Betty’s pivotal contributions has been in creating the End-of-Life Nursing Education Consortium project or @ELNEC - a national and international education initiative to improve palliative care. Congratulations Betty and we’re thrilled to have you as part of this series! Watch the premiere episode and discover more about these transformative stories: [https://vimeo.com/1011184941]() ### Influencer Interview: Bob Arnold, MD Source: [HTML](https://cunniffdixon.org/influencer-interviews/influencer-interview-bob-arnold-md/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/influencer-interview-bob-arnold-md/index.html.md) ![]()Bob Arnold, MD is a triple threat in medicine. An expert clinician, educator, and researcher, Dr. Arnold started the University of Pittsburgh Section of Palliative Care and Medical Ethics. He is now bringing palliative care education to physicians as early as possible in their careers for Mount Sinai's Brookdale Department of Geriatrics and Palliative Medicine. His work focuses on how clinicians operationalize ethical precepts in the care of seriously ill patients, and the intersection of communication skills training, medical ethics, and palliative care to improve clinician-patient relationships. Click here to watch Episode 3 --- [https://vimeo.com/cdfoundation/cdfii-ba]() ### Call for 2025 Nursing Award Nominations Source: [HTML](https://cunniffdixon.org/foundation-news/call-for-2025-nursing-award-nominations/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/call-for-2025-nursing-award-nominations/index.html.md) ### Call for 2025 Nursing Award Nominations Source: [HTML](https://cunniffdixon.org/foundation-news/call-for-2025-nursing-award-nominations-open-through-january-31-2025/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/call-for-2025-nursing-award-nominations-open-through-january-31-2025/index.html.md) **![]()** **2025 Nursing Award Nominations: Open Through January 31, 2025** The Hastings Center Cunniff-Dixon Nursing Awards is now accepting nominations for 2025! These prestigious awards recognize three exceptional nurses who provide exemplary end-of-life care, demonstrating outstanding compassion and service. Each award recipient will receive a $25,000 prize. **Eligibility:** - Open to nurses at all levels of practice (LVN/LPN, RN/APRN). - Past nominees who were not selected are encouraged to be re-nominated. **Submission Deadline:** January 31, 2025 Learn more about the nomination process through this brief video: [Nomination Process Video]() **Awards Selection Committee:**The committee includes distinguished leaders in nursing and end-of-life care: - **Dr. Betty Ferrell** (Chair): Director of Nursing Research and Education, Professor, City of Hope, Duarte, Calif. - **Dr. Ashley Leak Bryant**: Associate Professor of Nursing, University of North Carolina at Chapel Hill. - **Dr. Lynn Reinke**: Claire Dumke Ryberg RN Presidential Endowed Chair for Palliative and End-of-Life Care, Director of the Center for Family Integrated Healthcare, University of Utah College of Nursing. - **Dr. Tamryn Fowler Gray**: Assistant Professor, Carolina Nursing. - **Dr. Billy Rosa**: Chief Research Fellow, Memorial Sloan Kettering Cancer Center. **Submit Your Nomination:** Visit [**CDFAwards.org**]() to begin the nomination process. For questions or additional information, please contact Susan at susan@cunniffdixon.org. Honor the extraordinary contributions of nurses in end-of-life care—consider nominating a deserving candidate today! ### Planning My Way, Espanol: A Guide for the Spanish-Speaking Community Source: [HTML](https://cunniffdixon.org/foundation-news/planning-my-way-espanol-a-guide-for-the-spanish-speaking-community/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/planning-my-way-espanol-a-guide-for-the-spanish-speaking-community/index.html.md) **![]()** **Planning My Way, Espanol: A Guide for the Spanish-Speaking Community** Making decisions about your healthcare, especially at the end of life, can be tough for anyone. These conversations may be even harder for Spanish-speaking communities, due to language barriers, cultural differences, or a lack of understanding about advanced care directives. The Cunniff-Dixon Foundation (CDF) works to improve the patient-provider relationship at the end of life through education and support. Realizing many individuals lack the resources to make important healthcare decisions, CDF created a guide for end-of-life planning called *Planning My Way* in English. In 2019, CDF introduced the Spanish version: *Planning My Way, Espanol*. **How*****Planning My Way, Espagnol*****Can Help:** 1. **Language Barriers**: Many advanced care documents are in English, which can be difficult for those who don’t speak the language fluently. Even translated versions may not always be clear or culturally sensitive, leading to confusion. 2. **Cultural Differences**: In many Spanish-speaking families, healthcare decisions are made by relatives, not individuals. This makes it harder for people to think about and plan their care. 3. **Legal Complexity**: Some people find legal documents overwhelming. They may feel advanced care directives are too complicated or they need expert help to understand them. 4. **Limited Awareness**: Many in Spanish-speaking communities may not know about advanced care directives or understand their purpose. In some cultures, verbal agreements have been the norm, making written documents unfamiliar. 5. **Discomfort with Death**: In some cultures, talking about death or end-of-life care can be uncomfortable or even taboo. This can make it difficult for people to think about or discuss these decisions. 6. **Emotional Impact**: Planning for the end of life can be emotionally tough, especially when families are involved in decision-making. 7. **Misinformation**: Legal and medical jargon can be confusing, and translated documents might not always explain things clearly, leading to misunderstandings. 8. **Lack of Resources**: In some areas, there aren’t enough Spanish-speaking healthcare professionals to help people complete advanced care directives, leaving them feeling unsupported. To help address these issues, *Planning My Way, Espanol* was created to guide Spanish-speaking individuals and families to think about their healthcare preferences, understand their options, and communicate what matters most to them. *Planning My Way* *Espanol*is a simple workbook that helps people consider their values and healthcare preferences. It walks them through a process to create an advanced care directive, to be sure their wishes are clear. *Planning My Way Espanol* has been carefully translated to ensure it’s accessible and relevant for Spanish-speaking communities. To access the complimentary version of *Planning My Way Espanol*, visit [https://www.planningmyway.org/esp](). If you need additional information or have inquiries on using *Planning My Way Espanol*for groups, please contact susan@cunniffdixon.org. Photo by [Jeremy Bishop]() on [Unsplash]() ### Founders Statement Source: [HTML](https://cunniffdixon.org/about-cfd/founders-statement/) Markdown: [Markdown](https://cunniffdixon.org/about-cfd/founders-statement/index.html.md) ### Letters From Andy Baxter and Carley Cunniff Source: [HTML](https://cunniffdixon.org/about-cfd/remembering-andy-letter-from-dr-peter-dixon-2/) Markdown: [Markdown](https://cunniffdixon.org/about-cfd/remembering-andy-letter-from-dr-peter-dixon-2/index.html.md) ### CDF Awardee Featured on Duke Podcast and in Newsweek Source: [HTML](https://cunniffdixon.org/foundation-news/cdf-awardee-featured-on-duke-podcast-and-in-newsweek/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/cdf-awardee-featured-on-duke-podcast-and-in-newsweek/index.html.md) **![]()** **CDF Awardee Featured on Duke Podcast and in Newsweek** Dr. Anthony Nicholas Galanos (aka Dr. G), a CDF 2011 Mid-Career Awardee and esteemed member of our Physician Award Selection Committee, was recently featured on Duke Clinical Research Institute’s *Beyond the Endpoint* podcast. He shared valuable insights on navigating grief in the clinical setting. [Listen to the podcast](). In addition, Dr. G’s recent poignant essay on grief was published in [*Newsweek*.]