I think we're going to go ahead and get started. This lecture is actually something that's near and dear to my heart because how many of you have had the experience of actually having been on the end of managing a patient with GBM and coming to that end-of-life discussion, and it's so tough, and you don't really know what are the words that you say, and this is a great opportunity to kind of hear from someone who manages a palliative care program and help us to understand what words would help us with that patient that's at the end of life. Dr. McMillan is the Director of Palliative Care Services at UC Davis. He's board certified in internal medicine, and he's going to talk to us today about tips for palliative care discussions in the neurosurgery population. Thank you so much for joining us, Dr. McMillan. Can you hear me? All righty. Well, thank you, Christy, for the opportunity. Where's the mouse? Very good. So I have no conflicts of interest to disclose here. I was downstairs, and I was talking to Dr. Waldo, who's in the audience, and walking around and looking at all of the tools and the amazing technology down there, and it's amazing to think about when I trained in neurosurgery many decades ago and seeing where we have come now. So my goal today is maybe to add a couple of other tools to your toolbox around when you're talking with families. That's what I hope to bring today. I would like to start my goals today, really quick introduction to palliative care, really describe an overview of neurosurgical patients and the challenges you all face, maybe some challenges in approaching goals of care discussions in this patient population, goals for family meeting. Hopefully, you'll walk away with a little bit of language that can help you be useful working with families. We'll talk a little bit about managing emotion, maybe some cultural issues of how to broach those. And maybe at the end, I don't know if we'll have time, but the role of time-limited trials as you're helping facilitate goals of care and care plans for your patients. So I usually like to start my talks with a quote, and this is from Osler from back in the 1890s. I think it is still relevant today, again, how we, despite all the technology and all we have, it's often the human touch that is so important to our patients and our families. So real quick, what is palliative care? If I asked people all in this room to define palliative care, I'd come up with a bunch of different definitions. I love this slide because it's a bunch of blind people walking around and touching the elephant and describing what you're seeing. And really, even after people feel like they understand palliative care, they don't. And you ask palliative care providers, and I don't even think we're consistent about what we say we do. So, but why has palliative care become important? I think it's important to understand medical progress, and again, you guys are at the forefront of medical progress. It has changed the way we live, it's changed how we get sick, and it's changed how we die. For many of my patients, oh, I'm an internist by training, I'm a hospitalist and I work with a lot with the residents. So in my patient population, you can imagine I'm dealing with chronic illness, and we often deal with a problem list of our patients, and we have COPD, we have CKD, we have diabetes, you know, all the acronyms, boom, boom, boom, you know, 20 acronyms down there. But the thing I often say to the residents, you know the number one problem on their list should be chronically dying, because many of these illnesses are progressive, and while they're not actively dying in front of us, they may be life expectancy of a year, two years, three years, five years, and we don't, if we don't think about that, we lose the opportunity to have really good advanced care planning for those patients on their trajectory and the road ahead. So that's a plug for advanced care planning. But as we know, that often doesn't happen for many of our patients. They arrive either in the hospital acutely, or in your clinics, and they have a devastating diagnosis and you're there having those first discussions. So if you ask, here are some of the elements of palliative care, I think, but when we think about it, palliative care is very different in different patient populations, as I've come to learn over my career. And when you look at palliative care in the neurosurgically or neurocritically ill patient, four big themes emerge for the role of palliative care physicians in helping care for these patients. It's really helping, along with the neurosurgery team, understanding the illness. Helping elicit family values, patient values. Really, again, you guys can all speak, identifying the conflict that often comes up in these cases as we're trying to move these cases and work with families and arrive at meaningful plans. And the biggest thing for a lot of this is understanding medical options in the setting of what is very much uncertainty. In a lot of illness, and cancer is a very different beast. I think many people understand the road ahead and cancer trajectory is a lot easier to understand. But again, in neurocritical illness, it is very hard to understand. And one of the other things that happens, again, this theme will pop up, is patients get sick very quickly and decisions need to be made in a very short period of time. And the patient hasn't even had time to wrap their hands around what is going on. So we're often making decisions with a lot of uncertainty. So one of the challenges, too, in caring for all critically ill patients really is this balance between overtreatment, which may prolong suffering and not accomplish meaningful outcomes, may not be something the patient wants, but also avoiding premature closure, preventing stopping therapies that may have resulted in meaningful outcomes and prevented what we may think is avoidable deaths. This is a challenge in all ICU medicine. So