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theory"},{"term":"tappana"},{"term":"tarbi"},{"term":"taylor"},{"term":"tea"},{"term":"telehealth"},{"term":"theatre"},{"term":"thienprayoon"},{"term":"thurston"},{"term":"time"},{"term":"tinianov"},{"term":"toomey"},{"term":"transdisciplinary"},{"term":"transgender"},{"term":"transition"},{"term":"trapasso"},{"term":"trauma"},{"term":"triangulation"},{"term":"tribute"},{"term":"trust"},{"term":"twiter"},{"term":"uncertainty"},{"term":"unconscious"},{"term":"universe"},{"term":"upstairs"},{"term":"urology"},{"term":"van Meines"},{"term":"van mienes"},{"term":"vandekieft"},{"term":"veteran"},{"term":"video"},{"term":"volunteering"},{"term":"warraich"},{"term":"washington"},{"term":"weakness"},{"term":"webinar"},{"term":"whitburn"},{"term":"wollesen"},{"term":"young"},{"term":"young adult"},{"term":"zitter"}],"title":{"type":"text","$t":"Pallimed"},"subtitle":{"type":"html","$t":"Pallimed covers current palliative medicine, hospice, and end-of-life research and news, with a particular focus on publications not from the major palliative care journals.  It is aimed at health care professionals who work with people nearing the end of life."},"link":[{"rel":"http://schemas.google.com/g/2005#feed","type":"application/atom+xml","href":"https:\/\/www.pallimed.org\/feeds\/posts\/default"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/-\/hospice?alt=json-in-script\u0026max-results=6"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/search\/label\/hospice"},{"rel":"hub","href":"http://pubsubhubbub.appspot.com/"},{"rel":"next","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/-\/hospice\/-\/hospice?alt=json-in-script\u0026start-index=7\u0026max-results=6"}],"author":[{"name":{"$t":"Drew Rosielle MD"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/04345646798042773615"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"32","height":"32","src":"\/\/3.bp.blogspot.com\/-sdxTTBPb3Kw\/UddApiGn9-I\/AAAAAAAABLE\/mriu5xh44dA\/s113\/ea37b7645cd78e7867d246cd755bc8d4.jpeg"}}],"generator":{"version":"7.00","uri":"http://www.blogger.com","$t":"Blogger"},"openSearch$totalResults":{"$t":"224"},"openSearch$startIndex":{"$t":"1"},"openSearch$itemsPerPage":{"$t":"6"},"entry":[{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-8011067724340048792"},"published":{"$t":"2021-03-22T14:18:00.002-05:00"},"updated":{"$t":"2021-03-22T14:18:39.256-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"hospice"},{"scheme":"http://www.blogger.com/atom/ns#","term":"leff"},{"scheme":"http://www.blogger.com/atom/ns#","term":"palliative care"},{"scheme":"http://www.blogger.com/atom/ns#","term":"social work"},{"scheme":"http://www.blogger.com/atom/ns#","term":"social worker"}],"title":{"type":"text","$t":"On the Value of Social Work in Palliative Care"},"content":{"type":"html","$t":"\u003Cdiv class=\"separator\" style=\"clear: both;\"\u003E\u003Ca href=\"https:\/\/1.bp.blogspot.com\/-aYm0GHyYw5U\/YFjqx0b0fkI\/AAAAAAAAAZI\/sP0azOyEBiQGEGrN31RHkzsKI7kuoMQrACLcBGAsYHQ\/s1080\/transdermal%2Bfent%2Bto%2Bmethadone%2B%25283%2529.png\" style=\"display: block; padding: 1em 0; text-align: center; clear: right; float: right;\"\u003E\u003Cimg alt=\"\" border=\"0\" width=\"320\" data-original-height=\"1080\" data-original-width=\"1080\" src=\"https:\/\/1.bp.blogspot.com\/-aYm0GHyYw5U\/YFjqx0b0fkI\/AAAAAAAAAZI\/sP0azOyEBiQGEGrN31RHkzsKI7kuoMQrACLcBGAsYHQ\/s320\/transdermal%2Bfent%2Bto%2Bmethadone%2B%25283%2529.png\"\/\u003E\u003C\/a\u003E\u003C\/div\u003Eby Vickie Leff (\u003Ca href=\"https:\/\/twitter.com\/vickieleff\" target=\"_blank\"\u003E@VickieLeff\u003C\/a\u003E) \u003Cbr\u003E\u003Cbr\u003EAnother year, another study proving the value of the palliative care social worker. Edmonds et al (2021) found that when a social worker was involved in a palliative care consultation, whole-person care components were more likely to be addressed, including addressing psychological (82% vs 18%) and spiritual needs (92% vs 8%) and documenting advance directives (90% vs 10%). This adds to what we already knew: involvement of social work impacts quality of care and patient satisfaction (Auerbach, 2007; O’Donnell et al., 2018).  \u003Cbr\u003E\u003Cbr\u003EIt surprises me that despite much research and team role development, palliative care team members may not be aware of the importance of the palliative care social worker. And yet, as a Hospice Social Worker, in the year of the pandemic, I was considered non-essential. I was not the only one. Around the country, I heard stories of many palliative care and hospice social workers being sent home. Unfortunately, many articles had to be written this year arguing that the social worker is essential (Guerrero 2020; Lipe 2020; Abrams 2020; Gewirtz 2020). Still, so many of us continue to be asked: What does a palliative care social worker do? \u003Cbr\u003E\u003Cbr\u003EIf what you know about social workers comes from TV you would think we primarily work for child protective services. If all you know of us is what you see in your ambulatory clinic you might think a social worker is only helpful for ordering a patient oxygen or a rolling walker. These misconceptions are common. After all, the profession of Social Work is represented in many different fields of practice. Our educational training varies and there are many levels and degrees one can have to be called a social worker. \u003Cbr\u003E\u003Cbr\u003EThere is a wide range of variation for social work practice in the healthcare setting. Hospitals have social workers as case managers doing discharge planning; some are employed as behavioral health specialists, substance use experts and counselors, and population health managers; some clinical social workers are on Palliative Care teams providing extensive psychosocial care; and some are cognitive behavioral therapy experts in the outpatient setting. Quite a wide gamut. This broad range of practice is both a strength and a challenge for the social work profession because it can make it difficult for others to understand our value.  \u003Cbr\u003E\u003Cbr\u003EAs March is social work month, let’s spend some time reflecting on the value of social work within the palliative care team. So here is what we do…. (this is not all inclusive!) \u003Cbr\u003E\u003Cbr\u003EBroadly, we provide psychosocial care to patients and families. We are mental health providers who are trained to facilitate family meetings, manage family dynamics, and assess and treat anxiety and depression. We provide counseling to patients, children, and families. We assess for pain, spiritual needs, and advocate for a clear plan of care. We have advance care planning conversations and help to locate resources for patients and families.  \u003Cbr\u003E\u003Cbr\u003EWe have an expert understanding of the social determinates of health and engage in cultural curiosity, often helping reframe concerns for our team members. For instance, we interpret medical information for the patient and family (think of your patients asking, “What did they just say?”). We coach surgeons prior to a “difficult” conversation, sharing our insight about family dynamics, use of language, and culture to guide them. We listen to the moral distress from bedside nurses in ICU units, offering strategies for well-being. We are often the team member who takes responsibility for team wellness and reflection, helping our colleagues identify their own reactions to difficult cases. \u003Cbr\u003E\u003Cbr\u003EPalliative care social work has come a long way. Like our physician and nursing colleagues, we now have our own evidence-based certification: \u003Ca href=\"http:\/\/www.aphsw-c.org\/\" target=\"_blank\"\u003Ethe APHSW-C\u003C\/a\u003E. We have a national organization of 1,000 members – the Social Work Hospice and Palliative Network (SWHPN) and over 10 social work fellowships across the country, to train post-masters social workers in specialty level palliative care.   \u003Cbr\u003E\u003Cbr\u003EAll palliative care team members listen with their own attention, intention, and biases. That is surely the beauty of working as a team, learning and depending on each other to provide the best care. As Rosa, et.al. suggests, we have an opportunity, right now, to become transdisciplinary teams “co-creating a unified framework for delivering palliative care that transcends disciplinary perspectives.”  (Rosa et.al., 2020) This transcendent palliative care team requires that we all commit to having a shared understanding of each other’s value. While social work may be a large umbrella, our role in serious illness care is clear and rooted in data. Please stand with us and use your voice to tell others about our value: We are crucial members of the palliative care team and we are essential. \u003Cbr\u003E\u003Cbr\u003EFor more Pallimed posts by \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/leff\" target=\"_blank\"\u003EVickie Leff, click here.\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003EFor more Pallimed posts about \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/social%20workers\" target=\"_blank\"\u003Esocial workers, click here.\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003E\u003Ci\u003EVickie Leff, LCSW, APHSW-C is the Executive Director of the Advanced Palliative \u0026 Hospice Social Work Certification Program; she is also an Adjunct Instructor at the UNC School of Social Work, Chapel Hill. She still thinks that running a 6 hour marathon is actually a really good finish time.\u003C\/i\u003E\u003Cbr\u003E\u003Cbr\u003E\u003Cdiv class=\"separator\" style=\"clear: both;\"\u003E\u003Ca href=\"https:\/\/1.bp.blogspot.com\/-hq59iVgVrL8\/YFjtZabMkgI\/AAAAAAAAAZg\/Buc4g0nqfmMRPVyvqFz7NoniRwQrPbvtACLcBGAsYHQ\/s2804\/PCSW%2BInfographic-1.png\" style=\"display: block; padding: 1em 0; text-align: center; \"\u003E\u003Cimg alt=\"\" border=\"0\" height=\"600\" data-original-height=\"2804\" data-original-width=\"1122\" src=\"https:\/\/1.bp.blogspot.com\/-hq59iVgVrL8\/YFjtZabMkgI\/AAAAAAAAAZg\/Buc4g0nqfmMRPVyvqFz7NoniRwQrPbvtACLcBGAsYHQ\/s600\/PCSW%2BInfographic-1.png\"\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003Cbr\u003E\u003Cbr\u003E\u003Cb\u003EReferences\u003C\/b\u003E\u003Cbr\u003E\u003Cbr\u003EAbrams, L. S., \u0026 Dettlaff, A. J. (2020). Voices from the Frontlines: Social Workers Confront the COVID-19 Pandemic. Social work, 65(3), 302–305. \u003Ca href=\"https:\/\/doi.org\/10.1093\/sw\/swaa030\" target=\"_blank\"\u003Ehttps:\/\/doi.org\/10.1093\/sw\/swaa030\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003EAuerbach, C. (2007). Evidence that Supports the Value of Social Work in Hospitals. Social Work in Health Care, 44(4), 17–32. \u003Ca href=\"https:\/\/doi.org\/https:\/\/doi.org\/10.1300\/J010v44n04_02\"\u003Ehttps:\/\/doi.org\/https:\/\/doi.org\/10.1300\/J010v44n04_02\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003EEdmonds, K. et al (2021). \u003Ca href=\"https:\/\/www.jpsmjournal.com\/article\/S0885-3924%2821%2900211-6\/fulltext\" target=\"_blank\"\u003EAn Exploratory Study of Demographics and outcomes for Patients Seen by Specialist Palliative Care Social Work in the Inpatient Setting at an Academic Center\u003C\/a\u003E. Journal of Pain and Symptom Management.  \u003Cbr\u003E\u003Cbr\u003EGewirtz, R. (2020) As I See It: Social Workers are Essential personnel; So, why aren’t we talking about them? Retrieved from: \u003Ca href=\"https:\/\/www.telegram.com\/news\/20200330\/as-i-see-it-social-workers-essential-personnel-so-why-arent-we-talking-about-them\" target=\"_blank\"\u003Ehttps:\/\/www.telegram.com\/news\/20200330\/as-i-see-it-social-workers-essential-personnel-so-why-arent-we-talking-about-them\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003EGuerrero, L., Avgar, A., Phillips, E., Sterling, M. (2020). They are Essential Workers now, and should continue to be: Social Workers and Home Health Care workers during COVID-19 and Beyond. Journal of Gerontological Social Work.