() The Cunniff-Dixon Foundation is thrilled to see the continued achievements of our awardees and the exceptional contributions they are making in the field of palliative and end-of-life care. ### Celebrating National Healthcare Decision-Making Day with Heart and Purpose Source: [HTML](https://cunniffdixon.org/foundation-news/celebrating-national-healthcare-decision-making-day-with-heart-and-purpose/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/celebrating-national-healthcare-decision-making-day-with-heart-and-purpose/index.html.md) **[![]()]()** **Celebrating National Healthcare Decision-Making Day with Heart and Purpose** Andy Baxter, the compassionate and loving founder of the Cunniff-Dixon Foundation (CDF), lost his beloved wife, Carley Cunniff, to metastatic breast cancer. Carley was cared for by their family physician, Peter Dixon, MD. Thanks to Peter’s gentle and expert care, Carley passed away peacefully at home, in her bed, surrounded by the love of her family. Andy knew this wasn’t the typical experience for most people, and it sparked a mission in his heart: to help others find that same connection and comfort at the end of life. He founded CDF to enrich the relationship between patients and healthcare providers through education, collaboration, and recognition. One of Andy’s proudest creations was *Planning My Way*, a heartfelt project from CDF. This initiative was shaped with input from a wonderful group of end-of-life and ethics experts—doctors, clergy, and everyday advocates—who all came together to make something truly special. The result? A free, easy-to-use workbook (available in both English and Spanish, in print and digital versions) that’s all about empowering you and your loved ones. It’s a friendly guide to reflect on what matters most to you, learn about your options, and share your wishes for future healthcare decisions. As we prepare for National Healthcare Decision-Making Day on April 16th, we warmly invite you to check out [*Planning My Way*](). There’s no better time to create your advance care directive—especially while you’re still feeling strong and healthy! Taking this step now can bring peace of mind to your family, provide clarity when tough choices come up, and give your healthcare team a clear roadmap to honor your wishes. Want to bring [*Planning My Way*]() to a bigger group or use it in a clinical setting? We’d love to help! Please be in touch with our Executive Director, Andy Peters, at **andy@cunniffdixon.org** for more details. Let’s make planning for the future a little less daunting and a lot more meaningful—together! *Photo courtesy of Leon Seibert, Unsplash* ### 2025 Hastings Center Cunniff-Dixon Nursing Awards Announced Source: [HTML](https://cunniffdixon.org/foundation-news/2025-hastings-center-cunniff-dixon-nursing-awards-announced/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/2025-hastings-center-cunniff-dixon-nursing-awards-announced/index.html.md) **![]()2025 Hastings Center Cunniff-Dixon Nursing Awards Announced** The Hastings Center and The Cunniff-Dixon Foundation are pleased to announce three recipients of the 2025 Hastings Center Cunniff-Dixon Nursing Awards, which honor nurses who demonstrate extraordinary compassion and skill in caring for patients nearing the end of life. The Cunniff-Dixon Foundation, whose mission is to enrich the provider-patient relationship near the end of life through education, collaboration, and recognition, created and funded the awards, which are $25,000 each. The Hastings Center, a bioethics research institute that has done groundbreaking work on end-of-life decision-making, cosponsors the awards. The 2025 recipients are: **![]()** **Erin Collins, **MNE, RN, CHPN,** Cofounder and Director of Programs, The Peaceful Presence Project in Bend, Oregon**. Collins is a certified hospice and palliative care nurse with 17 years of experience in hospice and adult and pediatric oncology. Trained as an end-of-life doula, she is a member of the board of directors for the Oregon Hospice and Palliative Care Association, an appointed member to the Oregon Health Authority’s Palliative Care and Quality of Life Advisory Council, and the former vice-chair of the National Hospice and Palliative Care Organization’s End-of-Life Doula Advisory Council. She cofounded The Peaceful Presence Project after seeing that many patients came to hospice afraid of death and largely unprepared for it. She is committed to educating the community at all levels, including individuals, families, students, and clinicians, in preparing for and talking about serious and terminal illness with compassion and tenderness. She empowers families to be present with their loved ones in the final stage of life, however long that may be, and believes that by talking about and planning for death with our loved ones, we can ease much of the suffering that arises at the end of life. **![]()Melinda “Mel” Mayorga,** **RN, MSN, CNS, AGCNS-BC, OCN,** **Clinical Nurse Specialist, Ambulatory Oncology****Services, University of Southern California, Norris Comprehensive Cancer Center.** Board-certified as an adult gerontology clinical nurse specialist and an oncology nurse, Mel chairs the Ambulatory Fall Prevention Council for Norris and Keck ambulatory clinics and co-chairs the Keck Nursing Professionalism program. In 2022, she was named the USC Nurse Humanitarian of the Year. Mel is a member of the Los Angeles Chapter of the Nurse Honor Guard, where she honors deceased nurses. In 2024, she was a recipient of the Simms/Mann Family Foundation’s Off the Chart award to recognize and reward greatness in nursing in the Los Angeles area. She was commended for her holistic approach to palliative care, grounded in evidence-based practice and inter-professional collaborations by creating the Sacred Pause Initiative- a just-in-time grief support for clinicians and staff, “By Your Side”- a hospital vigil program at End-of Life, and has lectured on her work involving “Last Responders”. **![]()Jackie Palmore,****RN, BSN, CHPN,****is the clinical coordinator for the UAB Center for Palliative and Supportive Care at the University of Alabama at Birmingham Medical Center.** A registered nurse for 38 years, she has devoted the majority of her career to palliative, supportive, and hospice/home care. She played a pivotal role in the development of UAB’s 12-bed inpatient Palliative and Comfort Care Unit in 2004 and has since helped establish the inpatient consult service and the broader palliative care interdisciplinary team. In addition, as a faculty member of the Palliative Care Leadership Center at the UAB Center to Advance Palliative Care, she has helped train more than 50 hospice and palliative care teams nationwide. In 2001, she spearheaded the creation of the first hospice program in the Alabama Department of Corrections. She was the first nurse at UAB to earn national certification in palliative nursing and recently completed UAB’s Pain and Addiction Scholars program. The awards selection committee is comprised of Dr. Betty Ferrell, director of nursing research and education and a professor at City of Hope in Duarte, Calif. (chair); Dr. Ashley Leak Bryant, associate professor of nursing at the University of North Carolina at Chapel Hill; Dr. Lynn F. Reinke, endowed professor in palliative care at the University of Utah; Dr. Billy Rosa, chief research fellow at Memorial Sloan Kettering Cancer Center in New York; and Dr. Tamryn Gray Fowler, assistant professor at the UNC School of Nursing. For more information, contact: Susan Gold Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Jeanne Twohig Palliative Care Trailblazer Source: [HTML](https://cunniffdixon.org/influencer-interviews/cdf-influencer-interview-jeanne-twohig-palliative-care-trailblazer/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/cdf-influencer-interview-jeanne-twohig-palliative-care-trailblazer/index.html.md) ![]()The Cunniff-Dixon Foundation is pleased to introduce its newest video series, Influencer Interview, showcasing compelling stories of influential figures from diverse backgrounds who are shaping the landscape of end-of-life care. Each uniquely stylized short video unveils the impactful journeys of these influencers highlighting their pivotal contributions. The premiere episode features Jeanne Twohig, an unsung hero, who alongside Ira Byock, MD, pioneered an early program promoting excellence in palliative care. Funded by the Robert Wood Johnson Foundation, their initiative laid the groundwork for similar programs nationwide. Executive Director of The Cunniff-Dixon Foundation, Andy Peters, remarked: “Our foundation is dedicated to support and shed light on the leaders and daily clinicians who have helped shape what we know today as Palliative Medicine. It is our hope that these short meaningful interviews offer wisdom, reflection and perspective along our path, as so many dedicated clinicians continue to tirelessly advance the field." Driving the creative vision behind the series is Nicole D. Glover, a seasoned producer mentored by acclaimed documentary filmmaker, Albert Maysles (known for Gimme Shelter, and Grey Gardens). Glover brings her expertise in producing for esteemed media outlets, individuals, and non-profit organizations. Watch the premiere episode and discover more about these transformative stories: [https://vimeo.com/956237522]() ### Influencer Interview with Robert Macauley, M.D. Source: [HTML](https://cunniffdixon.org/foundation-news/influencer-interview-with-robert-macauley-m-d/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/influencer-interview-with-robert-macauley-m-d/index.html.md) [**![]()**]()**Thrilled to showcase our *Influencer Interview* with Robert Macauley, M.D., F.A.A.P., F.A.A.H.P.M.