Monday, April 21, 2014

Empathy, Goals of Care & Training Opportunities to Improve Your Communication Skills and Teaching

Empathy plays an important role in all of healthcare communication, but it's especially heightened when clinicians are working with patients with serious illness and their families.  

Journal of Palliative Medicine published an article by Vital Talk's Tony Back and Bob Arnold recently about the role empathy can play in the delineation of goals of care for seriously ill patients.  Empathy without any specific action is valuable to the suffering person.  Merely being understood often times has some ameliorative impact on the suffering person and fosters a therapeutic relationship, even when some problems cannot be solved.


However, in the face of insoluble problems (e.g. cancer not responding to chemotherapy), patients understandably want helpful action, and clinicians still want to act.  Do something that will help me!  What can I do to help myself?  The question is, how do we figure out how to direct both our energy and the patient's? 

Back, Arnold, and others have written extensively on this topic, and the current article adds even more nuance to goals of care exploration.  They write about how patient emotion can be translated into meaningful action that moves patients towards achievable goals of care.  They recommend the following steps:

  1. See affect as a "spotlight"-  be curious about the reasons for the emotion.  Don't assume sadness is exclusively about dying.  The first step is merely recognizing the spotlight, even if it's not patently obvious where it's shining.  
  2. Use the affect to connect with the patient- bring it out in the open to demonstrate for the patient that you are noticing it.  They recommend doing this before moving on to figuring out what is being spotlighted.
  3. Read between the lines to infer what is important- listen for cues that suggest a deeper concern or narrative that isn't being openly talked about.  The evidence here will be incomplete, and the clinician needs to hypothesize and test the hypotheses with the patient.
  4. Develop action plan jointly with patient to address the need.  The patient needs to be committed to the plan, and when a patient is committed to action that helps them address the goal, the process is defined as a success.  

Image: FracFX "In the Spotlight"
The "goals of care" concept is already patient-centered and the described process adds to the patient centered-ness of it.  You don't automatically know what the patient's affect is about.  There's some guesswork.  But you're not going to move to an action plan until the patient confirms you've got it right AND that they are committed to the plan.  Step 4 suggests a role for patient behavior change in the goals of care process:  What can patients do to help themselves achieve important goals? In the face of serious illness, patients frequently feel like they lose control over activities in their life. Exploring emotions that might arise from this loss can help us figure out how to help patients restore some semblance of control. 

This newly described process shares elements similar to other communication skills and processes taught by Vital Talk. It's not meant to be a dogmatic process, but rather a distillation of small ingredients essential to meaningful conversations about serious illness.  

Vital Talk has some upcoming training opportunities for both clinicians wishing to improve their own communication skills and also for educators wishing to improve their teaching of communication skills. Having been through both types of training before, I would use the following descriptors: high yield, dynamic, supportive, fun, and life-long.  In addition to coming home with improved communication and teaching skills, you also come home with a process for how to continue your improvement.  

See here for more on my experience with a Vital Talk faculty development program for teaching communication.  


ResearchBlogging.org Back AL, & Arnold RM (2014). "Yes it's sad, but what should I do?" Moving from empathy to action in discussing goals of care. Journal of Palliative Medicine, 17 (2), 141-4 PMID: 24359216

Monday, April 21, 2014 by Lyle Fettig, MD ·

Wednesday, April 16, 2014

National Healthcare Decisions Day April 16th, 2014

What a great thrill it is to see something start from a small local idea and take on a full national impact. National Healthcare Decisions Day (NHDD) is today, Wednesday, April 16th, 2014 and so many more organizations are getting involved, beyond those who might naturally be inclined to assist their community with advance care planning. Many healthcare organizations, employers and communities are mobilizing today and this week to make sure that patient’s preferences wishes are being documented and recognized by the medical community. I even saw it on my health insurance employee wellness homepage!

Since the manufactured outrage over non-existent ‘death panels’ has appropriately faded, I think many people feel much more confident in addressing these issues. And interestingly it seems as if advance care planning is becoming a growth niche with so many different local, regional, and national options supporting this effort. So with all these options it is even more critical for health care providers and health advocates to be informed and involved with the people making these decisions.

If you are thinking to yourself, “Darn it, I always forget about NHDD every year and have always wanted to help and get involved,” well there are still some simple yet effective things you can do today!