\u003Ca href=\"about:invalid#zSoyz\" target=\"_blank\"\u003E http:\/\/doi.org\/10\/1080\/01634372.2020.1779162\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003ELipe, L. (2020) Social Workers are Essential Workers. Retrieved from: \u003Ca href=\"https:\/\/www.socialworker.com\/feature-articles\/practice\/social-workers-essential-workers\/\" target=\"_blank\"\u003Ehttps:\/\/www.socialworker.com\/feature-articles\/practice\/social-workers-essential-workers\/\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003EO’Donnell, A. E., Schaefer, K. G., Stevenson, L. W., DeVoe, K., Walsh, K., Mehra, M. R., \u0026 Desai, A. S. (2018). Social Worker-Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): A Pilot Randomized Clinical Trial. JAMA Cardiology, 3(6), 516–519. \u003Ca href=\"https:\/\/doi.org\/10.1001\/jamacardio.2018.0589\" target=\"_blank\"\u003Ehttps:\/\/doi.org\/10.1001\/jamacardio.2018.0589\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003ERosa, W. et al (2020)  Coronavirus Disease 2019 as an Opportunity to Move toward Transdisciplinary Palliative Care. Journal of Palliative Medicine, 23(10), pp. 1290–1291.\u003Ca href=\"http:\/\/doi.org\/10.1089\/jpm.2020.0306\" target=\"_blank\"\u003Ehttp:\/\/doi.org\/10.1089\/jpm.2020.0306\u003C\/a\u003E\u003Cbr\u003E\u003Cbr\u003E\u003Cmeta name=\"twitter:card\" content=\"summary\" \/\u003E\u003Cmeta name=\"twitter:site\" content=\"@pallimed\" \/\u003E\u003Cmeta name=\"twitter:title\" content=\"On the Value of Social Work in Palliative Care\" \/\u003E\u003Cmeta name=\"twitter:description\" content=\"March is Social Worker Month, and an excellent time for us to examine the importance of this role.\" \/\u003E\u003Cmeta name=\"twitter:image\" content=\"https:\/\/1.bp.blogspot.com\/-aYm0GHyYw5U\/YFjqx0b0fkI\/AAAAAAAAAZI\/sP0azOyEBiQGEGrN31RHkzsKI7kuoMQrACLcBGAsYHQ\/s1080\/transdermal%2Bfent%2Bto%2Bmethadone%2B%25283%2529.png\" \/\u003E\u003Cmeta name=\"twitter:url\" content=\"https:\/\/www.pallimed.org\/2021\/03\/on-value-of-social-work-in-palliative.html\" \/\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/8011067724340048792"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/8011067724340048792"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2021\/03\/on-value-of-social-work-in-palliative.html","title":"On the Value of Social Work in Palliative Care"}],"author":[{"name":{"$t":"Pallimed Editor"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/11358791266969988517"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/1.bp.blogspot.com\/-aYm0GHyYw5U\/YFjqx0b0fkI\/AAAAAAAAAZI\/sP0azOyEBiQGEGrN31RHkzsKI7kuoMQrACLcBGAsYHQ\/s72-c\/transdermal%2Bfent%2Bto%2Bmethadone%2B%25283%2529.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-765750173112298570"},"published":{"$t":"2019-05-22T06:08:00.002-05:00"},"updated":{"$t":"2019-05-22T06:08:09.576-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"hospice"},{"scheme":"http://www.blogger.com/atom/ns#","term":"perception"},{"scheme":"http://www.blogger.com/atom/ns#","term":"social worker"},{"scheme":"http://www.blogger.com/atom/ns#","term":"time"}],"title":{"type":"text","$t":"In Hospice, Time is an Illusion"},"content":{"type":"html","$t":"\u003Cinsert here=\"\" picture=\"\"\u003Eby Lizzy Miles (@LizzyMiles_MSW)\u003C\/insert\u003E\u003Cbr \/\u003E\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-SUKcLlJSJCI\/XOCPGu1OIWI\/AAAAAAABljM\/zD89TuZHz-E11scGq1q_yk-FuQmOtPxzQCLcBGAs\/s1600\/Time%2Bis%2Ban%2Billusion%2B%25281%2529.png\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"800\" data-original-width=\"800\" height=\"320\" src=\"https:\/\/2.bp.blogspot.com\/-SUKcLlJSJCI\/XOCPGu1OIWI\/AAAAAAABljM\/zD89TuZHz-E11scGq1q_yk-FuQmOtPxzQCLcBGAs\/s320\/Time%2Bis%2Ban%2Billusion%2B%25281%2529.png\" width=\"320\" \/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003Cbr \/\u003ELately I’ve been thinking a lot about the perception of time and how it affects our patients. Because their time is limited, their perception of time and its value can often be magnified. This is our job, but this is the patient’s LIFE. We have to remember that for our patients, they may be hyper-focused on time. How do we help them feel good about timing and the time we spend with them? We can do this by being mindful of how we use our time with them and also how we show respect for their time.