** As one of the few pediatric palliative care doctors in the United States, Bob Macauley was used to people saying, “I’m so glad I don’t have your job.” He would explain that palliative care is more about living than dying, then offer to share some inspiring stories he witnessed daily. *Because I Knew You*, his latest book, tells the stories of children facing life-threatening illness, from babies diagnosed before birth through adolescence. They and their parents face incredible challenges with immense courage and devotion, inspiring doctors like Bob Macauley and showing them how much they have left to learn. For Bob, the work is personal: having survived abuse as a child, he dedicated his life to making sure that no other child would hurt the way he did. After growing up in a world where people did things no one ever should, he found a home among people who loved more deeply than he thought anyone could. As the director of the OHSU Doernbecher Bridges program, Dr. Macauley specializes in palliative care, which focuses on improving quality of life for kids facing life-limiting illness. He is one of only three hundred pediatricians in the United States board-certified in palliative medicine. He values the chance to help children and their families work through some of the most difficult situations anyone can ever face. When life ends far too soon, there are a lot of tears, hand-holding, and silence. And when a child makes it through, there are tears of a different kind. The sweetest words he can ever hear from a family are “We don’t need you anymore.” Watch the video here: [https://vimeo.com/cdfoundation/iibm]() For more information, contact: Susan Gold, Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Influencer Interview: Bob Macauley, MD Source: [HTML](https://cunniffdixon.org/influencer-interviews/influencer-interview-bob-macauley-md/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/influencer-interview-bob-macauley-md/index.html.md) ![]() **Thrilled to showcase our *Influencer Interview* with Robert Macauley, M.D., F.A.A.P., F.A.A.H.P.M.** As one of the few pediatric palliative care doctors in the United States, Bob Macauley was used to people saying, “I’m so glad I don’t have your job.” He would explain that palliative care is more about living than dying, then offer to share some inspiring stories he witnessed daily. *Because I Knew You*, his latest book, tells the stories of children facing life-threatening illness, from babies diagnosed before birth through adolescence. They and their parents face incredible challenges with immense courage and devotion, inspiring doctors like Bob Macauley and showing them how much they have left to learn. For Bob, the work is personal: having survived abuse as a child, he dedicated his life to making sure that no other child would hurt the way he did. After growing up in a world where people did things no one ever should, he found a home among people who loved more deeply than he thought anyone could. As the director of the OHSU Doernbecher Bridges program, Dr. Macauley specializes in palliative care, which focuses on improving quality of life for kids facing life-limiting illness. He is one of only three hundred pediatricians in the United States board-certified in palliative medicine. He values the chance to help children and their families work through some of the most difficult situations anyone can ever face. When life ends far too soon, there are a lot of tears, hand-holding, and silence. And when a child makes it through, there are tears of a different kind. The sweetest words he can ever hear from a family are “We don’t need you anymore.” Watch the video here: [https://vimeo.com/cdfoundation/iibm]() For more information, contact: Susan Gold, Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Dr. Peter Dixon, MD, FACP Source: [HTML](https://cunniffdixon.org/about-cfd/dr-peter-dixon-md-facp/) Markdown: [Markdown](https://cunniffdixon.org/about-cfd/dr-peter-dixon-md-facp/index.html.md) ### A Heartfelt Celebration for 2024 Mid-Career Awardee, Lynn Flint, MD! Source: [HTML](https://cunniffdixon.org/foundation-news/celebration-for-2024-mid-career-awardee-lynn-flint/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/celebration-for-2024-mid-career-awardee-lynn-flint/index.html.md) [**![]()**]()**A Heartfelt Celebration for 2024 Mid-Career Awardee, Lynn Flint, MD!** We’re absolutely thrilled to shine a spotlight on the incredible Lynn Flint, MD, Medical Director of Outpatient Palliative Care at the San Francisco VA Health Care System, who’s been honored as a 2024 Mid-Career Awardee! ???? Lynn’s dedication to her patients and her field is nothing short of inspiring, and we’re over the moon to see her basking in the joy of this well-deserved recognition! To celebrate her achievement, Lynn decided to sprinkle a little stardust on her life by treating herself and her husband, Andrew, to an unforgettable Taylor Swift concert! ????✨ Picture them singing their hearts out, dancing under the twinkling lights, and soaking in every magical moment of the night. We’re obsessed with how Lynn embraced this opportunity to let loose and celebrate in true superstar style! ![]()Our Mid-Career Awardees are extraordinary clinicians who pour their hearts into their work, and they deserve every ounce of joy they can find. Lynn didn’t just find joy—she seized it, and we’re cheering her on every step of the way! ???? Want to share in the excitement? Check out Lynn’s heartfelt video from her award [ceremony here]() and join us in celebrating her remarkable achievement! Here’s to Lynn, joy, and to making every moment sparkle! ???? You can learn more about Dr. Flint and her amazing accomplishments in palliative care with Veterans. Watch her Physician Award video here: [https://cunniffdixon.org/founders-statement/foundation-videos/]() For more information, contact: Susan Gold, Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Influencer Interview with Arion Lillard-Green, MHA, M.TS. Source: [HTML](https://cunniffdixon.org/foundation-news/influencer-interview-with-arion-lillard-green-mha/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/influencer-interview-with-arion-lillard-green-mha/index.html.md) [**![]()**]()**We are proud to present an Influencer Interview with Arion Lillard-Green, MHA, M.TS.** Arion Lillard-Green, MHA, M.TS, is a native of Prince George’s County, Maryland. Lillard-Green has emerged as a passionate advocate for equity and inclusion. As a first-generation college student, Arion navigated her academic journey with resilience, balancing her studies with leadership roles that amplify marginalized voices. “We need to find ways to collect better, meaningful data to gain a well-rounded understanding of social risk factors,” she says. “The end-of-life journey should not start at the end of life. Unfortunately, aging and dying well is a privilege that needs to be extended to all persons earlier in the health care continuum.” A former Chaplain with Goodwin House Palliative Care and Hospice in Falls Church, VA. She is an advocate for making health education and health literacy accessible to all people through inclusion and is dedicated to making an impact on chronic illness within the African American community through outreach. Arion has served as a contributor to the development of provider resources and tools aimed at assisting hospice and palliative care organizations with diversifying patient populations. She is a member of the National Hospice and Palliative Care Organization’s Diversity Advisory Council, a commissioner on the City of Alexandria’s Commission on HIV/AIDS, and a consultant to organizations building programs to expand their reach