WEBVTT 00:00:00.000 --> 00:00:02.000 Alright. 00:00:02.000 --> 00:00:09.000 All right, welcome everyone! My name is Chelsea Perez. I'm an Education Associate here with the Center to Advance Palliative Care. I'm very excited to welcome you to today's. 00:00:09.000 --> 00:00:14.000 webinar, Key Insights from Integrative Health for Palliative Care Teams. 00:00:14.000 --> 00:00:19.000 Before we begin, I just want to briefly provide you with instructions on how to participate in today's webinar. 00:00:19.000 --> 00:00:23.000 If you need technical assistance from myself as the CAPSI host. 00:00:23.000 --> 00:00:31.000 Please use the chat function and select Host from the drop-down menu. You can also use the chat function to submit comments and questions on the presentation as we go along. 00:00:31.000 --> 00:00:50.000 Um, and we encourage you to do so. Um, it's best to make sure these comments are visible to everyone by making sure that option is selected in that drop-down menu right in the chat box, so… Just make sure if you're submitting to, um, the audience and all attendees, just to click everyone in that chat box. We will be keeping an eye on the chat. 00:00:50.000 --> 00:00:57.000 And we will direct you to add some submissions to some questions here in the chat in just a few moments. 00:00:57.000 --> 00:01:00.000 You can also use the Q&A panel to submit questions. 00:01:00.000 --> 00:01:05.000 This option allows you to submit questions anonymously, should you wish to do so. 00:01:05.000 --> 00:01:12.000 As always, the webinar recording and slides will be available on CAPSE's website under the On-Demand webinars page. 00:01:12.000 --> 00:01:22.000 We can find all of our recorded webinars. Lastly, we ask you to provide your feedback on this session in the very brief survey you will see pop up in your browser once we end. 00:01:22.000 --> 00:01:32.000 So now, on to today's session. We are lucky to be joined by our presenter today, um… I'll go ahead and introduce my pleasure to introduce Dr. Lucille Marchand. 00:01:32.000 --> 00:01:38.000 Dr. Marchand is a nationally. Excuse me, respected leader in palliative care and integrative medicine. 00:01:38.000 --> 00:01:49.000 She has served in several distinguished roles throughout her career, following Farber Endowed Professor in palliative care education and professor and section chief of palliative care in the University of Washington's. 00:01:49.000 --> 00:02:00.000 Department of Family Medicine in Seattle. She also served as the Executive director of the Osher Center for Integrative Health at the University of Washington, where she helped. 00:02:00.000 --> 00:02:14.000 Advanced, whole person and evidence-informed approaches to care. Dr. Marchand is recognized as a fellow of both the American Academy of Hospice and Palliative Medicine and the American Academy of Family Physicians. 00:02:14.000 --> 00:02:22.000 She currently holds the title of Emerita and serves as a clinical adjunct professor in the Department of Family Medicine at the University of Wisconsin in Madison. 00:02:22.000 --> 00:02:27.000 Please join me in welcoming Dr. Lucille Marchon. 00:02:27.000 --> 00:02:35.000 Hello! It's such a pleasure to be with you today, and to be able to present to you one of my absolute favorite topics. 00:02:35.000 --> 00:02:41.000 Um, I invite you today to be curious. And with that. 00:02:41.000 --> 00:02:47.000 we'll go to our first. slide. And these are our objectives. 00:02:47.000 --> 00:02:56.000 I'd like to, um, have you at the end of the session to be able to discuss the unifying person-centered care approaches to integrative medicine and palliative care. 00:02:56.000 --> 00:03:02.000 to examine the interactions of symptom clusters in integrative palliative care and how to best approach their treatment. 00:03:02.000 --> 00:03:15.000 and to identify integrative modalities that effectively expand the toolbox of conventional treatments for the relief of suffering in serious illness. 00:03:15.000 --> 00:03:16.000 So we have… yeah, we have an icebreaker here. 00:03:16.000 --> 00:03:18.000 So… 00:03:18.000 --> 00:03:26.000 Um, please let us know in the chat how familiar are you with integrative medicine? Not at all, little, somewhat very, we'd love to hear your responses, so we'll give you. 00:03:26.000 --> 00:03:30.000 about a minute, um, to let us know right in the chat here. 00:03:30.000 --> 00:03:34.000 Chelsea, there was one person that said that. she couldn't hear us. 00:03:34.000 --> 00:03:39.000 Oh, okay, perfect, I'll go ahead and send her a message. 00:03:39.000 --> 00:03:46.000 Alright, I see a lot of, um… thanks, everyone, for putting your, uh, comments here in the chat. 00:03:46.000 --> 00:03:52.000 Uh, some people say vary a little. Somewhat familiar, very… a lot of varies, uh, somewhat. 00:03:52.000 --> 00:04:03.000 Familiar from education but limited clinical experience. I love the idea of integrative medicine, I'm very familiar and want to learn more. So, um, it's great to see a lot of folks have some. 00:04:03.000 --> 00:04:18.000 somewhat of a decent, um… At least, um, understanding of, of… integrative medicine. So, um, I can go ahead and… 00:04:18.000 --> 00:04:33.000 Well, thank you so much for responding to us, and so it seems like we… are all over the place, and in terms of what we know about integrative health, and this is very exciting. So, some of this may be very familiar to many of you and others. 00:04:33.000 --> 00:04:46.000 may give you some food for thought. So, integrative health, one of our OSHA Center for Integrative Health definitions is integrative health care reaffirms the importance of compassionate, relationship-centered care. 00:04:46.000 --> 00:04:58.000 focuses on the whole person. is informed by evidence and embraces all appropriate therapeutic approaches, and healthcare professionals to achieve optimal health and healing. 00:04:58.000 --> 00:05:02.000 And so I would say very, very similar to palliative. 00:05:02.000 --> 00:05:09.000 palliative care. Examples of integrative therapies, uh, are nutrition and movement supplements. 00:05:09.000 --> 00:05:22.000 Mindfulness, meditation, prayer, meditative movement, acupuncture, acupressure, massage, music therapies, both expressive and receptive. 00:05:22.000 --> 00:05:38.000 So, there'll be many more that we cover here, but what integrative therapies do you already recommend to your patients? And if you want to put that in the chat. 00:05:38.000 --> 00:05:54.000 I saw someone responded, uh, I am a Reiki Reiki master and do… that in my hospital, we use aromatherapy a lot with guided imagery, so that was, um, and I see mindfulness and meditation come up here as well. 00:05:54.000 --> 00:05:58.000 Massage and aromatherapies, a lot of aromatherapy coming up. 00:05:58.000 --> 00:06:06.000 Some more meditation, massage. Acupuncture coming up, acupressure. 00:06:06.000 --> 00:06:12.000 Resilience training. 00:06:12.000 --> 00:06:14.000 Prayer. Mm-hmm. 00:06:14.000 --> 00:06:22.000 Breath awareness… Music therapy coming up here as well. 00:06:22.000 --> 00:06:27.000 Hypnosis, diet. 00:06:27.000 --> 00:06:33.000 Guided imagery… Yes, yes. 00:06:33.000 --> 00:06:41.000 It is very expansive, isn't it? And integrative medicine just helps us have the greatest toolbox. 00:06:41.000 --> 00:06:51.000 for providing our care. And so I wanted to just review integrative person-centered, uh, care approach. 