Hospice and Palliative Medicine

Navigating the Changing Landscape of Health Care

Health care has become a world of dizzying change as more and more people realize that the current system is not working for anyone. There are new regulatory models, new care delivery models, and new funding models, but no one has the silver bullet. Along with the increasing pace of change comes a flood of new concepts and terms to describe them, many of which are ill defined and themselves evolving.

Nowhere is health care changing more fundamentally than in how it regards the role of the patient in the process of care. Patient satisfaction has long been a standard metric for many health care institutions, but for many never rose above a “nice to have” next to the “must haves” of clinical effectiveness and financial viability. In fact, many thought patient satisfaction often got in the way of the other two goals because giving patients what will satisfy them was thought to cost money and slow down or even subvert the clinical process.

Then HCAHPS drove a change to “patient experience” – related to patient satisfaction but not the same. Experience is about how reliably a given process like pain control happens and satisfaction is about how happy the patient is with that process. And finally we have arrived at “patient engagement”- a subset of “patient experience” perhaps but maybe the biggest change of all. Fundamentally, patient engagement requires that we who provide care involve the patient as a full partner in the planning and carrying out of that care. This change would seem to mark the official death of medical paternalism. But, it certainly feels like “selling the farm” to many. How can good care result when we let those without training in the field have at least a vote in the treatment decisions and maybe even a veto? Certainly lots of people will make “bad” decisions.

To those of us who are familiar with the history of how authority has operated in western religion, this debate has to sound familiar. Arguably, the most far reaching change Martin Luther and other reformers brought about in western Christianity in the 16th century is the idea that every Christian can have their personal relationship with God and can independently decide what they believe. This change was implemented in part by translating the sacred text of Christianity into a language that each believer could read or at least understand. For the most part, the authority of the ordained religious leader remained as the expert on belief and practice but that role became much more advisory than prescriptive. The religious leader now had to convince the faithful that a certain belief or behavior was “right” rather than having the belief or practice followed just because the leader said so.

Modern professional health care chaplains have long been trained to operate in this advisory model. It has been for years against the codes of ethics and best practice in professional chaplaincy to tell someone what to believe or practice unless specifically asked for that advice. Patient engagement has been the standard of care. Those of us who have worked in this way for a long time are very comfortable letting the patient lead the conversation and reach their own conclusions about what their own religious or spiritual belief and practice should be even when they differ from our own and how that belief and practice can help them cope with their illness. In fact, this model of care seems to work better than dictating to the patient beliefs and behaviors which they then mostly don’t follow.

That experience of chaplaincy practice leads me to feel confident that true patient engagement of the kind professional chaplains have long practiced will in fact improve, not only the process, but the outcomes of health care. Many will resist as many have and still do resist this model of chaplaincy. However, I am convinced that professional chaplaincy can be a major facilitator of this necessary change and can help our patients and our health care colleagues embrace this new and strange but ultimately very beneficial model.

George Handzo, BCC, CSSBB
President, Handzo Consulting
Senior Consultant, HealthCare Chaplaincy

Should Failure to Follow Preferences be a Medical Error?

This past Tuesday was the annual National Healthcare Decisions Day when patients are encouraged “to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.” To be clear, this is not about getting people to agree to a Do Not Resuscitate order or agreeing to limit their treatment options if that is not what they want. It is presumably an opportunity for patients to take control of their care at a time when they otherwise would not be able to do so. For those of us for whom religious beliefs and values inform and undergird these decisions, it is about taking advantage of an open invitation from a health care system which so often seems oblivious to those beliefs to make them known and document them in relationship to care decisions.

In observing this day, Dr. Eric Widera offers a very provocative post on GeriPal. He cites a recent editorial by Theresa Allison and Rebecca Sudore in JAMA Internal Medicine and a related study by Heyland and colleagues investigating documentation of treatment preferences by a sample of elderly patients in Canada. One of the most dramatic and disturbing findings of the study was that, for those who had stated preferences, over two-thirds of those preferences were either not documented at all or documented incorrectly in the medical record. This finding calls into serious question the basic premise of advance directives. If one’s stated preferences are likely not to be observed, why even bother?

But Allison and Sudore up the ante even further when they state:

“Discussions about goals of care and code status constitute a medical procedure every bit as important to patient safety as a central line placement or a surgical procedure. Much as we have developed systems to improve patient safety in surgical procedures, we need to develop systematic approaches to discussing patient values and goals of care.”