to underserved communities. Watch the video here: [https://vimeo.com/cdfoundation/ii-alg]() For more information, contact: Susan Gold, Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Influencer Interview: Arion Lillard-Green, MHA, M.TS Source: [HTML](https://cunniffdixon.org/influencer-interviews/influencer-interview-arion-lillard-green-mha/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/influencer-interview-arion-lillard-green-mha/index.html.md) ![]() **We are proud to present an Influencer Interview with Arion Lillard-Green, MHA, M.TS** Arion Lillard-Green is a native of Prince George’s County, Maryland. Lillard-Green has emerged as a passionate advocate for equity and inclusion. As a first-generation college student, Arion navigated her academic journey with resilience, balancing her studies with leadership roles that amplify marginalized voices. “We need to find ways to collect better, meaningful data to gain a well-rounded understanding of social risk factors,” she says. “The end-of-life journey should not start at the end of life. Unfortunately, aging and dying well is a privilege that needs to be extended to all persons earlier in the health care continuum.” A former Chaplain with Goodwin House Palliative Care and Hospice in Falls Church, VA. She is an advocate for making health education and health literacy accessible to all people through inclusion and is dedicated to making an impact on chronic illness within the African American community through outreach. Arion has served as a contributor to the development of provider resources and tools aimed at assisting hospice and palliative care organizations with diversifying patient populations. She is a member of the National Hospice and Palliative Care Organization’s Diversity Advisory Council, a commissioner on the City of Alexandria’s Commission on HIV/AIDS, and a consultant to organizations building programs to expand their reach to underserved communities. Watch the video here: [https://vimeo.com/cdfoundation/ii-alg]() For more information, contact: Susan Gold, Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Supporting the End of Life Nursing Education Consortium \(ELNEC\) Source: [HTML](https://cunniffdixon.org/foundation-news/supporting-elnec/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/supporting-elnec/index.html.md) [**![]()**]()**On campus at the University of Portland with amazing palliative care nursing educators.** The Cunniff-Dixon Foundation (CDF) is dedicated to enhancing the provider-patient relationship at the end of life through education, collaboration, and recognition. In line with this mission, CDF proudly supports the End-of-Life Nursing Education Consortium (ELNEC) Faculty Development and Leadership in Palliative Care Workshop for undergraduate and graduate faculty. From July 24-26, 2025, CDF joined ELNEC and 130 nursing educators on the campus of the University of Portland for an inspiring exchange of knowledge, wisdom, and experience. The strong sense of camaraderie among attendees was palpable, as they forged meaningful connections with one another, to enhance the palliative care curricula taught to their students back home. Organized by Andra Davis, PhD, MN, BSN, and Megan Lippe, PhD, MSN, RN, ANEF, FAAN, the workshop was established in 2024. It features nationally recognized presenters who empower participants to return to their schools with clear goals and actionable deliverables to enhance palliative care education. As an added benefit, CDF’s Executive Director, Andy Peters, provided participants with access to *Planning My Way*, CDF’s advanced care planning tool. This resource enables students to gain hands-on experience with end-of-life care planning in the classroom, further enriching their experiential learning opportunities. A highlight of the workshop was a heartfelt ceremony where CDF presented Erin Collins, MN, RN, CHPN, a 2025 Nursing Awardee, with her award certificate. Surrounded by her cheering peers and family, the emotional moment underscored the spirit of recognition and community that defines ELNEC and CDF’s shared mission. ![]() For more information, contact: Susan Gold, Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Trailblazer Erin Collins wins CDF Nursing Award 2025 Source: [HTML](https://cunniffdixon.org/foundation-news/trailblazer-erin-collins-wins-cdf-nursing-award/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/trailblazer-erin-collins-wins-cdf-nursing-award/index.html.md) [**![]()**]()**Celebrating Erin Collins, 2025 CDF Nursing Awardee and Trailblazer Blending Clinical Expertise with Empathy** On July 24, 2025, the Cunniff Dixon Foundation proudly honored Erin Collins, MN, RN, CHPN, Co-founder and Director of Programs at The Peaceful Presence Project, as a 2025 CDF Nursing Awardee. The celebration took place during the End of Life Nursing Education Consortium (ELNEC) workshop in Portland, Oregon, and was attended by over 150 guests, including Erin’s husband, Owen, and their sons, Angus and Daishell. The event was a heartfelt tribute to Erin’s transformative contributions to palliative and end-of-life care. With 17 years of experience as a certified hospice and palliative care nurse, Erin has made significant impacts in hospice care, as well as adult and pediatric oncology. Trained as an end-of-life doula, she brings a unique perspective to her work, blending clinical expertise with deep empathy. Erin’s leadership extends to her roles as a board member of the Oregon Hospice and Palliative Care Association, an appointed member of the Oregon Health Authority’s Palliative Care and Quality of Life Advisory Council, and the former vice-chair of the National Hospice and Palliative Care Organization’s End-of-Life Doula Advisory Council. Erin co-founded The Peaceful Presence Project to address a critical gap in end-of-life care: the fear and lack of preparation many patients face when confronting terminal illness. Through her organization, she has dedicated herself to educating individuals, families, students, and clinicians about serious and terminal illnesses. Her approach emphasizes open, compassionate conversations about death, empowering families to be fully present with their loved ones during their final moments, whether those moments are days or months. Erin’s philosophy is rooted in the belief that planning for death and discussing it openly can significantly reduce the suffering associated with life’s final chapter. Her work fosters a culture of acceptance and tenderness, ensuring that patients and their families are supported with dignity and care. Erin Collins’ work exemplifies the heart of palliative care, and her recognition as a 2025 CDF Nursing Awardee is a testament to her unwavering commitment to improving end-of-life care. Join us in celebrating her remarkable contributions and inspiring legacy by reliving the highlights from Erin’s award celebration here: [https://vimeo.com/cdfoundation/naec](). For more information, contact: Susan Gold, Director of Communications Cunniff-Dixon Foundation susan@cunniffdixon.org ### Call for Nominations - 2026 Hastings Center Cunniff-Dixon Physician Awards Source: [HTML](https://cunniffdixon.org/foundation-news/call-for-nominations-2026-cdf-physician-awards/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/call-for-nominations-2026-cdf-physician-awards/index.html.md) [**![]()**]()**2026 Hastings Center Cunniff-Dixon Physician Awards Call for Nominations** Nominations are open as of October 1, 2025, for the 2026 Hastings Center Cunniff-Dixon Physician Awards, which recognize physicians who provide outstanding care to patients nearing the end of life. The 2026 awards include: - **Three Early-Career Physician Awards**: Each award provides $15,000 to a physician with up to 10 years of practice who demonstrates excellence in palliative care. - **Dr. Richard Payne Senior Leadership Award**: A $25,000 award for a senior physician with 15-plus years of practice who is recognized for outstanding contributions to palliative care and dedicated service to underserved communities. Nominations will be accepted from **October 1, 2025**, until **January 31, 2026**. For full details and to submit a nomination, visit [CDFAwards.org](). The awards are funded by the Cunniff-Dixon Foundation, which is committed to enhancing the provider-patient relationship at the end of life through education, collaboration, and recognition. The Hastings Center for Bioethics, an independent, nonpartisan bioethics research institute that has done groundbreaking work on end-of-life