00:06:51.000 --> 00:07:08.000 And let me… And this is by Gerald Arbuckle, a wonderful book, Humanizing Healthcare Reform, and so much of integrative medicine and palliative care is very much in keeping with this person-centered approach. 00:07:08.000 --> 00:07:13.000 So, these are different aspects of care that we provide, and um. 00:07:13.000 --> 00:07:22.000 In palliative care and integrative medicine, cultural beliefs, traditional and spiritual health practices and rituals are so healing. 00:07:22.000 --> 00:07:28.000 and important to people's well-being and quality of life. Also, respect for the person. 00:07:28.000 --> 00:07:38.000 diversity, inclusion, presence, connection, compassion, story. Listening to patients deeply. 00:07:38.000 --> 00:07:46.000 a sustainable economic models. Primary care is a priority for delivering palliative care, population health. 00:07:46.000 --> 00:07:59.000 Um, evidence-informed, cost-effective drug and non-drug therapies. illness and well-being. And so what's at the center of this is the person, their values, their goals, their preferences. 00:07:59.000 --> 00:08:07.000 their emotions and shared decision-making is so important. So, aligning our care. 00:08:07.000 --> 00:08:15.000 With all that the patient kind of values and feels that is appropriate in their care, what's important to them? 00:08:15.000 --> 00:08:27.000 and also community engagement. Very important. And as we know, with a strictly Western medicine approach, which I have not seen too much in palliative care. 00:08:27.000 --> 00:08:45.000 not in integrative medicine, nor in hospice care. Uh, generally what we provide is a very creative approach, very broad approach, and way beyond just drug surgery, radiation. A sort of narrow view of Western medicine. 00:08:45.000 --> 00:08:53.000 But in Western medicine, I have seen this over and over again, where clinicians. 00:08:53.000 --> 00:09:03.000 will often, um, disregard patients. integrative approaches to their own health and well-being. 00:09:03.000 --> 00:09:14.000 and say, that's not important, that's not important to do, there's no evidence. And even though I have worked with practitioners where I've tried to provide them with a great deal of evidence, it's just been poo-pooed of. 00:09:14.000 --> 00:09:17.000 Well, I don't believe in that evidence, which is. 00:09:17.000 --> 00:09:32.000 fairly unscientific, but there is plenty of evidence to show that integrative therapies and the kind of approaches that we have in palliative care are very evidence-based and improve quality of life and well-being. 00:09:32.000 --> 00:09:41.000 So, in Western medicine, often there's very little time for talking, so there's very little time for listening, and often we do not have the patient's story. 00:09:41.000 --> 00:09:54.000 And often emotions are not okay, or. clinicians will leave the room if their strong emotions, or if they have strong emotions, not sure what to do with them. 00:09:54.000 --> 00:10:00.000 Often, our system is around profits, metrics, uh, cost containment. 00:10:00.000 --> 00:10:09.000 Uh, we're in love with the latest technologies, which are very powerful. I do not want to disregard or minimize. 00:10:09.000 --> 00:10:14.000 The importance of Western medicine approaches, especially for acute care. 00:10:14.000 --> 00:10:20.000 But, um, we cannot just leave our approach to the patient just. 00:10:20.000 --> 00:10:30.000 for a narrow approach of drugs, surgery, radiation. the randomized controlled trial seems to be the only kind of evidence that is, um. 00:10:30.000 --> 00:10:40.000 regarded as significant, whereas. There's plenty of research, uh, not only randomized controlled trials, which I have done. 00:10:40.000 --> 00:10:46.000 But, um, qualitative approaches to finding out what people really feel about different. 00:10:46.000 --> 00:11:00.000 types of therapies and their effectiveness. So, in all this, the patient becomes an object of care rather than the centerpiece of care. The person that knows the most about. 00:11:00.000 --> 00:11:06.000 who they are, their bodies, their spirits, their minds, and that. 00:11:06.000 --> 00:11:16.000 we want to really put the patient. at the center of care, and also that families and a whole host of. 00:11:16.000 --> 00:11:23.000 different kinds of practitioners are so important to the care of that person, and that there's no cookbook here. 00:11:23.000 --> 00:11:32.000 Uh, what resonates with one person may not resonate with another person. And so, really, the person is at the. 00:11:32.000 --> 00:11:46.000 the middle of all this, the important person. Uh, and when the patient becomes an object of care and we have a very narrow approach, we often are very susceptible and vulnerable to burnout. 00:11:46.000 --> 00:11:55.000 with depersonalization, emotional exhaustion, and a sense of low personal accomplishment. 00:11:55.000 --> 00:12:01.000 Common themes in integrative health and palliative care include well-being. 00:12:01.000 --> 00:12:06.000 and quality of life. So we use maybe different words, but we're meaning the same thing. 00:12:06.000 --> 00:12:14.000 Healing is valued, the nurturing of hope. Empowerment and person-centered care, relationship-centered care, shared decision-making. 00:12:14.000 --> 00:12:22.000 Compassionate care. Meaning and purpose in living fully. right to the very end of our lives. 00:12:22.000 --> 00:12:30.000 decreasing fear. Using modalities that are aligned with patient values and preferences and whole-person care. 00:12:30.000 --> 00:12:39.000 physical, psychosocial, spiritual, and cultural. 00:12:39.000 --> 00:12:46.000 We try in both places to avoid polypharmacy. medications and supplements. 00:12:46.000 --> 00:12:56.000 There is polypharmacy of supplements often, and patients may find or be advised by the internet or, uh. 00:12:56.000 --> 00:13:01.000 well-meaning, uh, people in their lives about different supplements they can take, and. 00:13:01.000 --> 00:13:13.000 Like medications, the list could be endless, and what we try to do is the right medication, the right supplement for the right indication at the right time, at the right dose. 00:13:13.000 --> 00:13:28.000 And using appropriate non-pharmacologic and pharmacologic therapies. Allowing for reduced doses of medication causing adverse effects when we use the whole host of resources at our disposal. 00:13:28.000 --> 00:13:42.000 attentiveness to cultural traditions, beliefs, lifestyle, internet information. So I'm always curious about what people are getting as far as information on the internet, and clarifying. 00:13:42.000 --> 00:13:49.000 Uh, perhaps some misconceptions, but also doing a little bit of research for them sometimes on the internet. 00:13:49.000 --> 00:13:58.000 Uh, to see what's really good information and what may be information that's more anecdotal or selling a product. 00:13:58.000 --> 00:14:12.000 advice from community friends and family. Use of the full interdisciplinary team, but also beyond just the clinical setting to all of our practitioners in the community as well. 00:14:12.000 --> 00:14:19.000 Seattle was a great example of that, is that we had excellent practitioners within our University of Washington system. 00:14:19.000 --> 00:14:23.000 But we also had a whole host of incredible. 00:14:23.000 --> 00:14:28.000 health practitioners in the community, and for us to know about them. 00:14:28.000 --> 00:14:34.000 Uh, and this is one of the ways that I found out about so many practitioners. 