Dr. Widera then raises the obvious question, “Should failure to follow preferences be a medical error?”

For those of us who are not physicians, this could be an invitation for doctor bashing. However, we need to all take seriously that patient safety is everyone’s responsibility. So if this is about patient safety, we are all culpable. But, even if this is not a patient safety issue, I would expect that all of us believe that patient’s wishes should be respected and every effort should be made to make that happen.

The newly released 3rd edition of the NCP Clinical Practice Guidelines contains the following criterion under Guideline 8.1. This criterion applies equally to all members of the treatment team.

“All expressed wishes, preferences, values, goals, plan of care, surrogate decision makers and advance care plans are routinely documented, including the completion of clinical orders such as inpatient resuscitation status, out of hospital do not resuscitate orders, and health care surrogate declaration documents for adult patients.”

So it seems to me the bottom line here is that all members of the treatment team are obliged, individually and as a group, to make sure that all stated treatment preferences and advance directives are well documented, well understood by the team, and observed. If the finding of this study turns out to be true more widely, all of us bear responsibility. Dr. Widera along with the authors of the editorial raise an interesting and provocative question. However, no matter whether consensus ever develops around the answer to that question or not, the findings of this study should galvanize us all to action. The findings point out that while getting patients to fill out their advance directives is a necessary first step, there is another necessary part to the process which may be seriously broken. Each of us needs to be committed to point out that brokenness each and every time we see it.

George Handzo, BCC, CSSBB
President, Handzo Consulting
Senior Consultant, HealthCare Chaplaincy

Hospice and Palliative Medicine Commit to ‘Choosing Wisely’

by Larry Beresford

On February 21 AAHPM, on behalf of its members and the specialty of hospice and palliative medicine, joined with 15 other medical societies to introduce Round Two of Choosing Wisely, a major national health care quality initiative sponsored by the ABIM Foundation. In a health care system undergoing rapid reforms, serious turmoil and escalating demands to raise quality and reduce costs, palliative care is often offered as a solution for providing appropriate care more in line with patients’ and families’ goals, with fewer unwanted and unhelpful treatments and, frequently, lower overall costs. But increasingly, HPM will be asked to show the evidence for the quality and efficiency of its own services, just like other sectors of health care.

The Choosing Wisely campaign challenges participating medical societies to name five treatments that are frequently performed but often unsupported by the medical evidence—and to share this list with their members and the public. AAHPM accepted that challenge, and took its place at the podium on February 21 with other societies concerned about their place in the health care value equation. The latest issue of AAHPM’s Quarterly newsletter describes how the academy developed its list, who participated in that work, and how academy members can join in the campaign in their own communities and facilities.

Now we’d like to hear from you. What do you think of the Academy’s Choosing Wisely list? Are there other treatments of questionable value that you think are equally deserving of quality improvement interventions to target unnecessary utilization? What is being done in your work setting to promote the goals and values of the Choosing Wisely campaign?

Larry Beresford is a freelance medical writer from Oakland, CA, who specializes in hospice and palliative care issues.

The Best Care Possible: A Conversation with Dr. Byock

In his new book, Dr. Byock shares his refined, crisp, socially and politically attractive call to action for people of our country to join in a thoughtful dialogue about how we all care for each through the end of life. The Best Care Possible follows The Four Things That Matter Most and Dying Well as a foundational contribution to Palliative Care and the American culture. Ira reframes the principles of palliative care in four simple words, The Best Care Possible. I spoke with my mentor about his new book.

Cory: I know you have been touring with your book, doing radio, television and press interviews. What is the dialogue you are hoping to incite?

Ira: The book is not the thing. I wrote the book to provoke discussion in the professional and general public about how we care for each other through the end of life. It is not from ill intention that people are dying badly, but rather because our culture doesn’t have a good sense of what good care is. Culturally we have to grow the rest of the way up. I want to feed the cultural imagination about what is possible through the end of life.

Cory:I want to ask a question that you likely haven’t been asked. As you taught me to state the obvious with patients and families, such as, “I want to make sure you receive the best care possible.” I can see your new book as a reframing of the principles of palliative care in four simple words, The Best Care Possible. I am interested to know how you would call the Academy to action to influence the national dialogue?

