Hospice Medical Director Course: A seamless Presentation of Material

Julie Bruno, AAHPM Director of Education, started the morning plenary session with a reminder that “life happens” at preconference workshops just as it does in real life, so one of the session speakers had to attend to a family health matter. The schedule was therefore rearranged a bit to provide the two remaining faculty time to cover the additional lectures. The speakers are experts and the presentation seamless.

So first off, Pat Schmidt gave her lecture on Communication, Psychosocial & Spiritual Care. Everybody has a story to tell, and sometimes they need help, but we have to hear and understand it for us to achieve our goal of allowing them to die with dignity and in comfort. She listed the barriers to effective communication to help us avoid them, and what we can do to make it better: body language, time, place, attitude. Different settings (hospitals, SNFs, ALFs, and homes) have different cultures and ground rules to consider. So do different patients. So do the different physicians who see each patient: the old yin-yang symbol about how we interact as consultants is pertinent here. Communication is not just about words; we listen not only to what is said, but how, and why – because we want to recognize and validate emotions, and words are just not good enough.

The other IDT members can be invaluable here, because they have more training in psychological, social, and experiential topics than physicians; Cecily Saunders was first a social worker. The entire team is essential in helping the patient and the family deal with the grief of illness, and death, and bereavement. Our tendency as healers is to want to fix, to do something, but what we really need to do is just be present, listen, accept, validate, and try to understand. It’s harder to take a spiritual history than a sexual history. Grieving is helped y our presence, faith, noticing what’s needed, offering, doing, patience, acceptance, and empathy – little of which we learned in medical school. The team chaplain can be of immense help when there is spiritual pain – which may be relieved, but sometimes worsened, by religion. Spiritual palliation is the goal; this requires reflective listening. Communication is the foundation of our work, and all members of the IDT play a role in the management of complex symptoms.

Next up was Lyra Sihra (yes, she told us, it rhymes) who talked about Medical, Ethical and Legal Issues. Ethical practice follows with the four principles of autonomy, beneficence, nonmaleficence, and justice (societal and distributive) – all discussed, as was the principle of double effect, now being used more by courts and less by physicians, and withdrawing treatment – on which the ethics and policy have changed; n.b.: in medical ethics today there is no moral distinction between withholding treatment and withdrawing it. Long discussion of Karen Quinlan, Nancy Cruzan, Terri Schiavo, and the need for advance directives ensued.

Palliative sedation, and the new concept of “respite” palliative sedation, and whether they are OK for existential distress, and the fine lines between this and euthanasia and physician-assisted suicide concluded that at lease in the US, the Supreme Court has ruled that this is a state, not a federal issue. So know your state’s law; it’s important to understand what your courts say about what you do.

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