as we're thinking and we're approaching, and you guys probably do this with your patients, one of the important things is not whether we have a treatment or a treatment option, but important in all of the discussions, and this is so important that I have with all of my patients and families, is what is the anticipated quality of life if the patient were to survive? And when we talk about that, we can use a scenario called best case, worst case scenario. And you may have heard this. The best case scenario is what may happen would be the 25 percentile if we're thinking about a spectrum. We describe the best case outcome. The worst case outcome is what the likely, the 75 percent, the bottom quartile is likely to experience. But more importantly in that, when I'm having the discussion, is what is the most likely outcome? And that may not even be either end of the spectrum. So part of it is what is the anticipated quality of life? And then more important in the patients that you deal with is what is the time it will take to be able to achieve that outcome? And part of that will be, again, as we go in a lot of neurosurgical illness and recovery, recovery is not on the order of days or weeks. It's on the order of months to maybe a year. So what is the patient and the family, are they willing to endure the trials and tribulations of those months ahead, year ahead, with the outcome being something that they may find acceptable or not? So those are imperative things that we have to think about and foster in our communication with our patients and families. One of the challenges too is 70 percent of patients who present with neurocritical illness have a precipitous loss of function and or cognition. That doesn't mean they're perfectly healthy prior to coming in, but again, significant loss. This is a significant change in their life. And then often because of the cognitive decline, family members are put in the arena of being surrogates. And oftentimes patients don't have advanced directives. So surrogates and the amount of angst and stress and anxiety they feel around having to make decisions, especially early in disease when we don't know the prognosis or outcome. And then often our patients may not die from their injuries, but they may have a prolonged time from recovery, or they may stagnate over the next several months or years as they're attempting to recover. One of the other things that clouds all of this, and probably all of us in medicine lambash Wikipedia and Dr. Google. I have this cup I carry around a lot when I'm on rounds when I have a particular family that says, please don't confuse your Google search with my medical degree. Oftentimes just send a message to patients and families. But again, if you think about the media and movies and Hollywood, which influences everything, you know, people, you know, we cringe when we see a patient who has a devastating coma and all of a sudden in the movies they wake up and miraculously they're fine and their motor function is fine and they're back to normal. And if you look at this, you know, in 30 movies between 1970 and 2004, only two movies realistically portrayed what patients with either persistent vegetative state or minimally conscious state, what the outcomes look like. So again, we're dealing with what the public perception, the reality already walking in. So that's one of the biases that our patients and families already bring in that we need to negotiate around. Never mind the, you know, the long lost family member who had a, you know, miraculously woke up. I mean, it's amazing how many families I work with and all of a sudden they all have a family member who woke up from a coma. It's unbelievable to me, you know. When I think about illness, you can think about illness as a trajectory. And if you look up in the upper right-hand corner, neurocritically ill illness is very different from a lot of the other illnesses that we think about. You have function on the y-axis, you have time on the x-axis, the recipitous drop. And then some patients may succumb to their initial illness, but a lot of patients will remain at a very low level function. And then over time, we will see whether or not there's recovery or they remain in their persistent vegetative state or they succumb to a consequence of their illness. Very different from cancer, frailty, organ failure. And then just, this is a chart from what was a big NIH review, just looking about neurocritical illness and mortality, both immediate mortality, in-hospital mortality, third-day mortality and functional outcome. It just gives us the scope of the problem of your patients and what we're dealing with around facilitating goals of care and advanced care planning. So this is our patient. Our patient, when we go, often is going to be, we're at a fork in the road when they present with their illness, and we're going to help navigate the road ahead for our patients and families, and it goes several ways. So one of the things that often comes up early is families often talk around prognosis. And I'm very hesitant to often go to prognosis, because most of the time, prognosis, we focus in on prognosis as a matter, as a unit of time. And we're notoriously bad at that, especially as clinicians. We tend to, as physicians, all the literature suggests, physicians, we overestimate by a factor of five patients how well they're going to do. The closer your relationship you are to have the patients, the more biased you may become. Because you want them to do well. So really, what I tend to do is if, one of the, maybe the tricks or tips I give you as you're going home, some patients and families, time is very important to them around for decision making. What I usually do is I put time in a sort of, in the context of buckets. I talk to patients and families about time, it comes as days to weeks, or hours to days, to weeks, weeks to months, and months to years. And I tell them, where you are right now, you're