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003ESet expectations\u003C\/b\u003E\u003Cbr \/\u003EThere is research in the ambulatory care arena that says that patient satisfaction is increased if a patient knows how long they are going to have to wait to see the practitioner. It would be reasonable to conclude that this would apply to hospice visits as well.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIntervention: Always give a time range for when you’re going to visit so you bake time in for traffic, other longer visits, etc.\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003ESo much caregiver distress could be alleviated if we just set expectations appropriately.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EInterventions:\u003C\/i\u003E\u003Cbr \/\u003E• On admission, make sure you tell patients and families the visit frequency for each discipline.\u003Cbr \/\u003E\u003Cbr \/\u003E• Inform family members how your organization’s paging system works. Encourage them to let us know when they call how important their call is. Encourage them to call back if they haven’t heard back from the staff member and they feel it’s urgent.\u003Cbr \/\u003E\u003Cbr \/\u003E• If you’re taking a message for another staff member, don’t make promises for others. If you know there is a potential for delay in the other staff member calling them, let the patient know.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003ECoordinate with all team members to address patient\/caregiver crises in a timely manner\u003C\/b\u003E\u003Cbr \/\u003EOur perception of a reasonable response time for telephone calls or visit likely differs significantly from what a patient or caregiver feels they need. We may think two or three hours is a reasonable response time to visit when a caregiver calls about a new symptom that is causing panic. The caregiver may want us there ASAP. When we can’t get there quick enough, what happens? They call the squad. Emergency room visits for normal hospice symptoms are excessive, unnecessary and can be avoided with coordination.\u003Cbr \/\u003E\u003Cbr \/\u003ESometimes, the staff member who is initially requested may be caught up with something else, and another team member may have to temporarily assist.\u003Cbr \/\u003E\u003Cbr \/\u003EHere are some options to consider as well:\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIntervention: Can another staff member return the call to find out what is going on?\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EA social worker may be able to talk to the family member and learn that the caregiver simply wants to order equipment or supplies. Even if the need is for nursing, a call from a social worker to find out what’s going on can be helpful. The need may be for a question to be answered that social work can coordinate with the primary nurse or triage. If a nursing visit is needed, the social worker can inform the family the estimated time that the nurse will be coming out. Sometimes an estimate in itself all the reassurance the family needs.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIs it a matter of the caregiver just not knowing what medicine to administer and education can be provided on the phone by a triage nurse if primary nurse is unavailable?\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EThere is nothing worse for families to not receive a call back when their question was a simple one that could be answered with instructions and education.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIs the social worker or chaplain available for a visit? Sometimes the family wants a ‘body’ from hospice and are comforted by the present of a social worker or chaplain.