00:14:34.000 --> 00:14:42.000 In my rural community, when I was doing family medicine, is I would ask patients about who the best. 00:14:42.000 --> 00:14:48.000 acupuncturists would be in the community, who the breast healers were. 00:14:48.000 --> 00:15:01.000 all different kinds of modalities. What was most helpful to them, just like I would in, um… conventional medicine, asking someone if I referred them to an oncologist, what was their interaction like? 00:15:01.000 --> 00:15:15.000 Did they feel that that person really took care of them well, or to another specialist? And so, this is really important for us to gather this kind of information about all different kinds of practitioners. 00:15:15.000 --> 00:15:24.000 So, a patient case. Marie is a 65-year-old woman who's recently diagnosed with metastatic triple negative breast cancer to bone, lung, and brain. 00:15:24.000 --> 00:15:38.000 seriously ill. She presented to her PCP with right hip pain and found that that was a metastatic lesion. After more imaging and a biopsy, she was diagnosed with metastatic breast cancer with a primary lesion in her left breast. 00:15:38.000 --> 00:15:43.000 She was referred to an oncologist and breast surgeon for further workup and treatment. 00:15:43.000 --> 00:15:54.000 She was treated with targeted treatments and was stabilized for a time before she got worse. She was referred to palliative care shortly after the time of diagnosis for goals of care discussion. 00:15:54.000 --> 00:16:09.000 symptom management and advanced care planning. So, the kind of questions we ask in palliative care are similar to the questions we ask in integrative medicine. How does Marie see her situation? 00:16:09.000 --> 00:16:19.000 What resources does she have for her care? So, many people are already doing so many different kinds of practices. 00:16:19.000 --> 00:16:24.000 healing practices that will help them through their time with serious illness. 00:16:24.000 --> 00:16:30.000 to the end of their life. And these are important for us to, um. 00:16:30.000 --> 00:16:39.000 enhance or, uh, encourage. Uh, and these may be physical, emotional, spiritual, or social. 00:16:39.000 --> 00:16:43.000 What is most important to her was she hoping for at this time? 00:16:43.000 --> 00:16:49.000 What does she already do to improve her quality of life and well-being? This is really important. 00:16:49.000 --> 00:16:56.000 question for us to ask, what is she already doing to improve her quality of life and well-being? 00:16:56.000 --> 00:17:02.000 What is she worried or concerned about? Where does she live? 00:17:02.000 --> 00:17:13.000 Resources are very variable. throughout our country, throughout the world. And so, where someone lives and what kind of resources are available to them. 00:17:13.000 --> 00:17:18.000 will vary quite a bit. So, different practitioners may be available in a city. 00:17:18.000 --> 00:17:27.000 situation, but not in a rural area. And there may be a lot of resources in the rural area that actually. 00:17:27.000 --> 00:17:36.000 are harder to access in a city. Such as, perhaps, local communities that can really help. 00:17:36.000 --> 00:17:43.000 people and families, uh, with. serious illness. Um, and so. 00:17:43.000 --> 00:17:49.000 What are the resources available is always really important for us to know as practitioners. 00:17:49.000 --> 00:17:53.000 So her main symptoms are fatigue, nausea, pain, and anxiety. 00:17:53.000 --> 00:18:03.000 Generally, it's not just one symptom. Treatment can cause symptoms as well as the disease itself, as well as other diseases that may be. 00:18:03.000 --> 00:18:17.000 also occurring at the same time in a person. She lives in a rural community about one hour away from the city where she receives her oncology care and palliative care. Some people live way beyond one hour away, and there may be issues with them. 00:18:17.000 --> 00:18:25.000 being able to access resources such as palliative care and various integrative medicine therapies. 00:18:25.000 --> 00:18:37.000 She lives with her husband, who has significant heart disease and is compromised as a caregiver. So there are all these other issues that can occur with the patient that we have to take into consideration when we're caring for them. 00:18:37.000 --> 00:18:42.000 Uh, and that's where community really comes in handy as an incredible resource. 00:18:42.000 --> 00:18:50.000 They have two adult children, one lives nearby. Even though that one lives nearby, that person may be helpful, maybe not. 00:18:50.000 --> 00:19:01.000 Uh, and what are the other resources in the family that could be helpful? Sometimes it's someone living far away that moves to the area to be of assistance to our patient. 00:19:01.000 --> 00:19:12.000 They belong to a nearby church. She worries about her ability to care for herself and her husband. She feels very isolated and concerned about her quality of life. At this point. 00:19:12.000 --> 00:19:23.000 She's chosen that quality of life is most important to her rather than length of life, and we all know, with improving quality of life and symptom control, we can often. 00:19:23.000 --> 00:19:33.000 Uh, include longevity with quality of life. They are not binary, they are not mutually exclusive, as we all know. 00:19:33.000 --> 00:19:42.000 Symptoms occur in clusters. They're often multiple. They affect a person's physical, emotional, spiritual, and social well-being. 00:19:42.000 --> 00:19:52.000 Integrative therapies address the whole person and symptom clusters. So, there may be some medicines that will help with one or two symptoms. 00:19:52.000 --> 00:20:03.000 Often, integrative therapies are more holistic. and can address multiple symptoms and potentially reduce the need for. 00:20:03.000 --> 00:20:12.000 Higher doses of medication. Integrative therapies address the whole person treating one symptom often improves other symptoms. 00:20:12.000 --> 00:20:19.000 And this is just a schematic of that. symptoms exist in clusters. They affect each other, and at the heart of it. 00:20:19.000 --> 00:20:27.000 quality of life. And these are the major symptoms that we deal with. 00:20:27.000 --> 00:20:35.000 So, this is from, uh, data, 38 inpatient palliative care teams in the University of Washington was one of them. 00:20:35.000 --> 00:20:41.000 uh, sending data from, um, our care to the palliative care quality network. 00:20:41.000 --> 00:20:47.000 Uh, based at UCSF at the time, from 2012 to 2016. 00:20:47.000 --> 00:20:53.000 Patients with pain had higher rates of anxiety, nausea, and dyspnea. 00:20:53.000 --> 00:20:58.000 Improvement with pain was associated with improving anxiety and dyspnea. 00:20:58.000 --> 00:21:05.000 And so a conclusion was that pain improvement. associated with other symptom improvement. 00:21:05.000 --> 00:21:12.000 And this is so important. All understanding the interactions of our symptoms that we address. 00:21:12.000 --> 00:21:18.000 Patients with moderate to severe pain more likely to report moderate severe anxiety and nausea. 00:21:18.000 --> 00:21:23.000 But feel less likely to report moderate to severe dyspnea. 00:21:23.000 --> 00:21:31.000 And patients with moderate to severe nausea. were more likely to have pain compared with mild to no nausea. 