Ira: To the Academy’s members, I have to say that time is up. We have been talking for years about what needs to happen. We have been worried about what happens when the baby boomers approach the end of life. Now they have started to show up in the obituaries; 78 million of us. In medicine we have also created chronic illness with many people living with multiple serious illnesses.

I want the field to at least struggle with what is unfolding. Despite all the progress in hospice and palliative care, we are not ready. Look at all the technological advances in medicine, including the creation of the chronically critically ill patients….we are not ready. We have to rise to an unprecedented challenge to preserve western civilizations’ values of caring for each other and preserving the inherent dignity of each and every person as they approach the end of life.

The Academy has a leadership role in helping the culture grow the rest of the way up. There has to be a social and cultural transformation. We have to reframe illness and dying and the care throughout the end of life and reclaim caregiving through the end of life as a profoundly personal and only partially medical experience.

The Academy has to affirm the founding principles of the specialty. Physician-assisted suicide is one case in point. We can’t be neutral about the discipline’s stance. Physician assisted suicide and euthanasia are not the role of palliative care specialists. If you just think about it; we palliative care specialists are all pro-life. Preserving life is at the foundation of western civilization. That is why we have fire departments and police, to serve and protect. We have sanitation and clean water; these are pro-life parts of our society. To somehow allow a political movement to take that language from us and give it to those activists is far more power than they deserve. The Academy needs to start with affirming the principles of the discipline, the inherent dignity of people, the fact that we are pro-life, and that physician-assisted suicide is not part of medical practice.

The cultural transformation has to include being honest about preserving life and being honest about medical possibilities towards the end of life. As a culture we must recognize that we are mortal.

Branding what we do as providing “the best care possible” is consistent with enhancing quality of life, but has “social marketing” advantages. The boomers have always wanted the best. It is a simple message that works really well.

Cory: How is the Academy adopting this?

Ira: It is good language and messaging. In meeting new patients, I often say, “I want to give you the best care possible” as a way of framing the clinical relationship. The term is a vessel in which to pour individualized meaning. But the term is also effective in a social marketing. Giving and receiving “the best care” is meaningful individually and to the macro society. At all levels, palliative care is a way of delivering that goal.

After my conversation with Ira, I am doubly convinced that the best care possible isn’t a slogan or a sound bite. It is authentic. It cuts to the core of palliative care as we match medical possibilities to patient’s preferences and goals while managing symptoms, coordinating care with other medical providers, improving quality of life, providing a space for healing fractured relationships, fostering human development, honoring spiritual traditions and values, and baring witness to the bare and tender emotions of serious illness. Palliative care is the specialty that overflows the vessel of The Best Care Possible through the end of life. I thank Ira for his wisdom, vision and mentorship.

Cory Ingram, M.D.
Assistant Professor of Family and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director of Palliative Care
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System

Concurrent Session – Delirium

Trust psychiatrists to give an afternoon session that makes you completely forget about that nap you were craving! “Delirium: A Study of Difficult Cases” consisted of 3 vignettes about various forms of delirium, complete with very realistic role playing and chock full of wisdom from palliative care psychiatrists.

First there was a case of reversible hyperactive delirium. We were reminded that just about anything could be the culprit behind it, including common HPM meds like opioids and benzodiazepines, minor infections, metabolic derangements, and overstimulating environments.

How to treat the agitation in reversible delirium? First try to reduce stimulation and create a soothing environment. Can you eliminate any unnecessary meds? AVOID benzos! Use 1st generation antipsychotics such as haloperidol or chlorpromazine (more sedating than haloperidol), and dose the way you would dose pain medications.

What about irreversible delirium? This is the kind that occurs during the dying process, so a good clue that it’s not reversible is that there will be physical signs of dying. In this case, you can use antipsychotics, but you could also use benzos like lorazepam or midazolam. Remember that the goal is to reduce suffering by reducing the agitation of delirium — this is NOT palliative sedation, this is medical managment of a medical symptom.

Sometime benzos won’t be effective, and in those rare cases you could try propofol or phenobarbital. The key point is to treat agitation like a breakthrough symptom.

The final vignette illustrated a case of mixed delirium in pediatric palliative care (complete with role playing where the parent was as much the patient as the kid). Yes, delirium happens in kids too! This is a sneakier form of delirium (and can happen in adults too) that presents with waxing/waning symptoms. The gist is that you treat kids the same as adults (though with lower doses) — haloperidol and risperdal (both antipsychotics) are effective and safe in kids and infants.