in one of these buckets. But if something changes, we can, and if new information comes up, you may move into one of the other buckets. But I tend to keep it general like that for patients and families, because there's so many times you say, oh, you have two weeks. And then the patient may not have two weeks, and then they may survive. And then all of a sudden, how many of us had patients and families said, you know, my family member's been told that they're going to die multiple times. And then you can never have that discussion. So again, prognosis for me and time is not important. I tend to move over into what I call is more effective forecasting. And this is what we all know much better. So we all go to school, and our training and our experience teaches us the knowledge of the illness. We know about therapies. We know what the road ahead, what could happen. We know what recovery looks like. We know what decline looks like. And in my meetings with families, I focus more on effective forecasting and painting that picture and maybe giving some times to when I think the patient should show recovery, when I expect them to get better with the therapy, rather than focusing purely on time as a mortality. It helps us really for families to create the framework ahead about where we're going and how we think about the illness. And that's really important for families to try to understand that. It also creates expectations for the families along the way. And it also creates natural stopping points to regather when you reach one of those milestones, whether it is a milestone towards recovery or a milestone towards decline. You've already predicted that this may happen. And then I often say to families, if we start to see the following, and your loved ones in the ICU, if they're intubated, and we say after 72 hours, if we still see the hypoxic myoclonic jerking, that's not a good sign. So maybe we should plan in 72 hours to plan to meet again with the family and see where we are. And if that's happening, I've already forecasted to them, that's not a good prognostic sign. And then in 72 hours, we will reconvene and discuss where we are. So again, it really helps shape the conversations for families, but it also helps us shape what a good outcome would be or could be. So if you think about medical decision making, this is one of the most complex things that we do. And if you look at this diagram, this is the lens that both the patient uses and family uses, but it's also the same lens that we use when we're making decisions. And you can see how complicated it is, medical decision making, in all the factors. And I've probably even left some factors out here. So potential goals of care. I'm not going to spend a lot of time on this, but one of the things as we're listening and talking with patients and families, we're really trying to get at goals of care. Let me make a pitch. A plan of care is what we're going to do. And that evolves from what we call the goals of care. How do you want to live your life? How do you want to live your life with this illness? What don't you want to see happen? What's important to you? Those are the things that are goals that people have for living with their illness. And then from that, we all get together, all the team members and as clinicians with the family, we can write what that plan of care should look like. What are those interventions? People often get confused that interventions are a goal of care. I don't know the last time a patient really said to me that I want you to pound on my chest and do CPR and keep me alive. I don't think anyone has that as a goal. But patients look at our treatments to help them live their lives in some manner. So again, trying to get at these goals of care. And we'll talk about that. Patients often have multiple goals of care at the same time. They often contradict. We've all been there. And then when they contradict, one of the biggest focuses we have and I have is around pre-prioritizing what's most important. If we have to decide between all these goals, which one takes precedent if I have to let other ones go? That can be a difficult conversation. But again, I think as we're in these meetings and you're building rapport, you can reflect back to patients. And they often understand when you say, I can't do both of these. So if I have to choose one, which one? Okay. Shifts. Some takes precedence over others. The shift may occur quickly or it may occur gradually over chronic illness. So some things for us to think about. And you probably do this already. But as I'm thinking about going into a family meeting, I often meet with my whatever team I'm working with. Because I'm usually a consultant as a palliative care specialist. So I usually, in this case, I'll meet with my neurocritical care specialist, neurosurgeons, neurologists, advanced practice nurses, bedside nurses. And we'll talk about what are the treatments? What are we thinking about? What are people thinking about before we get into the family? And this is what I often, the questions I ask the team, so we're very clear on this. I think if we're clear on these things, it makes it clearer for what we can offer the patient. And again, will it cure the illness? Will it help the patient live longer? What's the quality of life that we can expect? Will it lessen their suffering? What's the burden of the therapy? This is often something that's very important to elucidate. What is the burden, the side effects? What is the time to achieve the benefits? These are all important questions that we should really discern before we go into a meeting with families about offering treatment, or have the answers to these questions, because often families will have these questions for us. So there's sort of a seven-step process that we go through. And I give you at the end, a couple slides near the end, I give you a very practical example of how you do this. But let me just take you through this