00:21:31.000 --> 00:21:35.000 Patience on comfort care were more likely to have improved pain. 00:21:35.000 --> 00:21:41.000 Improved anxiety, improved pain. Improve dyspnea, more likely to improve pain. 00:21:41.000 --> 00:21:48.000 So, you can see that, um… you know, really having a holistic approach is. 00:21:48.000 --> 00:21:58.000 of utmost importance to us in palliative care, in integrative medicine, and also other studies have shown that high symptom burdens decrease quality of life. 00:21:58.000 --> 00:22:07.000 Anticipating predictable symptom clusters around different serious illnesses can lead to addressing them proactively and comprehensively. 00:22:07.000 --> 00:22:12.000 Symptom clusters change with disease progression and treatment choices. 00:22:12.000 --> 00:22:19.000 And renal disease, for example, includes the symptom cluster of fatigue, pain, depression. 00:22:19.000 --> 00:22:23.000 As well as others, but those are the main ones. 00:22:23.000 --> 00:22:29.000 So, how did integrative palliative care improve her quality of life? 00:22:29.000 --> 00:22:33.000 Marie was in a choir at church, music was important to her well-being. 00:22:33.000 --> 00:22:37.000 And so, for her to be at home singing. 00:22:37.000 --> 00:22:44.000 listening to music that was uplifting, that may relieve some of her anxiety, that may then. 00:22:44.000 --> 00:22:50.000 help relieve a bit of her pain. Not completely eradicate it. 00:22:50.000 --> 00:23:00.000 There's always, um, a synergy of using very. thoughtful medication, uh. 00:23:00.000 --> 00:23:12.000 regimens, uh, prescriptions, as well as various. integrative therapies to help control these symptom clusters. So, using this love of music. 00:23:12.000 --> 00:23:23.000 For her well-being, and asking her what would be most important to her in terms of including that as an integrative modality in her care. 00:23:23.000 --> 00:23:29.000 At her cancer center, she was able to have an integrative consultation with an integrative health clinicians. 00:23:29.000 --> 00:23:37.000 So when I worked at the Carbone Cancer Center at the University of Wisconsin, I was that integrative consultant. And yet. 00:23:37.000 --> 00:23:45.000 it's very hard for many centers to have. an integrative consultant within the oncology department. 00:23:45.000 --> 00:23:52.000 Because often, when prophets. or, uh, costs are being considered. 00:23:52.000 --> 00:23:56.000 Often, integrative medicine may be one of the first things to go. 00:23:56.000 --> 00:24:08.000 Uh, fortunate for me, I was able to serve patients there for 8 years, and then started a palliative care service and devoted more of my time to integrative palliative care on that service. 00:24:08.000 --> 00:24:14.000 She received psychological support, often cancer centers, and other, um. 00:24:14.000 --> 00:24:23.000 centers will have psychologist. psychiatrist, often medications are needed, but also. 00:24:23.000 --> 00:24:31.000 listening and, uh, getting that psychological support. Patient navigation assistance with financial matters, nutrition support. 00:24:31.000 --> 00:24:39.000 So she was able to get these vital. Um, interventions at her cancer center. 00:24:39.000 --> 00:24:49.000 Her church community and other friends and family supported her with food and brides to the city through a Caring Bridge website, and often patients are not specific enough about. 00:24:49.000 --> 00:25:01.000 what exactly they need. And sometimes they don't know exactly what they need, and sometimes we can help with having a conversation about that. 00:25:01.000 --> 00:25:05.000 So… What else? 00:25:05.000 --> 00:25:14.000 became part of her, um, treatment. Marie was not interested in energy therapies such as Reiki, so for some people. 00:25:14.000 --> 00:25:23.000 Ricky is utmost importance, or other energy therapies. But she particularly felt it was a waste of time and money for her. 00:25:23.000 --> 00:25:32.000 Sometimes there are, um, volunteer. energy therapists that are available, and maybe money. 00:25:32.000 --> 00:25:46.000 is not such a priority. But for her. Again, not every important therapy is going to be in tune or aligned with what a patient feels is important for her. 00:25:46.000 --> 00:25:50.000 She was interested in her church community praying for her. 00:25:50.000 --> 00:26:00.000 and having that kind of spiritual support. She received acupuncture every two weeks in the city for her nausea, pain, fatigue, and anxiety, and she found this helpful. 00:26:00.000 --> 00:26:05.000 And for those who, uh, fear, um, needles, uh, which. 00:26:05.000 --> 00:26:11.000 For some people, that's important. Uh, there are seeds that can be impl- uh. 00:26:11.000 --> 00:26:19.000 put on the skin, uh, for, um, acupuncture or acupressure points can be shown to the patient and used. 00:26:19.000 --> 00:26:25.000 She found Tai Chi on a YouTube channel, relaxing and helpful for her fatigue and anxiety. 00:26:25.000 --> 00:26:30.000 She took a number of supplements, she thought, from internet information might help her. 00:26:30.000 --> 00:26:36.000 And her oncology pharmacist helped with determining any interactions with her medications. 00:26:36.000 --> 00:26:43.000 She reduced the number after discussion with an integrative clinician. 00:26:43.000 --> 00:26:49.000 I also want to emphasize here, and I don't think I did when we were talking about whole person care, is that. 00:26:49.000 --> 00:26:56.000 This is not the bailiwick of just one clinician. This is a whole host of clinicians. 00:26:56.000 --> 00:27:00.000 Be they in the facility where care is being delivered. 00:27:00.000 --> 00:27:09.000 or outside of the facility. or on the internet, online. There are many sources of integrative therapies. 00:27:09.000 --> 00:27:19.000 Um, but one thing is that burnout can occur if a clinician feels like it's their responsibility to be the expert in all of this. 00:27:19.000 --> 00:27:25.000 And that is really beyond one person, one clinician. 00:27:25.000 --> 00:27:32.000 Long ago, I was a hospice medical director, and I was part of interdisciplinary team meetings. 00:27:32.000 --> 00:27:38.000 And what I love so much about those meetings is the creativity. 00:27:38.000 --> 00:27:48.000 And the curiosity. And, of course, the compassion and the caring that came from all of the clinicians that were on the interdisciplinary team. 00:27:48.000 --> 00:27:57.000 From nursing assistants to pharmacists to the chaplain, to the social worker, to the nurse, to the physician, to the nurse practitioner, to. 00:27:57.000 --> 00:28:05.000 The physician assistant. On and on, all different kinds of people, and if a hospice has. 00:28:05.000 --> 00:28:16.000 Integrative therapies there to have integrative therapists also at the table there. So… There are many, many, uh, ways that we can add that. 00:28:16.000 --> 00:28:25.000 creativity and that respect for all of the therapists that, um, are helpful to the patient. 00:28:25.000 --> 00:28:30.000 And so, no one person again, and no one therapy. 00:28:30.000 --> 00:28:34.000 Generally, for the patient, it's going to be incorporation of many. 00:28:34.000 --> 00:28:45.000 different kinds of therapies, and to acknowledge that in palliative care, that there are many practitioners and many kinds of therapies that can be helpful to the patient. 