I left with the understanding that delirium is a form of suffering, and as patients who come out of it later say, is a terrifying and disorienting experience. Treat it proactively and don’t hesitate to consult psychiatry for tough cases!

Erin Zahradnik, MD, PGY-3 Yale University Dept of Psychiatry

The Devil Is in the Denominator

To improve quality, whom we measure is as important as what.

by Joe Rotella, MD, MBA, FAAHPM

The growing awareness in America that our healthcare system is unaffordable and fails to deliver consistent quality has led us to healthcare reform, mandatory quality reporting, pay-for-performance, and Accountable Care Organizations (ACOs). We need good measures of quality healthcare so we can direct our limited resources where they provide the most value. We would do well to pay particular attention to the quality of care near the end of life. As Ellen Goodman noted in her recent Harvard Business Review article “Die the Way You Want To”, 25% of Medicare expenditures are incurred by the 5% who are in their last year of life. Surely we can deliver more value by increasing quality of life and decreasing futile medical interventions for these patients.

It makes sense that we should measure quality in order to improve it, but figuring out exactly how can be a real devil. We often focus on what we should measure—the numerator, but whom—the denominator—is just as important. Working on the AAHPM Quality and Practice Standards Task Force this past year has been an eye-opening experience for me. Wading through ponderous technical documents describing a host of proposed national quality measures, I was struck with how hard it is to design a really good one. The National Quality Forum (NQF) recently recommended a set of quality measures for hospice and palliative care. The NQF only recommends measures with well-defined methodologies validated for the specific populations under consideration. Many employ a narrow denominator, e.g. hospice patients rather than dying patients. It’s a good start, but I hope policymakers and payers will be careful in how they incorporate them into mandatory quality reporting systems. Measuring only hospice patients in order to improve the quality of end-of-life care is like searching for a lost dollar bill only where the light is good. The real payoff may be lurking in that dark corner.

For example, the best set of quality measures we have for end-of-life care so far, the Family Evaluation of Hospice Care (FEHC), has only been validated for hospice patients. When we apply the FEHC to hospices, we can compare the quality of Hospice A with that of Hospice B. That might be good enough if most dying patients received hospice care, but the National Hospice and Palliative Care Organization reports in its 2011 Facts and Figures that only 42% of those who died in 2010 were enrolled in hospice. So what about the quality of end-of-life care for the majority of patients who die in hospitals, skilled nursing facilities and homes without the benefit of hospice care? How can we measure that?

Current and proposed mandatory quality reporting programs perpetuate the silos in our healthcare delivery system. Since hospitals are designed for treating acute, potentially-reversible problems, they report post-discharge, patient-rated satisfaction surveys that totally miss the experience of the many patients who die during their stay. Likewise, we see skilled nursing facilities as places for rehabilitation, so we require a Minimum Data Set that focuses on restoration of function, even though many patients languish and die there. Since hospice is the place for dying, that’s where we’ll mandate reporting of end-of-life quality measures, but that’s not going to improve the quality of dying where most of it happens.

The Medicare final rule creating ACOs requires them to report on 33 quality measures linked to how much they can share in any savings. Despite the striking disproportion of Medicare dollars spent in the last year of life, none of these measures has anything to do with comfortable dying or the appropriate utilization of hospice or palliative care. In the original 127-page proposed ACO rule, the word “hospice” appeared once and “palliative” not at all. Comments from the AAHPM and others must have been heard, because the terms appear about a dozen times in the final rule. It’s a step in the right direction, but we have a long way to go. We need researchers to develop and validate quality of life and quality of dying measures for all relevant care settings. Once available, we should push for their inclusion in all mandatory quality reporting and pay-for-performance systems. We’ll never get the maximum value for the Medicare dollar without it.

President Crossno’s Letter to American Medical News

Letter to American Medical News

January 6, 2012

Re: Handful of States Promise Physicians Online Access to Advance Directives, posted January 3, 2012 on amednews.com http://bit.ly/vFKMvx

When very sick patients are unable to express their wishes toward the end of life, nothing is more heartbreaking for doctors and loved ones than not knowing what those wishes are. It’s up to grieving and frightened family members to try to recall a past conversation, or remember whether there’s an advance directive, and if so, how to put their hands on it. Online registry programs for advance directives that give doctors access to this information would help ensure that we meet our patients’ wishes and that we don’t leave family members always questioning the decisions they were forced to make.