decision-making, co-sponsors these awards. Learn more about the physician awards selection committee at [https://cdfawards.org/about/physician-awards-committee/]() Watch a brief video on the nomination process at [https://vimeo.com/cdfoundation/cdfpav]() For more information, contact: Susan Gold, Director of Communications Cunniff-Dixon Foundation susan@cunniffdixon.org ### Unstoppable Mel Mayorga - CDF Nursing award Winner 2025 Source: [HTML](https://cunniffdixon.org/foundation-news/cdf-nursing-award-2025-mel-mayorga/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/cdf-nursing-award-2025-mel-mayorga/index.html.md) [**![]()**]()**Spotlight on Compassion: The Enduring Legacy of Mel Mayorga, RN, MSN, CNS, AGCNS-BC, OCN** In the bustling heart of downtown Los Angeles, where the demands of cutting-edge cancer care meet the quiet dignity of end-of-life support, one nurse stands as a beacon of unwavering empathy and innovation. Meet Mel Mayorga, a Clinical Nurse Specialist in Ambulatory Oncology Services at the University of Southern California's Norris Comprehensive Cancer Center. Board-certified as an Adult-Gerontology Clinical Nurse Specialist and an Oncology Nurse, Mel's expertise spans the complexities of geriatric care and the rigors of cancer treatment, ensuring patients receive holistic support at every stage. Beyond her clinical prowess, Mel is a driving force in fostering safer, more professional environments for both patients and colleagues. She chairs the Ambulatory Fall Prevention Council for Norris and Keck ambulatory clinics, spearheading initiatives that reduce risks and enhance mobility for vulnerable oncology patients. As co-chair of the Keck Nursing Professionalism Program, she mentors emerging nurses, instilling values of integrity, collaboration, and excellence that ripple through the entire healthcare team. What truly sets Mel apart, however, is her unyielding commitment to compassionate care—a philosophy she describes as "care that never quits." Her brilliance shines not just in patient rooms but in the innovative programs she champions and the humanitarian causes she embraces. A devoted member of the Los Angeles Chapter of the Nurse Honor Guard, Mel honors fallen colleagues by attending memorial services, offering a solemn tribute to those who dedicated their lives to healing others. In 2024, Mel's extraordinary contributions were celebrated with the prestigious Simms/Mann Family Foundation's Off the Chart Award, recognizing trailblazing nurses in the Los Angeles area. The accolade highlighted her pioneering work in palliative care, where she blends evidence-based practices with seamless inter-professional collaborations to address the emotional toll on everyone involved. Among her standout creations: - **The Sacred Pause Initiative**: A vital "just-in-time" grief support program for clinicians and staff, providing immediate tools and spaces to process loss amid the intensity of oncology work. - **By Your Side**: A compassionate hospital vigil program that accompanies patients and families through end-of-life moments, ensuring no one faces their final hours in isolation. - **Last Responders Lectures**: Drawing from her deep insights, Mel has delivered compelling talks on the role of nurses as "last responders"—the quiet heroes who provide closure and comfort when all other interventions fade. Mel's initiatives remind us that true healing extends beyond medicine; it's about honoring the human spirit in its most fragile states. As she continues to lead with heart and intellect, Mel Mayorga not only transforms lives at USC Norris but also inspires a new generation of nurses to embrace the sacred in their calling. In a field that can feel relentless, Mel proves that compassion, when paired with action, is the ultimate remedy. Watch a brief video of Mel's CDF Nursing Award ceremony at [https://vimeo.com/user26533658/cdf-mm]() For more information, contact: Susan Gold, Director of Communications Cunniff-Dixon Foundation susan@cunniffdixon.org ### 2025 has been an exceptional year at the Cunniff-Dixon Foundation Source: [HTML](https://cunniffdixon.org/foundation-news/exceptional-year-at-cdf/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/exceptional-year-at-cdf/index.html.md) [**![]()**]() 2025 has been an exceptional year at the Cunniff-Dixon Foundation, advancing our mission to strengthen the provider-patient relationship at the end of life through targeted education, strategic collaborations, and meaningful recognition programs. Our efforts reached thousands of healthcare professionals, patients, and caregivers nationwide, fostering compassionate care and innovative end-of-life planning. Highlights include: Celebrating three exceptional palliative care nurses who received the 2025 Hastings Center Cunniff-Dixon Nursing Award; Giving the CDFAwards.org website a refresh; Producing and distributing quarterly newsletters to our CDF and Planning My Way communities, reaching over 2,000 recipients; Releasing compelling Influencer Interviews with palliative care leaders to promote best practices and personal insights; Marking a significant four-year partnership with the End-of-Life Nursing Education Consortium (ELNEC), supporting their educational workshop and highlighting the transformative impact of ELNEC nursing education. Opening nominations for the 2026 Physician Awards and welcoming Dr. Justin Baker, MD, FAAP, FAAHPM, to our Physician Awards Selection Committee. We’re looking forward to a little rest over the coming Holiday Season, enjoying friends and family, and we are excited about all we will continue to create together in 2026! For more information, contact: Susan Gold, Director of Communications Cunniff-Dixon Foundation susan@cunniffdixon.org ### National Recognition for UAB Nurse Source: [HTML](https://cunniffdixon.org/foundation-news/boundless-compassion-jackie-palmore-wins-cdf-nursing-award-2025/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/boundless-compassion-jackie-palmore-wins-cdf-nursing-award-2025/index.html.md) [**![]()**]()**Boundless Compassion in Palliative Care Earns National Recognition for UAB Nurse** **Birmingham, AL – December 19, 2025** Jackie Palmore, RN, BSN, CHPN, a veteran palliative care nurse at the University of Alabama at Birmingham (UAB) Medical Center, has been honored with the prestigious 2025 Hastings Center Cunniff-Dixon Nursing Award for her extraordinary dedication to end-of-life care. The award, presented by The Hastings Center and the Cunniff-Dixon Foundation, recognizes nurses who exemplify exceptional compassion and skill in supporting patients nearing the end of life. Each recipient receives a $25,000 prize. Palmore is one of three nurses selected nationwide for 2025. As Clinical Coordinator for the UAB Center for Palliative and Supportive Care, Palmore has dedicated 38 years to nursing, with the majority focused on palliative, supportive, and hospice care. She played a key role in establishing UAB's 12-bed inpatient Palliative and Comfort Care Unit in 2004, building the inpatient consult service, and forming the interdisciplinary palliative care team. For more than two decades, Palmore has led the unit with unwavering compassion, modeling team-based care and advancing palliative practices across the hospital. She was the first nurse at UAB to achieve national certification in palliative nursing and recently completed the institution's Pain and Addiction Scholars program. Notably, Palmore extended her expertise beyond traditional settings by pioneering palliative care services within the Alabama Department of Corrections in 2001, creating the state's first hospice program for incarcerated individuals. As a faculty member of the UAB Palliative Care Leadership Center, affiliated with the Center to Advance Palliative Care (CAPC), she has trained over 50 hospice and palliative care teams across the country. The Cunniff-Dixon Foundation praised Palmore's lifelong commitment to compassionate care, highlighting how her work embodies the award's mission to enrich provider-patient relationships at the end of life. Please enjoy the video tribute to Jackie by clicking here: [https://cdfawards.org/awardees/jackie-palmore-rn-bsn-chpn/?portfolioCats=55]() For more information, contact: Susan Gold, Director of Communications Cunniff-Dixon Foundation susan@cunniffdixon.org ### 2026 Physician Award Nominations Deadline Extended through February 13, 2026 Source: [HTML](https://cunniffdixon.org/foundation-news/call-for-nominations-2026-hastings-center-cunniff-dixon-physician-awards-newdeadline/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/call-for-nominations-2026-hastings-center-cunniff-dixon-physician-awards-newdeadline/index.html.md) [**![]()**]() **2026 Physician Award Nominations Deadline Extended through February 13, 2026** Nominations are open, and the deadline has been extended through February 13, 2026, for the 2026 Hastings Center Cunniff-Dixon Physician Awards, which recognize physicians who provide outstanding care to patients nearing the end of life. The 2026 awards include: - Three Early-Career Physician Awards: Each award provides $15,000 to a physician with up to 10 years of practice who demonstrates excellence in palliative care. - Dr. Richard Payne Senior Leadership Award: A $25,000 award for a senior physician with 15-plus years of practice who is recognized for outstanding contributions to palliative care and dedicated service to underserved communities. For full details and to submit a nomination, visit [CDFAwards.org](). The awards are funded by the Cunniff-Dixon Foundation, which is committed to enhancing the provider-patient relationship at the end of life through education, collaboration, and recognition. The Hastings Center for Bioethics, an independent, nonpartisan bioethics research institute that has done groundbreaking work on end-of-life decision-making, co-sponsors these awards. Learn more about the physician awards selection committee at: [https://cdfawards.org/about/physician-awards-committee/]() Watch a brief video on the nomination process at[https://vimeo.com/cdfoundation/cdfpav]() For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### Call for Nominations: 2026 Hastings Center Cunniff-Dixon Physician Awards Source: [HTML](https://cunniffdixon.org/foundation-news/call-for-nominations-physician-awards-2026/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/call-for-nominations-physician-awards-2026/index.html.md) [**![]()**]()**Call for Nominations: 2026 Hastings Center Cunniff-Dixon Physician Awards** Nominations are open through January 31, 2026, for the Hastings Center Cunniff-Dixon Physician Awards, which honor exceptional physicians delivering compassionate palliative and end-of-life care across the United States. Think of a palliative care physician who exemplifies the very best in this vital field—one who: - Enters the most difficult moments with unwavering compassion and courage - Listens deeply, even when words are hard to find - Guides patients, families, and loved ones with wisdom, dignity, and grace - Infuses every day with meaningful moments of living, no matter the circumstances As a fellow clinician, take a moment to nominate a deserving palliative care physician for this prestigious recognition. These quiet heroes transform end-of-life journeys with profound humanity—and your nomination can help celebrate their extraordinary contributions. Nominations close **January 31, 2026**. For full eligibility criteria, guidelines, and the nomination form, visit: [**CDFawards.org**]() Here's a link to a short video about the CDF Physician Awards: [https://vimeo.com/cdfoundation/cdfpav]() Together, let's shine a light on the physicians who make our most vulnerable moments gentler and more humane. If you need assistance with the nomination process, please contact Susan at **susan@cunniffdixon.org**. ### 2026 Physician Award Nominations Close Source: [HTML](https://cunniffdixon.org/foundation-news/2026-physician-award-nominations-close/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/2026-physician-award-nominations-close/index.html.md) [**![]()**]()**2026 Physician Award Nominations Close** We’re delighted to share that we’ve just wrapped the 12th nomination period for the **2026 Hastings Center Cunniff-Dixon Physician Awards.**Thank you to everyone who submitted nominations—the response was truly inspiring, and we received an outstanding group of candidates dedicated to exemplary palliative and end-of-life care. Our distinguished selection committee will convene in late March to carefully review each nomination. We look forward to announcing the 2026 award recipients no later than May 1, 2026! For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### Launch of CDF INSIGHTS Source: [HTML](https://cunniffdixon.org/foundation-news/2026-launch-of-insights-series/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/2026-launch-of-insights-series/index.html.md) [**![]()**]()**Launch of CDF INSIGHTS: A New Video Shorts Series Illuminating Wisdom in Palliative and End-of-Life Care** We are thrilled to announce the launch of **INSIGHTS**, our new video shorts series dedicated to sharing concise, powerful pearls of wisdom from exemplary leaders and practitioners in palliative care, perinatal palliative support, hospice, and end-of-life care. At a time when thoughtful, humane approaches to serious illness and dying are more essential than ever, INSIGHTS brings you brief, heartfelt reflections from individuals whose decades of bedside experience, advocacy, and innovation have transformed how we honor life at its most vulnerable moments. These shorts are designed for easy sharing: perfect for clinicians, families, educators, students, and anyone seeking inspiration, practical guidance, or a moment of profound connection amid grief and caregiving. We are honored to launch the series with Fran McCarthy, MS, RNC-NIC, CPLC—former Clinical Coordinator of the Neonatal Comfort Care Program at New York-Presbyterian Morgan Stanley Children’s Hospital of Columbia University and winner of the 2023 Cunniff-Dixon Nursing Award. With over 40 years as a dedicated NICU nurse and pioneer in perinatal palliative nursing, Fran has supported countless families facing life-limiting prenatal diagnoses. In the inaugural INSIGHTS short, Fran shares a core truth drawn from her remarkable career: [https://fb.watch/FYbPWww\_NE/]() Wisdom often shines brightest in short, luminous bursts. These videos will aim to spark reflection, encourage dialogue, and remind us that compassionate care is a profound act of humanity. **Watch the Launch Episode Here, and please share the link widely.** For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### 2026 Hastings Center Cunniff-Dixon Physician Awards Announced Source: [HTML](https://cunniffdixon.org/foundation-news/2026-hastings-center-cunniff-dixon-physician-awards-announced/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/2026-hastings-center-cunniff-dixon-physician-awards-announced/index.html.md) **![]()**2026 Hastings Center Cunniff-Dixon Physician Awards Announced The Hastings Center for Bioethics and the Cunniff-Dixon Foundation are pleased to announce the recipients of the 2026 Hastings Center Cunniff-Dixon Physician Awards. They recognize physicians who provide exceptional care for patients nearing the end of life with outstanding technical competence, personal integrity, empathic communication, active family engagement, thoughtful discussions about advance directives, and compassionate relief of suffering. The 2026 awards include: - Three Early-Career Physician Awards: A $15,000 award for each physician with up to 10 years of practice who demonstrates excellence in palliative care. - Dr. Richard Payne Senior Leadership Award: A $25,000 award honoring a senior physician with 15 or more years of practice for outstanding contributions to palliative care and dedicated service to underserved and vulnerable communities. The Cunniff-Dixon Foundation created and funds these awards to enrich the provider-patient relationship near the end of life through education, collaboration, and recognition. The Hastings Center for Bioethics, which has done groundbreaking work on end-of-life decision-making, co-sponsors the program. “Our prestigious selection committee has once again selected a special group of physicians excelling in their field of palliative care and in the practice of heart and human-centered medicine,” said Andy Peters, Executive Director of the Cunniff-Dixon Foundation. “We hope that by shedding light on these leaders and their teams, the important model that is palliative care will continue to grow and serve our communities.” **The 2026 recipients are:** **![]()** **Dr. Richard Payne Senior Leadership Award Noelle Marie Javier, MD, AGSF, FAAHPM, Icahn School of Medicine at Mount Sinai** Dr. Javier is a professor in the Departments of Medicine and Medical Education and in the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai in New York. As a dedicated internist, geriatrician, and palliative care physician who carries and