00:28:45.000 --> 00:28:53.000 I wanted to acknowledge my collaborators on this patient, Dr. Bell, Doctor Liu, and Doctor Cheng, who. 00:28:53.000 --> 00:29:05.000 are incredible integrative, um, palliative care practitioners. And I have sent, um… some people, for their care, and again, it's been. 00:29:05.000 --> 00:29:13.000 Thank you, because. Perhaps they were seeing, you know, a specialist in conventional medicine. 00:29:13.000 --> 00:29:23.000 And it was just so narrow for them, and to be able to then, with serious illness, incorporate palliative care, and also an integrative approach. 00:29:23.000 --> 00:29:31.000 So, it's not that any one practitioner has to be, and I certainly am not an expert in any. 00:29:31.000 --> 00:29:37.000 many of these therapies. I'm not an acupuncturist, but I do. 00:29:37.000 --> 00:29:45.000 like to. educate myself as much as possible about healthy diet. 00:29:45.000 --> 00:29:53.000 healthy movement, mindfulness techniques, uh, yoga. So, I have my own, um. 00:29:53.000 --> 00:30:04.000 complement of integrative therapies and medication and procedures that have helped me stay in the best health, living myself with serious illness. 00:30:04.000 --> 00:30:09.000 And so, all of this helps us to walk our talk. 00:30:09.000 --> 00:30:14.000 And when I was doing integrative therapy in, uh. 00:30:14.000 --> 00:30:26.000 The Cancer Center, and then as a palliative care clinician doing integrative therapy, and as a family medicine, also incorporating integrative therapies. 00:30:26.000 --> 00:30:32.000 Hospice, integrative therapies, um. I learned what I can do for myself. 00:30:32.000 --> 00:30:38.000 To help prevent burnout. to be more patient-centered, to be a better listener. 00:30:38.000 --> 00:30:45.000 to be present, um… And… In my serious illness. 00:30:45.000 --> 00:30:51.000 I've had a really bad prognosis. And yet, and this isn't. 00:30:51.000 --> 00:30:54.000 And none of this is any kind of guarantees at all. 00:30:54.000 --> 00:30:59.000 But I have been able to beat the odds quite a bit. 00:30:59.000 --> 00:31:07.000 5 years at this time. And so… longevity, quality of life. 00:31:07.000 --> 00:31:15.000 of comes together here, and not that we can guarantee anything, even if someone had the most healthful life possible. 00:31:15.000 --> 00:31:20.000 we still get serious illness. And so, none of us are immune. 00:31:20.000 --> 00:31:29.000 And so, we, um… wrote this paper, and did incredible search of the evidence and also the resources that I'll impart. 00:31:29.000 --> 00:31:39.000 you with. Uh, also contain a lot of evidence for integrative therapies in palliative care and end-of-life care. 00:31:39.000 --> 00:31:48.000 So, we created this paper, 10 Tips for Palliative Care Clinicians Incorporating Integrative Medicine into their practice. 00:31:48.000 --> 00:31:55.000 Acupuncture is very effective treatment for fatigue, dyspnea, nausea, and pain. 00:31:55.000 --> 00:32:00.000 And so, of course, the quality of the therapist is very important. 00:32:00.000 --> 00:32:07.000 And… I have found in my practice that acupuncture was incredibly useful to my patients. 00:32:07.000 --> 00:32:15.000 As well as to myself. Mindfulness techniques, including mindfulness-based stress reduction, meditation. 00:32:15.000 --> 00:32:27.000 Deep breathing. guided imagery are effective tools for relieving pain, anxiety, depression, and insomnia related to serious illness. Again. 00:32:27.000 --> 00:32:37.000 addressing complex symptoms. A nutrient-rich, anti-inflammatory diet, so not everybody can do this. 00:32:37.000 --> 00:32:46.000 However, it can reduce myofascial pain, improve quality of life, and decrease risk of malnutrition and cachexia. 00:32:46.000 --> 00:32:50.000 And so, for me, at the cancer center, I love nutrition. 00:32:50.000 --> 00:32:56.000 Uh, and working with an incredible nutritionist at that center. 00:32:56.000 --> 00:33:07.000 And coming up with creative solutions. For patients in terms of minimizing the effects of treatment, such as chemotherapy. 00:33:07.000 --> 00:33:12.000 Or, um, any problems they may have had in swallowing. 00:33:12.000 --> 00:33:21.000 whatever, or digestion, to make sure that they were on the best regime possible if they were open to that. 00:33:21.000 --> 00:33:39.000 And generally, uh, most people were, especially with cancer treatment, because I don't think anything scares us as much as cancer. And so, uh, people were very much wanting to know this information. We also did, um, cooking classes and took people to. 00:33:39.000 --> 00:33:48.000 supermarkets to discover new foods, other foods that they can incorporate into their diet, and we had such a good time with that. 00:33:48.000 --> 00:33:56.000 Movement therapy such as walking. Yoga, Qigong, tai chi, and strength training are effective tools. 00:33:56.000 --> 00:34:03.000 to improve serious illness-related fatigue. cachexia, anxiety, depression, and dyspnea. 00:34:03.000 --> 00:34:09.000 So, again, I want to repeat, none of these therapies will completely. 00:34:09.000 --> 00:34:24.000 relieve someone's depression or anxiety, or fatigue. But they improve it, they help it, and not in every person. Some people will have more of an effect than others, but they're. 00:34:24.000 --> 00:34:34.000 important to try again. With the patient choosing what is aligned with their values and what they feel would be doable for them. 00:34:34.000 --> 00:34:42.000 So, for some people, yoga… They associate, and I would call it pretzel yoga. 00:34:42.000 --> 00:34:48.000 But, uh, not all yoga is like that, and so I do a very gentle yoga. 00:34:48.000 --> 00:34:58.000 Almost every day, that helps me stretch. and also gives me that sense of being in the present moment, and relieving anxiety. 00:34:58.000 --> 00:35:07.000 Walking, walking in nature. Qigong. Many of these are online and can be so helpful to patients. 00:35:07.000 --> 00:35:11.000 and do not have to cost very much money. 00:35:11.000 --> 00:35:24.000 And of course, classes are wonderful, but many people with serious illness cannot expose themselves necessarily in the middle of winter to an in-person class, so online classes might be very helpful. 00:35:24.000 --> 00:35:32.000 Uh, cannabis is an evidence-based adjunctive therapy for the treatment of pain, nausea, insomnia, anxiety, and depression. 00:35:32.000 --> 00:35:46.000 And we all know that cannabis is, um, more accessible in some states versus others, and so this really depends on where you are, again, and what resources are available to you. 00:35:46.000 --> 00:35:54.000 Um, while there's a role for judicious use of supplements in the setting of serious illness. 00:35:54.000 --> 00:36:12.000 nutraceutical polypharmacy carries risks. confers perhaps little benefit and should be avoided. So it's very important, just like any medication, you don't want someone on 20 different medications, and I've been in medicine long enough where I had patients. 00:36:12.000 --> 00:36:18.000 on a ridiculous amount of medications, and often it affected them adversely. 00:36:18.000 --> 00:36:26.000 and nutraceuticals or supplements can be the same. And so, going through the list of supplements and asking patients. 