Patients need to hear from their doctors the importance of advance directives. They need to know that an advance directive can be changed, and that it can direct doctors to stop aggressive life-saving treatments, or continue them. Most important, an advance directive needs to be readily accessible when you need it. The American Academy of Hospice and Palliative Medicine has information on advance directives at www.aahpm.org and www.PalliativeDoctors.org

Ronald J. Crossno, MD CMD FAAFP FAAHPM

President, American Academy of Hospice and Palliative Medicine

What Is Palliative Care?

by Ruth Mugalian, Public Communications Inc.

Read the full article about defining palliative care in the Winter issue of The Quarterly.

When I talk about my work with hospice and palliative medicine specialists and why I enjoy it, I usually say something like this: “They’re doctors who take care of very sick patients. They relieve their symptoms and make them feel better.” It should be a communications professional’s dream. It’s simple, understandable and positive. There’s no esoteric medical jargon or complex technical language to translate into layman’s terms.

And yet, that simple, positive description doesn’t quite capture it.

Describing what hospice and palliative medicine specialists do is an evolving challenge, as evidenced by the many different ways the doctors explain their work. Unlike many other medical specialties, there’s no simple one- or two-word description, like “heart surgeon” or “cancer specialist.” “They relieve symptoms” is far too narrow, but also too broad. Don’t most doctors relieve symptoms? And, what about all the other care they provide: the help with decision making and navigating the system, the coordination of care, the support for families?

Just summarizing the breadth of care is challenging enough, but of course, there’s another challenge. The heart surgeon fixes the heart. The cancer specialist attacks the cancer. HPM doctors don’t cure. They provide the care that helps the surgeon and the oncologist cure, and that helps the patient endure the cure.

And sometimes there is no cure. That’s when the HPM’s role takes on special meaning and ironically and frustratingly gets twisted into something negative: they withhold care, give up on the patient, hasten death. Of course, the opposite is true. They stay on the job when others have no more to offer. They continue, or begin, providing care when others have stopped. They’re passionate about controlling pain. Snappy phrases are tempting: “They don’t cure, they care.” “They never stop caring,” “Helping you endure, with or without a cure.” They’re simple, understandable and positive, and they don’t quite capture it.

REMS ARE COMING! – Comment before Dec 7!

It was a privilege to represent AAHPM at the fall meeting of the Council of Medical Specialty Societies in Washington D.C. on November 18 & 19, 2011. This was my first CMSS meeting and I was struck by the energy, collegiality, and nimble structure of this “society of medical societies.” There is no House of Delegates to debate everything like in the AMA – just a Board of Directors, Component Groups (CEO’s, Membership directors, clinical practice guideline developers, etc.) and occasional task forces. They have done a lot, but only taken a stand on 5 public topics – the most recent being support of comparative effectiveness research (in a letter the AAHPM signed).

I spent my time in a day-long seminar on the upcoming REMS – Risk Evaluation and Mitigation Strategy for long acting opioids. Regina Labelle, from the White House Office of National Drug Control Policy certainly got my attention when she explained that in 17 states, deaths from unintended drug overdoses now outnumber deaths from traffic accidents! Understandably Congress and the Administration want something done about this. Theresa Toigo, R.Ph., M.B.A., from the FDA explained that the Food and Drug Administration Amendments Act of 2007 (FDAAA) gave FDA the authority to require manufacturers to develop and implement a REMS when necessary to ensure the benefits of a drug or biological product outweigh its risks.

On April 19, 2011, in conjunction with the Office of National Drug Control Policy (ONDCP) release of the Obama Administration’s Epidemic: Responding to America’s Prescription Drug Abuse Crisis—a comprehensive action plan to address the national prescription drug abuse epidemic, FDA issued letters to application holders (makers and seller of opioids) directing them to submit a REMS within 120 days and describing the elements that needed to be included in the REMS (REMS notification letters).

So what is REMS and why should we care?