real quick. This is how you run the family meeting. We have to create the right setting. So that means who needs to be there? What important family members need to be there? Do we have advanced directive documents? Are we going to do it at the bedside? Can the patient be included in this or not? What are the key members of the team should be there? I always often recommend, I love to have the bedside nurse there present at the family meeting. Because often we go away, speaking me as the palliative care physician or even the treatment teams, and the nurses spend so much time at the bedside with the patient, they can follow up on questions, they can see how the family meeting is, they can give us feedback and they can help us as the meetings move forward. So creating the right setting. I can tell you that one of the most important things for creating the right setting is everybody has to sit down. The standing up around the bedside and doing it over the patient, that does not work well. Quick updates where you're standing up by the bedside and quick things, that's fine. But a family meeting, everyone should be sit down and relaxed. The first step really is, the goal of a family meeting is that you should talk less than 50% of the time. If you talk more than 50% of the time, we may not be really understanding what patients and families want and pulling the information out of them. It may be a bad analogy, but I often think the family meeting is like a game of poker a little bit. I want the family to lay down their cards. I want to pull their cards out of them. And I know then how I can help them, what I can play, what tools in my belt are going to be helpful for them. So the more I get them talking early on, the better. So what does the family know? What information has already been said? Do they have previous experience around this illness? Do they have other family members? Some of the things are, what are they worried about? So getting the family to talk and tell you what they're worried about. Next thing is exploring what they're expecting or hoping for. And this seems like a funny question, but you may ask them, what do you think is going to happen here? What do you hope will happen here? What are you worried about that won't happen? Those sorts of questions. So it's the worried statements. So again, you notice in the first parts of the meeting, a lot of it is just exploring what their worries, fears, concerns are for this patient. One of the most important things in here you can do is, after you, you may initially in the family meeting divulge the diagnosis and a little bit about the illness. One of the things I encourage you to do is take a step back, and I often say, tell me about the patient before they got sick and who they were as a person. And I want to know about them as a person. Were they married? What was their job? What were they doing? If they have chronic illness in the background before this illness, I say, tell me how they've been going the last couple of months. What have they been struggling with? All of that context before this illness will help me understand how I can help them afterwards. So the more you know about the person and the family, the easier it is to move forward. And as we move forward, the fourth step is, after you understand their values and their goals, knowing what treatments may be possible, you can begin to try to suggest. I often ask permission. Well, would it be OK for me at this point to offer you some recommendations about treatments that we have moving forward based on what I've heard you say? And oftentimes, the family will say, please. They want to know. And because I understand a little bit about the patient and what they're hoping for, I can suggest both realistic goals and try to give off realistic treatments. We'll talk in a minute about how do you respond to emotion and how do you respond to conflict, because that is one of the biggest problems. There's very few family meetings I've ever been in where there hasn't been some emotion. The biggest rule is when people, whatever the emotion is, if you name the emotion, even if they're angry, you'll say, and I'll say to families, too. We'll get a lot of families. And I'll say, man, you guys seem really pissed off. I'll use common language. And they'll say, yeah, you're right. I'm pissed off. And I'll say, well, what are you upset about? And I just acknowledge the pink elephant in the room. You acknowledge that. And it all of a sudden takes most of the emotion, and it just kind of dies down. It goes away, because you've acknowledged it. You're not running from it. And most of the time, they're not angry at you. They're angry at the disease. They're angry at the illness. They may perseverate on a small detail, something the ER nurse did when they first came in, and they just can't get over that. But again, it's just name the emotion, and then you can begin to move forward. So respond empathically. Make a plan to follow up. And make an action plan. And this is the most important part, when you have the family meetings, when are we getting together again? And the one thing I'll share with you, it does not have to be every day. I think that tends to overwhelm patients and families, and they get emotional burnout. And they're so afraid to meet with you. So unless the patient has a significant change in either direction, just set a timetable, maybe, for 48, 72 hours, whatever you think is reasonable based on the treatments and the plans ahead. So language I would want you guys to try to avoid. So one of the languages that I like to use is I'm always trying to tell patients what I'm willing to do, and I don't use the language of what I don't want to do. Does that make sense? I don't want to say, well, I don't want to do CPR. I don't want to do this surgery. I avoid language around those lines. I tell them, you know, if we say to patients, too, what do you want us to do, everything possible, how many