\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EEven with patients who are actively dying, I’ve found that as a social worker there is a lot we can do at the bedside to help the family. I’ve gone out to homes in advance of the nurse only to find that family just needed to know that the symptoms are normal and reassurances that they are doing everything right. There have been times where the family has said after my social work visit that they don’t need a nurse visit anymore. To be clear, I’m not in any way doing nursing work when I’m there. What I can do is assess if patient looks comfortable and there are no signs of distress or discomfort. Sometimes just hearing an outside person’s reassurances is all a caregiver needs in that moment.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIs there another nurse on the team who has a lighter load who can visit?\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EA good hospice organization will have a culture where staff members help each other out.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIntervention: Lead by example with your team members and provide support if another team member is “in the weeds.”\u003C\/i\u003E\u003Cbr \/\u003E\u003Cb\u003E\u003Cbr \/\u003E\u003C\/b\u003E\u003Cb\u003EWhen what you give is never enough\u003C\/b\u003E\u003Cbr \/\u003E\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Cb\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-rgxbG7mO3cU\/XOCRiaL3h_I\/AAAAAAABljY\/63tJjYNxqvMLFjoVFKuNqPeF9w6raAGRACLcBGAs\/s1600\/wil-stewart-24560-unsplash.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1067\" data-original-width=\"1600\" height=\"133\" src=\"https:\/\/2.bp.blogspot.com\/-rgxbG7mO3cU\/XOCRiaL3h_I\/AAAAAAABljY\/63tJjYNxqvMLFjoVFKuNqPeF9w6raAGRACLcBGAs\/s200\/wil-stewart-24560-unsplash.jpg\" width=\"200\" \/\u003E\u003C\/a\u003E\u003C\/b\u003E\u003C\/div\u003E\u003Cbr \/\u003EI have to acknowledge there are patients and caregivers who do seem “needy” with time and sometimes their needs are beyond the scope of the work that we do. Patients with COPD in particular can be highly anxious and can have emotional needs. For these patients, we do need to also set time boundaries.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIntervention: Set expectations by telling a patient at the beginning of the visit how much time you have.\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EThere are visits where you do have a limited amount of time due to another scheduled appointment. It’s best to acknowledge this for the patient or caregiver up front so that they don’t perceive that you are bored or impatient with the visit if you frequently look at your watch or the clock.\u003Cbr \/\u003E\u003Cbr \/\u003EIt may be helpful to know that there is patient satisfaction research that indicates that patients perceive that a provider spent more time with them if they sat down. Do you use a chair or stool in your visits?\u003Cbr \/\u003E\u003Cbr \/\u003EIf needs are emotional, be sure to be engaging the entire team in coordinating visits so they are spread out across the days. Utilize your volunteers to provide extra support to emotional patients and remember that telephone calls can be an intervention as well.\u003Cbr \/\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-qEPR-u8Ok-4\/XOCR0I6W-XI\/AAAAAAABljg\/4oqmBKKQIZQCzt_JOCLmNEYbmSgT3MrcQCLcBGAs\/s1600\/spicoli.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"181\" data-original-width=\"200\" height=\"180\" src=\"https:\/\/2.bp.blogspot.com\/-qEPR-u8Ok-4\/XOCR0I6W-XI\/AAAAAAABljg\/4oqmBKKQIZQCzt_JOCLmNEYbmSgT3MrcQCLcBGAs\/s200\/spicoli.jpg\" width=\"200\" \/\u003E\u003C\/a\u003E\u003Cb\u003E\u003Cbr \/\u003E\u003C\/b\u003E\u003Cb\u003EShow that we value the patient’s limited time\u003C\/b\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E“If I’m here and you’re here, doesn’t that make it our time?” – Jeff Spicoli\u003Cbr \/\u003E\u003Cbr \/\u003EPatients who are on hospice have limited energy. Caregivers can be overwhelmed and exhausted. If they’re not up for a visit, we shouldn’t force it because we need to check a box that we did our visit. There are nuances between someone declining a visit because they don’t want to bother you and declining a visit because they don’t need or want it.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EInterventions:\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E• Psychosocial support staff should always ask for permission to visit with patient, whether they are in a facility or in a home.