After notifying the makers and marketers of long-acting and extended-release (LA/ER) opioid drugs that they were required to submit a risk evaluation and mitigation strategy (REMS), FDA has been working with the sponsors that market these products on the required REMS. The central component of the Opioid REMS is an education program for prescribers (e.g., us) so that LA/ER opioid drugs can be prescribed and used safely. FDA expects the prescriber training to be conducted by accredited, independent continuing education (CE) providers (like AAHPM), without cost to the healthcare professionals, under unrestricted grants to accredited CE providers funded by the sponsors. Kate Regnier, M.A., M.B.A., from ACCME assured us that industry would not be dictating the curriculum so the CME can comply with ACCME standards.

What are they going to be teaching us?

On November 4, 2011, FDA announced the availability for public comment of a draft “Blueprint.” The Blueprint, developed by FDA with advice from other Federal agencies, is a basic outline and the core messages that FDA believes should be conveyed to prescribers in a basic two to three hour educational module. After it is completed and approved as part of the REMS, the Blueprint is posted on the FDA web site for use by CE providers in developing CE courses. The Blueprint for provider education can be found at

http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM277916.pdf

While, in general, I found these tenets reasonable, there isn’t a lot here about effective pain management for seriously ill patients. A few quotes will give you the flavor:

Health care professionals who prescribe extended-release (ER) and long-acting (LA) opioids are in a key position to balance the benefits of prescribing ER/LA opioids to treat pain against the risks of serious adverse outcomes including addiction, unintentional overdose, and death.

Prescribers should caution patients that ER/LA opioids can cause serious side effects that can lead to death.

Prescribers should explain that sharing ER/LA opioids with others may cause serious side effects including death, and that selling or giving away ER/LA opioids is against the law.

Prescribers should ensure that patients adhere to a treatment plan and monitor patients for misuse and abuse by

  • Recognizing aberrant behavior
  • Utilizing Prescription Drug Monitoring Programs to identify potential abuse where available
  • Understanding the role of drug testing and performing drug screens as indicated
  • Screening and referring for substance abuse treatment when indicated
  • Performing medication reconciliation at each visit

Whether this program will be required to maintain your DEA registration is being discussed. The REMS notification letters stated that although there is no mandatory requirement that prescribers take the course as a precondition to dispensing the medication to patients, application holders will be required to establish goals for the number of prescribers trained, collect the information about the number of prescribers who took the courses, and report the information to FDA as part of periodic required assessments. Although FDA recognizes that additional training modules could be helpful, FDA’s goal is to require basic education for all prescribers of long-acting and extended-release opioids, and at this time, FDA does not intend to develop or approve messages as part of the REMS beyond those approved in the basic core module.

Can we have any input into this?

We have until December 7 to submit comments on the draft Blueprint http://www.regulations.gov.

The AAHPM has been working with a group called CORE to develop a program that meets these criteria. Stay tuned for more about this.

Another Way to Advocate for Patients

by Emily Muse, AAHPM Communities Manager

I am a planner. I create lists, diagrams, and spreadsheets for almost everything. I even use a planning rubric when packing for weekend trips. Obviously, I began my preparation for the 2011 AAHPM Washington DC “Capitol Hill Fly In” by researching my congressional representatives and senators. I wanted to learn as much as possible about the people I would be meeting and were “representing” me in D.C. A lot of this investigation was done just by entering my zip code in the AAHPM Legislative Action Center. (http://www.capwiz.com/aahpm/home/)

At a glance I was able to discover all the committees that my senators and my congressional representative served on. How they had voted on specific legislation and issues and I read and reread all the proposed legislation that would affect AAHPM members. It was wonderful. After accessing their office addresses I plotted out where they were all located within the map of Capitol Hill.

I was ready, or so I thought.

What I was not prepared for was the knowledge, dedication and tenacity of our AAHPM members. It did not surprise me, it wowed me. Not only had our members prepared for this visit, they had been advocating and championing Hospice and Palliative in ways I had never thought about. One member encourages staff to contact elected officials regularly about HPM issues. Another invited his representative to visit his program and learn firsthand what Palliative Medicine provides for constituents. All of our members had brought with them anecdotes of patients achieving successful pain and symptom management, making decisions about their care that made sense for themselves and their families and utilizing allocated resources appropriately due to team based care and excellent communication among providers. And what was even more impressive, Senators, Representatives and Staffers all listened. They asked questions and posed some opposition, but they were open to learn more. I hope some of those members who participated in this year’s DC Fly In will write about their individual experiences. I think all of the participants were amazing, even one who commented that this was “just another way we advocate for our patients”.