people have heard people say that? Do you want us to do everything possible? First of all, you know, we never do everything that's possible to every patient. Second of all, not every treatment is indicated for every patient. People have no idea what you mean when you say they want everything possible. So I recommend never saying that. The second statement, you agree to discontinue care. Well, that's a big bugaboo. We always care for the patient. We never stop caring for the patient. We shift the focus of the care, right? But we never stop caring for the patient, okay? And families will hear people say that. Just the same thing, like, it's time to talk about pulling back. Again, I always, I never use that term. Again, I'll use the term, I think we should shift the focus of our care for things that I think we can be successful at. Here are the things that I don't think we can be successful at. So I, therefore, that's why I don't think we should proceed with these treatments, okay? So I define what are we gonna be successful at? I say, I think we should stop aggressive therapy. Well, again, what I'll, again, that, I think that's language that sends a wrong message that we really don't wanna do anything. I say, I often say, I wanna shift my focus to being aggressive to make sure that your loved one, if we're talking end of life, has, I wanna be aggressive to treat their symptoms and manage them through the end of their life so they have quality and dignity. So I wanna be aggressive doing that. That's a different, that's a different thing than saying, I just wanna stop all aggressive therapy. I actually don't even like the word aggressive, and I try to tend to avoid it at all times. So language that helps describe goals of care. I wanna try to give you the best care possible I can. I wanna concentrate on trying to improve your quality of life. I wanna help you live in a meaningful way in the time that you have left. These are all things that you're, they're action items of what you're willing to do. They're very positive. Here's some other examples. What can I do to help you maintain your independence? I want to make sure your father receives the kind of treatment he wants. And that's one of the most powerful statements when you're getting a surrogate decision maker and you have an advanced directive that's pretty clear about what the patient wants and the surrogate decision makers are not necessarily following the advanced directive. This is really a powerful statement. So again, some more language around what you're willing to try to do to treat the patient. Always say that, not what you're not willing to do. So Ron, so here's some methodology to responding to emotion. Again, most of the time when I get called in to the family meeting, I would say probably 80% of the time, there's, they're like, Dr. Mack, this is a tough family. And you're like, oh boy, here we go. Like, so I'm, you know, my Irish blood starts to boil and I'm like, oh God, what did they do? What did they do? And most of the time, it's amazing, it's not bad. It's pretty easy and manageable because most of the time they're just emotional and for many reasons. So again, I think trying to reflect on the struggle they have, reflecting on their emotion, reflecting on even if they're angry and something hasn't gone well. And there are times where things don't go well and their perception, even if we've done everything right and the outcome isn't what we anticipated, patients and families still blame us, right? As Dr. Waldo said, sometimes they're not willing to accept the risk of the treatment, even though you told them what the risk of the treatment was. So you just have to acknowledge that and try to work through it. I never run from the emotion, okay? I used to when I was a little resident. Now, I think with the gray hair, I think I'm okay. So, but that's the most important thing. And a lot of times when they're angry, silence is your best friend. Just let them talk. And if you don't know what to say, you know what the best word is? Tell me more. Tell me more what's going on. Tell me more how I can help you in this point. So emotion, you're gonna run into this. So one of the things Christy asked me to try to touch on and I can, is cultural medicine. And living in Sacramento where we have 13 major different nationalities, it is a cultural milieu every day in our hospital. So that's a whole separate talk. And I don't even think we fully understand completely how all cultures, how to best work with them around palliative care. But there's some simple principles that you ask. The first thing, if I get, now that I have enough experience I kind of know what to anticipate. But when I was younger, I would just go to whatever their ethnicity was and I'd say, I don't know much about your culture and how you guys respond to illness and how you respond to talking about death and dying. Can you teach me about how I should work with you? If you just say that up front with almost any group, they are more than happy to tell you and teach you and you can take your guidance from there. So again, that's another big thing for the tool belt. If I know something about their culture, I don't assume that they subscribe to that. But I will announce, I will make, you know, again for our mung patients, I'll say for our mung patients. So I recognize many of our mung patients, the community elders are the decision makers for many of our patients. Is that the case for you and your family or do you make decisions as a family? So I acknowledge, I understand a little bit about their culture, but I ask them how do they as a family proceed? Because we're getting a lot of second and third generation families, so some of the cultural rules that they subscribe to are starting to dissipate and they're becoming more westernized. So again, if you know something, just don't make the assumption you know, but ask. And asking these questions are very helpful because again, you