1) Sign up for the monthly NHDD newsletter that comes out on the 16th of each month,
2) Gather your team and start making plans for next year,
3) Find someone in your community who is already doing something for NHDD and partner with them,
4) Follow @NHDD on Twitter, and then Tweet and Retweet about it using the hashtag #NHDD
5) Go like and share the great viral info on the NHDD Facebook page


If you are seeing any innovative efforts on NHDD today, please share them in the comments below, on Twitter, or on Facebook. Happy NHDD!


NHDD Speak Up Video from NHDD on Vimeo.

Wednesday, April 16, 2014 by Christian Sinclair ·

Thursday, April 10, 2014

Cases: "Am I really going to have to live like this?": The Role of Octreotide in Patients with Persistent Nausea and Vomiting after Venting Gastrostomy

Case: 

Ms BB is a 57 year old woman with fallopian tube cancer with multiple mesenteric and peritoneal metastases and a history of large and small bowel obstructions. She presented with nausea, vomiting, and abdominal distention. She was found to have another bowel obstruction and had an NG tube placed with improvement in her symptoms. She then went to the OR for an exploratory laparotomy. She was found to have massive carcinomatosis and ascites and it was felt that a debulking was not possible so a venting gastrostomy tube (g-tube) was placed and the operation was aborted.

Palliative care was consulted to assist with postoperative nausea and vomiting. Despite placement of the venting gtube, the patient had persistent nausea and held a basin next to her during the interview to catch her frequent episodes of emesis. She was despondent because the surgeons had told her that the g-tube was working well and draining large amounts of fluid but that it was unable to keep up. Antiemetics were not helpful. The patient thought that there was nothing left to do and that she would have to live the rest of her life with this level of discomfort. A trial of octreotide 0.1mg subcutaneously three times daily was initiated in addition to continued drainage by her venting gtube. She was also given around-the-clock intravenous haloperidol and PRN intravenous ondansetron. By the next day, her g-tube output had decreased and her nausea and vomiting had resolved. Her pain was controlled with a hydromorphone PCA. She was eventually able to be discharged home with plans to follow up with her outpatient oncologist to consider next steps. With her symptoms controlled, she was able to move past her initial distress and talk openly about her hopes for the future and how she wanted to spend the time she had left.



Discussion:

Malignant bowel obstruction can occur with any cancer but is most commonly associated with advanced ovarian cancer, where it occurs in up to 50% of patients. It generally indicates a poor prognosis and carries a heavy symptom burden predominated by nausea, vomiting and abdominal pain. Patients with carcinomatosis, like Ms BB, are generally not candidates for surgical correction of the obstruction or endoscopic stenting. Fortunately, medical management can be very effective. Abdominal pain is treated with opioids and nausea is treated with metoclopramide in partial obstructions and haloperidol in complete obstructions. Corticosteroids are also often used for help in symptom control and because there is some indication that they may promote resolution of the obstruction presumably by decreasing inflammation and promoting salt and water absorption. Gastrointestinal secretions can be controlled with anticholinergics (such as scopolamine) and/or somatostatin analogues (such as octreotide).

Two prospective, randomized controlled trials suggest octreotide is superior to scopolamine. Octreotide works by inhibiting the release of several gastrointestinal hormones thereby reducing secretions, slowing motility, increasing water and electrolyte absorption, and reducing bile and splanchnic blood flow. It is generally dosed 0.1-0.3mg subcutaneously TID. Some palliative care units will use continuous infusions at higher doses with anecdotal success.

Current guidelines suggest placing a venting g-tube if medical management is unsuccessful. A venting g-tube is similar to a traditional g-tube but is used solely for drainage of the gastrointestinal secretions and the liquids taken by mouth that are unable to bypass the obstruction. This drainage prevents the backup of these fluids that would normally stretch the viscus and stimulate vomiting. As experience with this intervention increases, many clinicians advocate g-tube placement early in the treatment algorithm because it can provide more complete relief of vomiting and allow more extensive pleasure feeding. Venting g-tubes can, however, place the patient at greater risk for electrolyte imbalances.