celebrates multiple intersectional identities, including being a woman, Filipina, an immigrant, and born transgender, she has devoted her time and efforts in contributing to and amplifying the provision of high-quality, inclusive, affirming, and compassionate geriatric, hospice, palliative, and end-of-life care towards marginalized minority communities, especially the LGBTQI+ people living with serious and advanced illnesses. She has achieved these goals in part through ongoing interprofessional healthcare education, collaboration with research experts, and partnerships with local and national organizations to recommend changes in policies and practice patterns. She has presented her work in both national and international conferences. Dr. Javier is the past chair for both the Diversity, Equity, and Inclusion Committee and LGBTQI+ SIG of the American Academy of Hospice and Palliative Medicine, a past board member of GLMA: Health Professionals Advancing LGBTQ Equality, a current member of the Ethics Committee of the American Geriatrics Society, and a current member for both the Health Equity Commission and Women and Medicine Commission of the Society for General Internal Medicine. **![]()​​Early-Career Physician Awardee****Amar D Bansal, MD, FASN, Associate Professor of Medicine, UPMC and the University of Pittsburgh School of Medicine** **Dr. Bansal is a nephrologist and palliative care physician at UPMC. He is the associate program director for the nephrology fellowship. In the outpatient setting, his interests are in general nephrology and kidney palliative care. He is passionate about teaching doctors how to communicate with patients about serious illness clearly and compassionately. He is a senior faculty member at VitalTalk, an evidence-based training organization that teaches clinicians practical communication skills for discussing prognosis and navigating goals of care with seriously ill patients and their families. Dr. Bansal enjoys being part of a multidisciplinary team and takes special care to support patients and their families through complex decisions. His enthusiasm for team building and operational efficiency has led him to become one of the team members overseeing physician well-being at UPMC, where he serves as the Associate Medical Director of Physician Thrive.** **![]()** ****Early-Career Physician Awardee**Gina Piscitello, MD, MS, FAAHPM, Assistant Professor in the Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine** Dr. Piscitello is a palliative medicine physician and researcher at the University of Pittsburgh. She is also the medical director of the inpatient palliative medicine consult service at UPMC Presbyterian Hospital. Her research interests focus on the intersection of clinical medical ethics and palliative medicine, including identifying and addressing disparities in care for patients with serious illnesses. Her work has been published in journals including JAMA, JAMA Health Forum, CHEST, and the Journal of Pain and Symptom Management. She is passionate about promoting discussions and scholarship about clinical medical ethics locally and nationally. **![]()** ****Early-Career Physician Awardee**Ramy Sedhom, MD, FASCO, Director, Program in Geriatric Oncology & Supportive Care Innovation, Penn Center for Cancer Care Innovation; Section Chief, Medical Oncology and Palliative Care, Penn Medicine Princeton Health, Assistant Professor of Clinical Medicine in the Division of Hematology & Oncology at the University of Pennsylvania** Dr. Sedhom’s clinical and research interests are centered on one principle – improving patient-centered care for vulnerable populations with cancer and their caregivers. He has a robust portfolio of work in palliative care integration, geriatric assessment, psycho-oncology, caregiver support, and remote patient monitoring, all focused in the community setting. His work has been published in leading journals, including Journal of Clinical Oncology, JAMA, and the Journal of the National Cancer Institute. He is chair of the American Society of Clinical Oncology’s (ASCO) Supportive Care in Cancer Committee. He has received several awards for research, clinical excellence, and teaching, including the ASCO Conquer Cancer Foundation’s Young Investigator Award and the Association for Value-Based Cancer Care's 40 Under 40. Learn more about the Physician Awards Selection Committee:[https://cdfawards.org/about/physician-awards-committee/]() ****For information about past awardees and celebrations:[https://cdfawards.org/cdf-awardees]()**** For more information, contact: Susan Gold Director of Communications Cunniff Dixon Foundation susan@cunniffdixon.org ### Influencer Interview: Carrie Cormack, DNP, APRN, CPNP Source: [HTML](https://cunniffdixon.org/influencer-interviews/influencer-interview-carrie-cormack/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/influencer-interview-carrie-cormack/index.html.md) [**![]()**]()Meet **Carrie Cormack, DNP, APRN, CPNP** – an incredible pediatric palliative care nurse practitioner, educator, and leader based in Charleston, South Carolina! As Associate Professor and lead palliative care faculty at the Medical University of South Carolina (MUSC) College of Nursing, she's a Distinguished Professor in Palliative Care, dedicated to training the next generation of nurses. Carrie earned her BSN from Saint Anselm College, MSN and DNP from MUSC, and holds certifications from the Pediatric Nursing Certification Board and Hospice and Palliative Credentialing Center. She's also a Fellow of the Hospice and Palliative Nurses Association (FPCN) and the American Academy of Nursing (FAAN). Clinically, she specializes in perinatal and pediatric palliative care at MUSC Children's Health, including Shawn Jenkins Children's Hospital and the Advanced Fetal Care Center – providing compassionate, family-centered support from diagnosis through end-of-life when needed. We had the privilege of meeting Carrie at an ELNEC (End-of-Life Nursing Education Consortium) workshop and were blown away! She's been instrumental in integrating the ELNEC curriculum into MUSC's programs (one of the few requiring palliative care training for all students), contributing to graduate and pediatric modules, and even co-directing international seminars to advance care in low-resource countries. An emerging leader in palliative care education, Carrie has published on preparing advanced practice nurses for primary palliative care, earned the ELNEC Award of Excellence, and passionately advocates that palliative care is supportive care throughout serious illness – not just hospice. We hope you'll love her inspiring CDF Influencer Interview as much as we do! [https://vimeo.com/cdfoundation/iicc]() For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### Influencer Interview: Carolyn Phillips, PhD, RN Source: [HTML](https://cunniffdixon.org/influencer-interviews/influencer-interview-carolyn-phillips/) Markdown: [Markdown](https://cunniffdixon.org/influencer-interviews/influencer-interview-carolyn-phillips/index.html.md) [**![]()**]()**Blending Music and Medicine to Transform Patient Care** Dr. Carolyn Phillips is an emerging leader in integrating the arts into clinical practice. A nurse scientist, educator, and accomplished musician, Dr. Phillips is redefining how emotional healing and resilience are supported among patients, caregivers, and healthcare professionals. With more than two decades of experience in oncology nursing, advanced postdoctoral training at Dana-Farber Cancer Institute and Harvard Medical School, Dr. Phillips has built a career at the intersection of science and creativity. Her work centers on developing innovative, evidence-based interventions that use music and storytelling to strengthen emotional communication and psychological well-being. This work reflects Dr. Phillips’s longstanding mission: to deepen understanding of patients’ emotional lives—what she often describes as their “emotional bandwidth.” By translating personal narratives into music and through her non-profit, [*Song for the Soul*](), Dr. Phillips creates a space where patients, caregivers, and healthcare professionals can explore and express complex emotions that are often difficult to capture through traditional clinical dialogue. Her integration of expressive arts into research and practice underscores a central theme in her career: emotional understanding is fundamental to effective, compassionate care. We’re honored to share her Influencer Interview with you here: [https://vimeo.com/cdfoundation/iicp](). For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### National Nursing Award Nominations Open This Fall Source: [HTML](https://cunniffdixon.org/foundation-news/national-nursing-award-nominations-open-this-fall/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/national-nursing-award-nominations-open-this-fall/index.html.md) **![]()** **National Nursing Award Nominations Open This Fall** Nominations for the 2026 Cunniff-Dixon Foundation Nursing Awards open on October 1st. The national awards recognize excellence in professional practice and leadership for exemplary nurses in palliative care. The esteemed selection committee is headed by Dr. Betty Ferrell, PhD, RN, MA, FAAN, FPCN, CHPN. Up to three nurses are recognized. Each receives an unconditional financial award of $25,000. For full details regarding the nursing award nominations process and criteria, please visit: [https://cdfawards.org/nominations-process/criteria-nursing-awards/]() The nominations video is also helpful when considering creating a nomination: [https://vimeo.com/cdfoundation/na27]() Videos of past award winners may be found here: [https://cunniffdixon.org/founders-statement/foundation-videos/]() For more information, please email Susan Gold, Director of Communications, Cunniff-Dixon Foundation, susan@cunniffdixon.org. ### Celebrating Early Career Awardee Gina Piscitello, MD, MS, FAAHPM Source: [HTML](https://cunniffdixon.org/foundation-news/physician-award-2026-gina-piscitello/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/physician-award-2026-gina-piscitello/index.html.md) [**![]()**]()We were delighted to celebrate **Gina Piscitello, MD, MS, FAAHPM**, one of three 2026 Early Career Physician Award recipients, during a special gathering in Pittsburgh on June 30. Gina was nominated by Robert Arnold, MD, and Donna Durant, DNP. Jane Schell, MD, Section Chief of Palliative Care and Medical Ethics and Associate Professor of Medicine at UPMC, welcomed those attending. Jane received a CDF Physicians Award in 2018. Gina was honored for her outstanding contributions at the intersection of medical ethics and palliative care. We captured her celebration through this video and are delighted to share it with you here: [https://vimeo.com/cdfoundation/cdfpagp]() For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### Shellie Williams, MD, Named to Cunniff-Dixon Physician Awards Selection Committee Source: [HTML](https://cunniffdixon.org/foundation-news/shellie-williams-md-named-cdf-physician-award-committe/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/shellie-williams-md-named-cdf-physician-award-committe/index.html.md) [**![]()**]() It is a privilege to welcome [Shellie Williams, MD](), to the Cunniff-Dixon Physician Awards Selection Committee. Dr. Williams is a board-certified physician specializing in geriatric medicine, palliative care, and internal medicine at UChicago Medicine and received the inaugural Cunniff-Dixon Richard Payne Senior Leadership Award in 2022. She joins an esteemed selection committee that includes Chairperson Kathy Foley, MD; Diane Meier, MD, FACP; Justin Baker, MD, FAAP, FAAHPM; and Rodney Tucker, MD, MMM, FAAHPM. For more information about the Cunniff-Dixon Physician Awards, visit[cdfawards.org](). For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### Investing in Nursing Educators, Transforming End-of-Life Care Source: [HTML](https://cunniffdixon.org/foundation-news/elnec-investing-in-nursing-education/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/elnec-investing-in-nursing-education/index.html.md) [**![]()**]()The End-of-Life Nursing Education Consortium (ELNEC) Faculty Development and Leadership in Palliative Care Workshop Advanced was held last month in Portland, Oregon. aims to prepare nursing faculty to advance undergraduate and graduate palliative care curricula. The July 2026 gathering marked the second year of the Cunniff-Dixon Foundation's four-year commitment to support this exceptional program. The goal of the two-day immersion is to equip nursing educators from across the country with the knowledge, skills, and resources to prepare the next generation of nurses to provide compassionate, high-quality care for individuals and families facing serious illness and the end of life. The impact of the workshop was evident throughout the two-day gathering. Meghan Lippe, PhD, RN, ANEF, FPCN, FAAN, one of the workshop creators, shared, "I truly believe this was our best workshop yet. One participant, who has been a nurse for more than 30 years, told us these were two of the best days of her entire career." An especially meaningful highlight was the return of a participant who presented a poster showcasing the progress she had made over the past year in implementing the goals she established at the previous workshop. While much of the educational content is intentionally consistent from year to year, she reflected that she was in a completely different place with curriculum integration this year. As a result, the same material resonated in new ways, meeting her evolving needs and inspiring the next phase of her work. Adding another memorable dimension to the experience, University of Portland faculty member Maureen Briare shared the gift of live harp music throughout the workshop, creating moments of reflection, peace, and connection that beautifully complemented the learning environment. The workshop was filled with rich educational content, meaningful collaboration, and countless moments of inspiration. The Cunniff-Dixon Foundation is deeply grateful for the opportunity to support this remarkable gathering and its mission of strengthening end-of-life nursing education across the country. For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ### Call for Nominations: Hastings Center Cunniff-Dixon Nursing Awards 2027 Source: [HTML](https://cunniffdixon.org/foundation-news/call-for-nominations-cunniff-dixon-nursing-awards/) Markdown: [Markdown](https://cunniffdixon.org/foundation-news/call-for-nominations-cunniff-dixon-nursing-awards/index.html.md) [**![]()**]()Nominations are open for the [2027 Hastings Center Cunniff-Dixon Nursing Awards](). Prizes of $25,000 each will go to up to three nurses who provide outstanding end-of-life care based on compassionate service and merit. Nurses at all levels of practice (LVN/LPN, RN/APRN) qualify for nomination. The nomination **deadline is January 31, 2027.** The Cunniff-Dixon Foundation, whose mission is to enrich the provider-patient relationship near the end of life through education, collaboration, and recognition, created and funds the awards. The Hastings Center for Bioethics, the oldest independent nonpartisan bioethics research institute, co-sponsors the awards. The awards selection committee is composed of Betty Ferrell, director of nursing research and education and a professor at City of Hope in Duarte, Calif.(chair); Ashley Leak Bryant, associate professor of nursing at the University of North Carolina at Chapel Hill; Lynn F. Reinke, endowed professor of palliative care at the University of Utah; Tamryn Fowler Gray, associate professor of clinical instruction at the University of North Carolina at Chapel Hill School of Nursing; and Billy Rosa, chief research fellow at Memorial Sloan Kettering Cancer Center. [Learn more about the awards](). [Watch this brief video with winning nurses](). [Access the nomination form](). For additional information, please contact: Susan Gold Communications Director Cunniff-Dixon Foundation Email: susan@cunniffdixon.org ## Avada Portfolio ### CLEAN WATER Source: [HTML](https://cunniffdixon.org/portfolio-items/clean-water/) Markdown: [Markdown](https://cunniffdixon.org/portfolio-items/clean-water/index.html.md) ### EDUCATION Source: [HTML](https://cunniffdixon.org/portfolio-items/education/) Markdown: [Markdown](https://cunniffdixon.org/portfolio-items/education/index.html.md) ### VACCINES Source: [HTML](https://cunniffdixon.org/portfolio-items/vaccines/) Markdown: [Markdown](https://cunniffdixon.org/portfolio-items/vaccines/index.html.md) ### FARMING Source: [HTML](https://cunniffdixon.org/portfolio-items/farming/) Markdown: [Markdown](https://cunniffdixon.org/portfolio-items/farming/index.html.md) ### SHELTER Source: [HTML](https://cunniffdixon.org/portfolio-items/shelter/) Markdown: [Markdown](https://cunniffdixon.org/portfolio-items/shelter/index.html.md) ### FAIR TRADE Source: [HTML](https://cunniffdixon.org/portfolio-items/fair-trade/) Markdown: [Markdown](https://cunniffdixon.org/portfolio-items/fair-trade/index.html.md)