00:36:26.000 --> 00:36:43.000 why they're taking any particular supplement. And if they don't know, or that somebody suggested it to them, perhaps helping them with a little bit of research, um, such as the comprehensive natural database that hopefully is available to many of us. 00:36:43.000 --> 00:36:58.000 through our libraries, where we can look at what are the interactions, and of course, our pharmacists are so important here in terms of looking at databases to look for interactions, because there may be, um. 00:36:58.000 --> 00:37:09.000 Certain medications, being, of course, metabolized in the liver, that may interact with some of the supplements that someone may be taking. And so, it's incredibly important. 00:37:09.000 --> 00:37:21.000 For a pharmacist to look at these, and now, uh, you know, a lot of our, um, our medical records will alert us to significant interactions, should they be occurring. 00:37:21.000 --> 00:37:33.000 But perhaps many people may not be telling their conventional clinicians about their supplements because they don't want to be told, oh, you should be off of all of that. 00:37:33.000 --> 00:37:41.000 But to really take a scientific approach to this, and at least consult with a pharmacist regarding this. 00:37:41.000 --> 00:37:50.000 And I'm sure most of our pharmacists would be happy to do this and be involved in this. Psychotherapy modalities such as life review. 00:37:50.000 --> 00:37:55.000 So I've done quite a bit of research on this, and um. 00:37:55.000 --> 00:38:02.000 in a randomized control trial, and that we found that it significantly increased a sense of peace. 00:38:02.000 --> 00:38:08.000 in patients. Dignity therapy, um, Harvey Chotanov has, um. 00:38:08.000 --> 00:38:14.000 really, uh, helped us, uh, with understanding this and being trained in this. 00:38:14.000 --> 00:38:25.000 psychedelic-assisted psychotherapy. are beneficial tools that can reduce anxiety and depression and enhance well-being among individuals approaching end of life. 00:38:25.000 --> 00:38:31.000 And so, this is really important to know what resources are in your community. 00:38:31.000 --> 00:38:37.000 And what volunteers are, uh… doing, perhaps, some of these therapies. 00:38:37.000 --> 00:38:44.000 Um, at our local VA, we have, uh, for a long time now, uh, story therapies. 00:38:44.000 --> 00:38:48.000 Uh, that have been very important in life review for patients. 00:38:48.000 --> 00:38:58.000 And then massage therapy with or without aromatherapy is highly valued by patients and alleviates pain, depression, anxiety, and fatigue. 00:38:58.000 --> 00:39:04.000 And so, massage therapy can be done by a qualified massage therapist, but it. 00:39:04.000 --> 00:39:13.000 As a nurse, I was a former nurse, I did massage therapy on the second shift every night for all of my patients, massaging their backs. 00:39:13.000 --> 00:39:22.000 And helping them with any part of their body. Let's say they were having distress in a joint or whatever, to just gently massage that. 00:39:22.000 --> 00:39:26.000 And at end of life, perhaps massaging a hand, or massaging feet. 00:39:26.000 --> 00:39:32.000 is of very, very great comfort and can help relieve. 00:39:32.000 --> 00:39:47.000 some discomfort and pain. Music therapy significantly improves pain and quality of life for individuals with serious illness, and so there are some centers that are fortunate enough to have music therapists. 00:39:47.000 --> 00:40:01.000 But there are many, many places that do not have this resource. And so, um… active creating music, singing, uh, playing a drum, uh, playing piano. 00:40:01.000 --> 00:40:12.000 Or, um, more, uh, receptive, passive. Um, therapy, music therapy, such as listening to music that inspires you. 00:40:12.000 --> 00:40:25.000 That helps you relax. that helps you… just settle into, kind of, the present moment, or remind you of a time in your life when you were happy. 00:40:25.000 --> 00:40:31.000 And this has been very, very helpful. Um, I have seen this be. 00:40:31.000 --> 00:40:44.000 important, and I was just… uh, you know, listening to public radio, and, uh, one of our palliative care clinicians using music therapy in a very creative way, um. 00:40:44.000 --> 00:41:00.000 in the Southwest. And so. really important for us to remember and very inexpensive. And energy medicine therapies, including Reiki therapeutic touch and healing touch, can improve pain, anxiety, and quality of life. 00:41:00.000 --> 00:41:09.000 So, when I, uh, was working at a particular hospital in Madison, most of the nurses that I encountered were. 00:41:09.000 --> 00:41:15.000 trained in healing touch. And it was incredibly important to me to bring that. 00:41:15.000 --> 00:41:24.000 to the patients that I was caring for in palliative medicine, and I saw some remarkable results at the bedside. 00:41:24.000 --> 00:41:31.000 I also want to, um. emphasize two modalities such as PET therapy. 00:41:31.000 --> 00:41:37.000 Uh, forest bathing, oh my god, there are so many different kinds of therapies. 00:41:37.000 --> 00:41:41.000 So those 10 are the ones that we wanted. 00:41:41.000 --> 00:41:53.000 Palliative care clinicians to be especially cognizant about. But there are so many other therapies out there that could be incredibly helpful, and patients, of course. 00:41:53.000 --> 00:41:59.000 may, in their own infinite wisdom, know what their bees are most healing to them. 00:41:59.000 --> 00:42:05.000 So, it's not just presenting patients with a smorgasbord of therapies, but. 00:42:05.000 --> 00:42:11.000 asking them what they love. What is important to them? What has been healing to them? 00:42:11.000 --> 00:42:17.000 What helps them decrease their anxiety? And then, using that more. And. 00:42:17.000 --> 00:42:23.000 I can't tell you how important it is for a patient to hear from their clinician. 00:42:23.000 --> 00:42:35.000 That what they're doing is important. And it is contributing in a very, very significant way to their quality of life, well-being, and possibly. 00:42:35.000 --> 00:42:51.000 and possibly longevity. So, many of these therapies are low-cost, readily available in local communities, national online healing circles, support groups, professional societies, uh, providing patient information. 00:42:51.000 --> 00:43:01.000 up-to-date databases that are, uh, for clinicians, but also databases that may be available to, um. 00:43:01.000 --> 00:43:10.000 people as well. Uh, but not necessarily available to them. I know that UpToDate, uh, being just one of many, many, many. 00:43:10.000 --> 00:43:15.000 has patient education materials that we can give to patients as well. 00:43:15.000 --> 00:43:21.000 And they review, um… integrative therapies on a regular basis. 00:43:21.000 --> 00:43:28.000 Um… One anecdote that I wanted to present, because I think we have a little bit of time here. 00:43:28.000 --> 00:43:39.000 And so, I was caring for a patient with congestive heart failure at the University of Washington. He was in his. 00:43:39.000 --> 00:43:46.000 young 80s, uh, but, um, had been suffering from heart disease for a long time and was. 00:43:46.000 --> 00:44:03.000 at the very, very end of his life. And so, I was the clinician doing a palliative care consult. And of course, uh, the nurses are hugely important in palliative care, especially inpatient settings, and all the various therapists that are involved. 00:44:03.000 --> 00:44:07.000 in the care of the patient. Uh, and the chaplain. 00:44:07.000 --> 00:44:15.000 And so, we had just started a pet therapy program at the University of Washington, and it was the first day. 00:44:15.000 --> 00:44:24.000 that, um, Mason, the dog. was going to be, uh, coming to the CCU to provide pet therapy. 