Most guidelines and many clinicians consider venting g-tube placement and medical management with octreotide/ anticholinergics as two separate treatment pathways. This case highlights the fact that, occasionally, both may be needed simultaneously. Although Ms BB’s venting g-tube was draining effectively, she still experienced severe nausea and vomiting, and it was not until octreotide was added to the regimen that her symptoms became controlled. This scenario is borne out in some of the data regarding venting g-tubes.

In one series of patients with gynecological malignancy and upper intestinal obstruction, 4 in 31 had incomplete resolution of their symptoms with placement of a venting g-tube alone. All 4 had complete symptom relief when octreotide was added to the regimen. Clinicians need to be aware that venting gastrostomy tubes and medical management with octreotide/anticholinergics are not mutually exclusive treatment algorithms and a small percentage of patients will require both for adequate symptom control. Fortunately, as was the case with Ms BB, this approach can allow almost all patients with malignant bowel obstruction to regain some measure of comfort.

References:

1. Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer (2008). doi:10.1016/j.ejca.2008.02.028

2. Campagnutta E et al. Palliative treatment of upper intestinal obstruction by gynecological malignancy: the usefulness of percutaneous endoscopic gastrostomy. Gynecologic Oncology. 1996;62:103-105. doi:10.1006/gyno.1996.0197

3. Ripamonti CI et al. Clinical-practice recommendations for the management of bowel obstruction in patients with endstage cancer. Support Care Cancer. 2001; 9:223-233. doi:10.1007/s005200000198

Original Case by Gordon J Wood, MD, Edited by Christian Sinclair, MD

Pallimed Case Conference Disclaimer: This post is not intended to substitute good individualized clinical judgement or replace a physician-patient relationship. It is published as a means to illustrate important teaching points in health care.

Thursday, April 10, 2014 by Christian Sinclair ·

Tuesday, April 1, 2014

Innovative Palliative Fellowship Using Snapchat for Family Meetings

April 1, 2014 by Abe R Feaulx, Special Reporter 

Dr. Arya Kiddenme, a palliative care fellow at University of State College Medical School is preparing for a potentially very tense family meeting. The patient is unresponsive in the ICU and the family is having a difficult time coping with a sudden decline in their condition. When it is time to get ready to enter the room, Dr. Kiddenme quickly remembers to grab her iPhone 5s. “Can’t forget the most important tool!” She sits down to begin the family meeting, opens up the Snapchat app, and sends off a short introductory video clip. In a few seconds the family responds, with their first question, “Will dad make it out of the ICU?”

Dr. Hurley Hadopter is the program director at USCMS and believes strongly in capitalizing on the words and tools families use to communicate. “We were seeing more and more families not participating in family meetings and only paying attention to their smartphones. It was clear we had to reach them where they were, so we took a survey and found that many families would be very comfortable with using Snapchat, Twitter, Facebook, LinkedIN, Vine, iMessage, FaceTime and others, although no one choose Google Plus. We settled on using Snapchat because my teenage son said it really was useful to talk to girls, his bros and stuff like that.”

In the first month using Snapchat for family meetings, the palliative care team has already been seeing some impressive results. New consults have dropped off considerably. When asked for comment on why they no longer consulted the palliative care team, the chief oncologist at USCMS state, “I know palliative care clinicians really pride themselves on being great communicators but this is taking the whole ‘communication and listening stuff’ a little too far.”

Tuesday, April 1, 2014 by Abe R Feaulx ·

Pediatric Hospice is First in the Country with Emoji-Based Pain Map

April 1, 2014 by Abe R Feaulx, Special Reporter 


Pediatric Hospice of the Silicon Valley watches emerging trends in technology very closely. Seeing patients who had already staked a preference for Apple products, they wanted to make sure they could understand and relate to them differently then they would to children who grew up on Android based platforms, and the small minority that have Windows, Blackberry or Palm Pilot smartphone experience.  

Social Worker Jo King emphasized, "We noticed that the iOS children in our program would communicate using almost exclusively using Emoji. And we thought, how can we better understand what they are feeling, fearing, and thinking about.  They don't type words, even though they may be 11 or 12.  They just kept going back to these icons."  The team is eventually hoping to publish research about this strange new way of communicating.  Also understanding that a scale was too constricting, the pediatric team took a Ouija board approach and just placed Emoji all over a page and let the children pick without subjecting them to a constricting scale from 0-10.