ask these questions to them, you can begin to understand how they think about illness. One of the important things is that you talk about is again, if you're talking about a situation around critically ill patient about death and dying, it is important to recognize that many of our cultures do not want to talk about death and dying. So a lot of our Middle Eastern families and cannot, will not ever talk about death and dying. They will not pursue hospice, don't even bring it up. A lot of our Orthodox Jewish, the culture is once you start a treatment, you can never stop a treatment. So there's, so again, asking these patients and these families about how do you family approach? How do you talk about it? How can we talk about it? They'll tell you how to proceed so you don't feel like you're walking on eggshells, okay? The other big question is when you're talking with patients around or especially around cultural issues, this may put us in a little bit of an angst where the patient will say to you, they're fully competent and they say, I don't want to know anything. Talk to my brother, talk to my husband, talk to, how many of us have had that before? Okay, does that make you a little bit nervous? Okay, well, it shouldn't. Let me tell you why. So we in Western medicine, we subscribe to four bioethical principles. The first one is called patient autonomy, right? The patient has a right to the information and make their decisions. But in that paradigm that I just described where the patient tells you they don't want to make decisions, they're actually practicing patient autonomy and telling you, I don't want to know anything, I want somebody else to do it. So we should feel comfortable doing that. If you ask me on a personal level, I'd love the patient to be more involved. But again, I recognize from their culture and other things, they are giving us permission to move and talk to other folks. And I think we have to respect that in the realms of patient autonomy of modern bioethics. So here's some other tested language. This comes from Dr., you guys have all heard of Atul Agwandi and all the wonderful stuff he's done. He's a surgeon from Mass General who's really become to do some profound writing around advanced care planning, hospice, palliative care. And this comes from his research lab and this is patient tested language. And if you look at the link at the bottom there, I'm sorry, I forgot to upload it. This is their communication guide called For Serious Illness. I recommend you could pull this down, it's free and you can read it. But this is some of the patient tested language that you can use for patients and their families. Okay. And I'm gonna wrap up with this and then I'm not gonna get to the time limited trials at the end here. But again, one of the big things that often comes up when you get involved into a case is conflict. And when you get stuck working with patients and families, one of the things I teach the residents and my palliative care fellows when we go in is go identify the areas of conflict. And once we know the areas of conflict that are going on, we can begin working and helping families. So it may be family versus clinician. It may be clinician versus clinician. You got two doctors talking about two different things. They don't agree on treatment options. They're saying different things to the family. Well, how many have seen that? We all have seen that. It may be family versus family and that's the problem. It may be patient versus clinician. It may be patient versus diagnosis. And oftentimes the literature suggests in cases like this, there's two or three areas of conflict in the case. And once we get those areas of conflict, we can begin using some tools and communication tools to start exploring these areas of conflict to begin addressing them. A lot of it is active listening. A lot of it is acknowledging the conflict as well. Again, naming the conflict. I may say to a patient, it seems like you guys are really devastated by this illness and are really struggling with the diagnosis of cancer here. And they say, yes, and they'll tell me more about that. So those are things to do when you avoid conflict. This is probably good. I've learned this. Actually, this has helped me in my marriage. So this is wonderful. The first one, the first one, stop trying to convince the other patient with more information and repeatedly saying that you're right. It doesn't matter. This isn't a thing about right or wrong. It's about trying to get them information. So please don't do that. Don't avoid the conflict. Avoid questioning the patient's ethics. Don't let the issues percolate. So, and here's a nice step-wise approach to handling conflict that you guys, that's out of Tony Bach's group up in Washington, who's done a lot of publishing around this. So with that, I'm gonna wrap up with this. So really at the end, what we're trying to do here is there's two sides to these family meetings and negotiation around goals of care and care plans. There's physician and clinician and input. There's a lot of prognostic scoring systems out there that are validated for certain disease processes. The problem with those scoring systems, they predominantly focus only on mortality. I wish that some of them focus on motor function and other types of recovery, but most of them don't have quality of life as part of those scores. But again, they're a starting point. And then you have the patient and family input. And then together, it becomes a team approach about how do we end up setting goals and setting treatment plans. So with that, I'll sort of wrap up and I'm happy to answer any questions. Thank you. Thank you, Dr. McMillan. Does anyone have any questions for him as Dr. Waldau comes up to set up? No, no questions? Well, thank you so much. Thank you.

effective communication

end-of-life discussions

palliative care

patient's values and goals

forecasting

decision-making

cultural considerations