00:44:24.000 --> 00:44:31.000 Um, and so, this patient seemed, from a dyspnea point of view, very comfortable. 00:44:31.000 --> 00:44:36.000 His niece was there, he had very little family. 00:44:36.000 --> 00:44:45.000 And I also knew about his dog called Bingo, which was too large a dog to sneak into the CCU, so we couldn't bring Bingo there. 00:44:45.000 --> 00:44:50.000 But, um, we had provided a quilt, we had volunteers making beautiful quilts. 00:44:50.000 --> 00:45:07.000 to, um, reflect his love of the Southwest, even though he was living in Seattle. And, um… But he seemed agitated. He was… unconscious, so he was just really uncomfortable, squirming. 00:45:07.000 --> 00:45:12.000 But he didn't seem like he was in pain. He was being covered for pain. 00:45:12.000 --> 00:45:21.000 He was being covered for dyspnea. But something wasn't right with him. And so, we were going to try some lorazepam. 00:45:21.000 --> 00:45:33.000 For possibly anxiety, agitation. And before the nurse had a chance to give him the lorazepam, I saw the team, our pet therapy team, coming down the hall, and I. 00:45:33.000 --> 00:45:41.000 ask the therapy team to come in. that I had a patient that was in distress, and we couldn't figure out what was going on. 00:45:41.000 --> 00:45:48.000 And so, Mason came in, and we brought. a chair, uh, close to the patient's bed. 00:45:48.000 --> 00:45:56.000 And he was lying on his back, and Mason put his two paws on my patient's arm. 00:45:56.000 --> 00:46:05.000 It's still… this was a while back, and it still is just… so emotional for me, because it was incredible to see. 00:46:05.000 --> 00:46:10.000 Mason put his paws on my patient. This may seem far-fetched to many of you. 00:46:10.000 --> 00:46:17.000 I saw it with my own eyes. together with my, uh, a team of people. 00:46:17.000 --> 00:46:22.000 He put his paws on my patient's arm for about 10 minutes. 00:46:22.000 --> 00:46:28.000 And the dog was utterly still. And then he looked up. 00:46:28.000 --> 00:46:36.000 And he was done and ready to go. And so he left with the pet therapy person, but in that 10 minutes. 00:46:36.000 --> 00:46:42.000 The niece was there, the nurse was there, I was there. The patient was completely relaxed. 00:46:42.000 --> 00:46:48.000 No more agitation. No more squirming. 00:46:48.000 --> 00:46:53.000 And then he died about 6 hours later. And he stayed in that situation. 00:46:53.000 --> 00:47:00.000 He was perfectly relaxed. That whole time. I was blown away. 00:47:00.000 --> 00:47:09.000 not to overemphasize pet therapy. But you just never know what therapy is going to be right. 00:47:09.000 --> 00:47:13.000 for that person. And we have to be creative. 00:47:13.000 --> 00:47:20.000 And we have to be curious. And this patient couldn't tell me this, but his niece could tell me. 00:47:20.000 --> 00:47:28.000 How important his dog was to him. And bingo couldn't be there, but Mason could be there. And so. 00:47:28.000 --> 00:47:35.000 just a little bit of an anecdote there. Um, and so, again, I invite you. 00:47:35.000 --> 00:48:05.000 to, uh, submit your questions to, uh, the question and answer area, just so we can have a conversation about this. 00:48:05.000 --> 00:48:15.000 Well, Dr. Marchin, I just… Dr. Marchand, I just want to, um… Re, uh, to share some of the messages that are coming in, just, uh, thanks for. 00:48:15.000 --> 00:48:23.000 sharing, um, that beautiful story, and, um… We're very glad that Mason could be there for the patient. 00:48:23.000 --> 00:48:31.000 That moment. I see a question here about the slides. We will post the slides, and. 00:48:31.000 --> 00:48:41.000 the, uh, recording on demand on KEPSE's website as well. 00:48:41.000 --> 00:48:46.000 I think someone asked about, when did I learn about acupuncture? 00:48:46.000 --> 00:49:02.000 I happen… my second job in healthcare was as a medical assistant in the Beverly Hills Acupuncture Clinic on Wilshire Boulevard in Los Angeles. That's where I learned about acupuncture. 00:49:02.000 --> 00:49:09.000 And, uh, at that time. could not… this was 1972. 00:49:09.000 --> 00:49:17.000 could not provide acupuncture, only physicians. who were licensed could provide acupuncture, so we taught. 00:49:17.000 --> 00:49:23.000 US physicians or licensed physicians to do acupuncture, but. 00:49:23.000 --> 00:49:30.000 I happen to have a chronic problem at that time, and I received treatment from a Korean acupuncturist. 00:49:30.000 --> 00:49:39.000 not legally, and it was remarkable. the results. I was sold on acupuncture then. 00:49:39.000 --> 00:49:46.000 But then, you know, throughout. my, um… career as a physician especially. 00:49:46.000 --> 00:49:52.000 Um, I have just been so impressed with the results. 00:49:52.000 --> 00:50:00.000 of acupuncture, so I've received my. Personally, acupuncture for maybe 25 years, 20 years by the same acupuncturist. 00:50:00.000 --> 00:50:14.000 Uh, and so… Uh, and when I was doing integrative oncology, I worked with an exceptionally talented acupuncturist, and the results were astounding to me. So. 00:50:14.000 --> 00:50:20.000 not only is there evidence. Uh, for this, um, and. 00:50:20.000 --> 00:50:28.000 all these resources, please look at them, uh, especially this chapter that I wrote in Rakel and Minicello's, um. 00:50:28.000 --> 00:50:43.000 integrative medicine, um. book, it's, I think, a wonderful chapter, but I present all of the evidence, and then most recently, um, the resource number 2, Bell, Lu, Cheng, Marshand, the 10 tips. 00:50:43.000 --> 00:50:48.000 Uh, that also provides a great deal of evidence in there. 00:50:48.000 --> 00:50:58.000 I saw a question come in in the Q&A as well here about how to navigate situations where a culturally rooted healing practice. 00:50:58.000 --> 00:51:06.000 is maybe deeply meaningful to a patient, but conflicts with standard medical recommendations, and if you've run into any situations like that. 00:51:06.000 --> 00:51:14.000 I really haven't, uh, unless. the cultural tradition, um. 00:51:14.000 --> 00:51:24.000 sort of has a taboo on certain types of interventions that may be appropriate for that patient. And so. 00:51:24.000 --> 00:51:32.000 bringing, um… someone from that cultural tradition, perhaps in some kind of family conference. 00:51:32.000 --> 00:51:39.000 might be helpful, and of course, being curious to know what exactly they're. 00:51:39.000 --> 00:51:46.000 is the contradiction or the, perhaps, interaction that may not be. 00:51:46.000 --> 00:51:54.000 right, or, um. Or is it an either-or type situation? I've had many patients, maybe not even. 00:51:54.000 --> 00:51:59.000 culturally, but have felt that conventional medicine is bad. 00:51:59.000 --> 00:52:08.000 and have addressed, perhaps, like, let's say, their cancer in just using, um… alternative therapies. 00:52:08.000 --> 00:52:24.000 That, to me is, um. concerning. And so, generally, I want to have a conversation, but I want to listen deeply. I want to be very curious about what are the person's fears, because usually fear. 00:52:24.000 --> 00:52:29.000 is at the crux of that. Um, but how can we do both? 00:52:29.000 --> 00:52:37.000 and do both in a way that works for that person and their values, and what is important to them. 00:52:37.000 --> 00:52:49.000 And also, addressing their worries and their concerns. Uh, and so, our usual way that we do palliative care, and the important questions we ask, will go a long way. 00:52:49.000 --> 00:53:02.000 In trying to kind of come to an interaction, a way of integrating all of that for the benefit of the patient, and not leaving out anything important. 