When asked for clarification on how this was different than just giving the child an iPad, Ms. King replied, "Yeah, basically we just let them play on an iPad."

by Abe R Feaulx ·

Monday, March 31, 2014

Preserve HPM's Efforts to Improve Care for the Seriously Ill

For a long time hospice and palliative medicine have been wearing the mantle of outsider; never really understood by the rest of health care, or even the public, a growing group of clinicians and advocates kept pressing to deliver great quality and compassionate care. You might even hear insiders lament about how it is tough to get any respect or attention from some of the bigger, powerful organizations in health care locally, regionally and nationally. Well I’m here to tell you, we have made a BIG breakthrough, because the cool kids are starting to ask us to come sit at their table.

But this doesn't happen for free. To get here, it has taken a lot of volunteer sweat equity and time, but now as our field begins to play a larger role, more resources are needed. One critical area is our participation in the American Medical Association. If you were at the recent Annual Assembly of AAHPM and HPNA in San Diego, you likely heard a few requests to join the American Medical Association before April 1st. You may have read this excellent post by Dr. Paul Tatum on GeriPal, or past AAHPM President Dr. Ron Crossno on the AAHPM blog. Both have stellar examples of why every physician member of the AAHPM needs to sign up for the AMA. If you really don’t have time to read them, I’ll make it simple.

1. We are making a difference.
Our AAHPM delegate is Chad Kollas, MD, FACP, FCLM, FAAHPM and he is currently chair of the Pain and Palliative Medicine Section Council. What a great leadership role to have, and such a sad one to have to abdicate. We are also influential in the House of Delegates. See the AAHPM post for more details.

2. We are networking.
Because of our visibility in the AMA, other organizations are realizing the importance of collaboration with a group that crosses so many different specialties. And when we get involved with organizations we can help make sure their policies and advocacy efforts improve care for the seriously ill and those at the end of life. If you sign up for the AMA just this year, you are helping people you will never ever meet. You’re a pretty great person.

3. We’re on probation (and we already used our ‘get out of jail free’ card).
To cast a vote, chair committees, and essentially participate in AMA leadership we need to have 20% of AAHPM members be a part of the AMA. If we don’t meet this threshold by April 1st, then all the progress we have made in the last 5 years when we got an exception*, start to erode.

*Yes we already asked for a pass once and it was granted. Not so sure they will let that happen again.

4. I never ask someone to do something, if I have not done it myself.
Five years ago when this issue came up, I signed up for the AMA, despite having some reservations about their goals and process. You may have some of your own barriers. But we can’t fix this problem without engaging, and so I have signed up again this year. This is an investment in my own career, the career of many of my friends, and the care of the people I most want to help. And when you add that up,
it is a pretty small ask.

For just over $1 per day you can sign up for the AMA (and join the AAHPM if you have not done that either!) by April 1st, so we can show we really care about changing palliative medicine in the United States. Even better after you sign up, convince a colleague to follow through as well.

To make sure your membership is counted, please do two things - 1) make sure your primary specialty is listed as 'palliative medicine' with the AMA. You can do this by phone or on the Online Data Collection Center (AMA) and 2) complete this 20 second survey with AAHPM.

Monday, March 31, 2014 by Christian Sinclair ·

Monday, March 24, 2014

Hospice Medical Director Certification Board - Deadline March 24th

The deadline for application for the first Hospice Medical Director Certification Board is tonight, Monday, March 24th at 11:59pm CT.  



Surprisingly, we have not really commented on the HMD Certification on Pallimed yet, which is unfortunate because I believe this is a really great step forward to elevating the quality of Hospice Medical Directors in the US. It has been a long time in the making after getting the initial seed funding from the American Academy of Hospice and Palliative Medicine. Having been fellowship trained in Hospice and Palliative Medicine (HPM) at a program based in a community hospice (Thanks Hospice and Palliative Care Center, Winston-Salem, NC!), I spent the majority of my fellowship in a hospice setting.  Once fellowships had to be accredited by ACGME, they all had to move to University affiliated training programs, with hospice as a partner, no longer the primary.  This was an important and necessary step since it helped with the legitimacy of the fellowship and integration into the rest of medical education. But the cost was the potential move to the periphery of the hospice part of the curriculum.  It is possible for someone to complete a HPM fellowship with very little knowledge and experience of the administrative and clinical peculiarities of hospice if you have a fellowship that just passes the bare minimum standards of hospice experience.

So I am glad to see this pathway to emphasize the clinical and administrative responsibilities of the Hospice Medical Director, especially for the many part-time HMDs who care deeply about the quality of the care they deliver and oversee.  These HMDs are unlikely to do a HPM fellowship, but still are very committed to the principles of hospice.  With this certification it may spur hospice organizations increase the orientation and onboarding experience for new HMDs, so that we make sure we are not just pulling in any doctor to sit down and sign papers without any knowledge, skill, or competency in hospice.

So hopefully many more of you beat the deadline tonight to sign up for this certification if you are a practicing HMD.  This first wave will be an important one; leaders who can help raise the profile of HMDs.  Whether you are a part-time or full-time HMD, I hope you take this test, and get engaged with AAHPM and NHPCO, because our field needs your voice.

If you are taking the test, please share why you decide to sign up, we're curious.  If you decided to not take it or wait until the next cycle, please share your reasons as well.  If enough of you tell us that you are taking the test, then maybe we'll create some test questions similar to the ones we did with for the HPM Blogs to Boards Review.

Monday, March 24, 2014 by Christian Sinclair ·

Tuesday, March 18, 2014

Remembering Palliative Care Pioneer: Marion Pohlen Primomo, M.D.

May 15, 1920-March 1, 2014


When I think of people who have paved the way to make my professional career possible I think of Dr Marion Primomo. Not only was she one of the first women physicians; It is fair to say that she is the mother of the hospice movement in Texas.  She was one of the founders of the first hospice in San Antonio in 1978. She was a Founding Member of the Academy of Hospice and Palliative Medicine and the International Association of Hospice and Palliative Medicine.  In the 1980s, she had established an elective for medical students on their family medicine rotation in which medical students visited patients on hospice and their caregivers.  In the late 1990s she led the efforts to establish the palliative care fellowship program at Universityof Texas Health Science Center at San Antonio (UTHSCSA). The fellowship was a possibility because of Dr.  Primomo’s leadership to combine efforts from community hospices, UTHSCSA and the Veterans Affairs. She served as the first fellowship director. 

Dr. Primomo With Dr. Mark Prange.
As a medical student Dr. Prange visited dying patients and their families with Dr. Primomo
As a fellow, I interacted with Dr. Primomo teaching palliative care to the residents, when she was well into her 80s. She was always very energetic and ready to teach, she would have already read the latest article of  the New England Journal or other journal that have been published that week.  She taught us about opioid conversions, gave us a detailed palliative care must reads list, and more importantly she inspired us to be better healthcare professionals and human beings.  I still think of her as the type of person I want to be “when I grow up”.

You can learn more about the history of palliative care in Texas and get a sense for the wonderful person Dr. Primomo was in this YouTube video of her February 2008 Grand Rounds. The quality of the video is a little bit grainy but you can hear her well.
   

Dr. Primomo was an outstanding mentor, teacher and clinician.  Her efforts, vision and uncompromising passion have set the foundation for us to continue growing the programs in palliative care medical education and making it possible for us to have a strong palliative care fellowship that today is one of the largest inter-professional fellowship programs in the nation and a well-established clinical program where many patients and families find comfort and symptom relief.

Rest in Peace Dr. Primomo. I hope you know that you have paved the way for us to continue to make a difference in the lives of those who are seriously ill, their families and ourselves.

You can see Dr. Primomo’s obituary and sign the memorial guest book.

Memorial donations may be made to: UTHSCSA

I want to leave you with a quote from Dr. Primomo's presentation (41:00 of video above)
 Palliative care is greater than palliative care. For me my experience in Palliative care has been the icing on the cake as far as my medical practice and my life. I have found great fulfillment and I see great potential in hospice and palliative care. As palliative care physicians, nurses, social workers, chaplains and even volunteers we have gotten a peek to an aspect of living that we can explore further.  Palliative care is actually service to others and in the service to others is where we find ourselves. We find our spiritual selves; we find our answers to our own questions.  Palliative care in giving good symptom control, in fostering good communication, in good ethical practice and in looking out for the spiritual side of life; can assist us in overcoming the fear of death. And in making death a safe, fulfilling and enriching experience not only for the dying patient and their family but also for the physicians and nurses caring for the patients.