00:53:02.000 --> 00:53:14.000 Thank you so much, Dr. Marshan. I also saw a question come up in both related to, um, if you recommend specific interventions for… specifically for grief. 00:53:14.000 --> 00:53:25.000 Yes, so. Grief, yes. There are many psychotherapists, uh, that could be incredibly helpful for grief. 00:53:25.000 --> 00:53:38.000 There are, um, wonderful books and webinars, and uh… Francis Weller comes to mind and, um, perhaps his website. 00:53:38.000 --> 00:53:53.000 W-E-L-L-E-R. Um, hospice will provide grief services in the community, so if there's a hospice nearby, there are grief services nearby, chaplains provide great grief. 00:53:53.000 --> 00:53:59.000 Therapies. And also, just listening to the person. So. 00:53:59.000 --> 00:54:07.000 Almost any practitioner can help someone with grief. if they listen to the grief. 00:54:07.000 --> 00:54:12.000 to what that person has to say. Just being listened to. 00:54:12.000 --> 00:54:16.000 When you are in grief. is incredibly important. 00:54:16.000 --> 00:54:26.000 And then there are grief retreats. Um, I attended one a little over a year ago that, in Wisconsin, that was incredibly important. 00:54:26.000 --> 00:54:29.000 to me. So, um, doing a search of that. 00:54:29.000 --> 00:54:37.000 uh, you know, grief kind of resources generally will get you to an abundance of, uh, helpful. 00:54:37.000 --> 00:54:44.000 therapies for grief. But hospice being one of the main ones. They are experts in this. 00:54:44.000 --> 00:55:03.000 and also chaplains. Uh, any… any… person that's associated with a church community, or a spiritual community, often there is resources there for helping someone with their grief. 00:55:03.000 --> 00:55:08.000 Thank you so much. I saw some other questions come in related to, um. 00:55:08.000 --> 00:55:17.000 how you… what's been your experience in… in… Working to convince other clinicians on the importance of. 00:55:17.000 --> 00:55:24.000 Some clinicians do not want to be convinced. They just feel that what they do is the end-all be-all. 00:55:24.000 --> 00:55:34.000 And, um, again, you know. feeling that the patient has a particular problem, and they have the, the. 00:55:34.000 --> 00:55:41.000 treatment for it, and not. really expanding. 00:55:41.000 --> 00:55:47.000 their approach to the patient to regard other therapies. 00:55:47.000 --> 00:55:52.000 Uh, for me, sometimes, um, doing, uh, presentation like I just did. 00:55:52.000 --> 00:56:00.000 Or, um. giving people resources, like I'm doing for you. 00:56:00.000 --> 00:56:13.000 Um… can help. Yes, but if somebody doesn't want to, um, change, that's why I think if a patient really wants an integrative approach, a whole-person approach, and is feeling. 00:56:13.000 --> 00:56:20.000 like they are an object of care, they need to find different clinicians to care for them. 00:56:20.000 --> 00:56:29.000 If possible, some places do not allow that, because there may be only one specialist in a particular area. 00:56:29.000 --> 00:56:36.000 So, for them, they need to find it, um, elsewhere. And, uh, that's where. 00:56:36.000 --> 00:56:46.000 You know, even, uh, looking online can be helpful, although online does have its pitfalls. 00:56:46.000 --> 00:56:51.000 And I hope that most people have a trusted clinician that they can go to. 00:56:51.000 --> 00:56:58.000 Uh, perhaps the specialist, there may be only one in a particular rural area. 00:56:58.000 --> 00:57:04.000 But hopefully they have some trusted clinician that they can go to to help. 00:57:04.000 --> 00:57:16.000 have a person-centered, um, approach to their care. And as a family physician, certainly, I felt that family physicians often fill that role. 00:57:16.000 --> 00:57:21.000 Or internist, or… Others. 00:57:21.000 --> 00:57:29.000 Thank you. Um, I hear, uh, from the chat about how can we include integrative medicine in training. 00:57:29.000 --> 00:57:38.000 Hospice and palliative medicine fellows, and if you know of any good resources that are good for learners and kind of. 00:57:38.000 --> 00:57:44.000 Ah, excellent. So, there are many of us in palliative care that do integrative medicine, so. 00:57:44.000 --> 00:57:53.000 Um, I know AHPM, maybe HPNA has, um. interest groups in integrative medicine. 00:57:53.000 --> 00:58:10.000 Uh, Osher centers are at many, um, Osher Centers for integrative health are at many academic centers, and so inviting someone from one of these academic centers, or from our palliative care clinicians who. 00:58:10.000 --> 00:58:25.000 do integrative palliative care to give a presentation. Um, certainly, you know, I like to be as involved here in teaching at the University of Wisconsin as I can be. 00:58:25.000 --> 00:58:35.000 But, um, uh. Yes, and I think as palliative care clinicians, as we sort of expand our toolbox. 00:58:35.000 --> 00:58:42.000 Uh, to include integrative medicine, then we can be the ones giving a presentations on incorporating. 00:58:42.000 --> 00:58:49.000 integrative medicine, um. into palliative care, perhaps, um. 00:58:49.000 --> 00:59:03.000 using this webinar, uh, from CAPSE. Uh, to present to our palliative care fellows. I generally found with palliative care fellows that they are very open to an integrative approach. 00:59:03.000 --> 00:59:15.000 And when they go through hospice, hospice. Uh, I'm sure there are some hospices that don't, but I have been very impressed with most of the hospices that I've worked with. 00:59:15.000 --> 00:59:24.000 that use an integrative approach. Um, and. Many practitioners different, uh, of different disciplines. 00:59:24.000 --> 00:59:29.000 also provide, uh, integrative perspectives to the care of patients. 00:59:29.000 --> 00:59:37.000 And it may be very simple, like. someone, uh, is having… being fairly isolated. 00:59:37.000 --> 00:59:41.000 And how can we incorporate them more into the community? 00:59:41.000 --> 00:59:49.000 Um, how can we have volunteers be a part of their care so that there's less isolation? And so, these are. 00:59:49.000 --> 00:59:54.000 What I consider integrative therapies. giant toolbox. 00:59:54.000 --> 00:59:57.000 for looking at the patient and trying to help them. 00:59:57.000 --> 01:00:08.000 Uh, and serve them in any way possible that would improve their quality of life. 01:00:08.000 --> 01:00:17.000 All right, we are at the top of the hour, so I just want to… Um, give a huge thanks to Dr. Marchant for presenting today. 01:00:17.000 --> 01:00:33.000 Thank you all so much for taking the time. As I mentioned, the resources, uh, the slides and the recording will be available on our website, so if you missed any portions, this webinar was free and open to all, and will be as an on-demand resource as well, so feel free, as Dr. Marshan mentioned, to share this. 01:00:33.000 --> 01:00:44.000 Oh, see lots of love and thanks coming in. So, um, yeah, just want to echo those again, so huge thank you. And, um, yeah, feel free to share this resource with your teams, their colleagues, and with other folks in the field. 01:00:44.000 --> 01:00:47.000 Um, with that, uh, just a big thanks to you for what you do every day, and take care, everyone. 01:00:47.000 --> 01:00:54.000 Stay