Dr. Primomo in 2007 presenting on spirituality
Dr. Malakoff on the left was the first palliative fellow at UTHSCSA
Dr. Sandra Sanchez-Reilly on the right is the UTHSCSA and VA Palliative Care Fellowship Director

References: 
  1. Mary M. Heidbrink, Dr. Primomo pioneered hospice care here San Antonio Express-News : March 8, 2014 accessed March 8,2014 at http://www.mysanantonio.com/obituaries/article/Dr-Primomo-pioneered-hospice-care-here-5298564.php
  2. Marion Primomo MD February 2008 Grand Rounds: The history of palliative care.  Accessed March 8, 2014 at http://youtu.be/ZzLP_XKjJpc
  3. Marion Primomo MD March 2007 Grand Rounds: Spiritual/Existentialism Needs at End of Life http://youtu.be/rHsz_rXBYTA   
  4. Kelly A. Goff. Women Physicians. San Antonio Women magazine May/June 2004 Accessed March 8 2014 at http://www.sawoman.com/women-physicians
  5. Porter Loring obituary  Marion Primomo MD. Accessed March 8, 2014 at http://www.porterloring.com/sitemaker/sites/Porter1/obit.cgi?user=1260662PrimomoMD
  6. Dr. Marion Primomo was given the "Outstanding American by Choice" recognition by the US citizen and immigration service (USCIS) in San Antonio Jun. 22, 2006 http://www.uscis.gov/archive/archive-citizenship/archived-outstanding-americans-choice/2006-outstanding-american-choice-event-photos
  7. Memorial donations may be made to:  http://makelivesbetter.uthscsa.edu/primomo 
  8. Photos  courtesy of  Mark Johnson
  9. Dr. Primomo’s must read suggestions:Man's Search for Meaning by Viktor E. Frankl
    I and Thou by Martin Buber
Follow Dr. Jeanette Ross @rossjeanette on Twitter

Tuesday, March 18, 2014 by Jeanette Ross ·

Wednesday, March 12, 2014

It's Here! 2014 AAHPM/HPNA Annual Assembly in San Diego

Hopefully many of you are arriving (or have already arrived in San Diego) for the AAHPM/HPNA Annual Assembly.  I love this conference and this is my 11th year in a row, that I have been lucky enough to attend. There is great knowledge and wonderful camaraderie here, and I want to make sure that no matter where you are, you can take advantage of all this week has to offer.

If you are at the conference, please consider using Twitter as a way to spread information. Every year participation has grown and diversified way beyond the walls of the conference halls.  We've talked a lot about the benefits of Twitter at a Medical Conference before.  Your participation really makes this a success.  There is a large community of advocates who look for good material from HPM professionals to pass on.  So sign in and ask for your password if you forgot it, and began re-tweeting, and engaging.  The hashtag to use this year is #hpm14.  You can see the latest tweets using the hashtag even with out a Twitter account.

Some good resources for Twitter:




HPNA Leadership Institute: Finding Your Social Media Rhythm from Renee Berry

Also don't forget to check out the AAHPM blog, AAHPM Facebook Page, HPNA Facebook Page, and Pallimed Facebook Page for updates throughout the week.  Of course, liking, sharing and engaging on these platforms help spread the good information that we all care about.

And don't forget the Pallimed / GeriPal Party on Thursday night.  Let us know if you are coming, and follow #hpmparty on Twitter for more up to date details that evening.

Look forward to seeing you there!




Wednesday, March 12, 2014 by Christian Sinclair ·

Monday, March 10, 2014

Join the Pallimed & GeriPal party at the AAHPM/HPNA/SWHPN 2014 Annual Assembly

The annual Pallimed / Geripal party is back on for this year's AAHPM/HPNA/SWHPN 2014 Annual Assembly.   We are going to do a similar progressive party as we did at the 2013 annual meeting in New Orleans.  What does this mean? Basically we will start off at the Field Irish Pub at 9pm on Thursday March 13, and as the evening progresses, we will be moving to different locations.  The only way to find out where we are is to use social media and follow on of the Pallimed/Pallimed feeds, or the #HPMparty hashtag. 


Date: Thursday, March 13th.  Start time 9pm.  End time TBD

Where: Depends

Starting location: The Field Irish Pub



Monday, March 10, 2014 by Christian Sinclair ·