\u003Cbr \/\u003E\u003Cbr \/\u003E• Always ask for permission to visit with caregiver. If a caregiver says it’s not a good time because they have a hair appointment, celebrate that they are doing self-care.\u003Cbr \/\u003EAlso, patients or caregivers may want a visit to end before they tell you. Always assess nonverbal behavior to see if they’re talking because they want to or if they are just being polite.\u003Cbr \/\u003E\u003Cbr \/\u003ESometimes patients or caregivers say no to a visit because we are vague with the request. They may be more open to us visiting if we clarify how much time we plan to spend and the purpose for our visit. The more information they have with the inquiry, the more likely they are open to meeting with us.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EHere are some of my favorite quotes on time:\u003C\/b\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EBetter three hours too soon, than one minute too late.\u003C\/i\u003E\u003Cbr \/\u003EWilliam Shakespeare\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EA man who dares to waste one hour of life has not discovered the value of life.\u003C\/i\u003E\u003Cbr \/\u003ECharles Darwin\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EAll that really belongs to us is time; even he who has nothing else has that.\u003C\/i\u003E\u003Cbr \/\u003EBaltasar Gracian\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EThe bad news is time flies. The good news is you’re the pilot.\u003C\/i\u003E\u003Cbr \/\u003EMichael Altshuler\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EIf not now, when?\u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Ci\u003ELizzy Miles, MA, MSW, LSW is a hospice social worker in Columbus, Ohio and regular contributor to Pallimed.org. Lizzy authored a book of happy hospice stories: \u003Ca href=\"https:\/\/www.amazon.com\/Somewhere-Between-Chocolate-Shared-Experience\/dp\/1937574024\/ref=tmm_pap_swatch_0?_encoding=UTF8\u0026amp;qid=\u0026amp;sr=\" target=\"_blank\"\u003ESomewhere In Between: The Hokey Pokey, Chocolate Cake and the Shared Death Experience.\u003C\/a\u003E Lizzy is best known for bringing the \u003Ca href=\"https:\/\/deathcafe.com\/\" target=\"_blank\"\u003EDeath Cafe\u003C\/a\u003E concept to the United States. You can find her on Twitter \u003Ca href=\"https:\/\/twitter.com\/LizzyMiles_MSW\" target=\"_blank\"\u003E@LizzyMiles_MSW\u003C\/a\u003E.\u003C\/i\u003E\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Ci\u003E\u003Cbr \/\u003E\u003C\/i\u003E\u003C\/span\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Ci\u003EPhoto credits:\u0026nbsp;\u003C\/i\u003E\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Ci\u003ECover image uses photo from\u0026nbsp;\u003Ca href=\"https:\/\/unsplash.com\/@jontyson\" target=\"_blank\"\u003EJon Tyson\u003C\/a\u003E via Unsplash\u003C\/i\u003E\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Ci\u003Ewatch via \u003Ca href=\"https:\/\/unsplash.com\/@wilstewart3\" target=\"_blank\"\u003EWil Stewart\u003C\/a\u003E on Unsplash\u003C\/i\u003E\u003C\/span\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/765750173112298570"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/765750173112298570"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2019\/05\/in-hospice-time-is-illusion.html","title":"In Hospice, Time is an Illusion"}],"author":[{"name":{"$t":"Lizzy Miles"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/06871018407337559011"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/2.bp.blogspot.com\/-SUKcLlJSJCI\/XOCPGu1OIWI\/AAAAAAABljM\/zD89TuZHz-E11scGq1q_yk-FuQmOtPxzQCLcBGAs\/s72-c\/Time%2Bis%2Ban%2Billusion%2B%25281%2529.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-3355110906847263552"},"published":{"$t":"2019-05-04T12:16:00.000-05:00"},"updated":{"$t":"2019-05-04T14:58:39.085-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"comfort"},{"scheme":"http://www.blogger.com/atom/ns#","term":"hospice"},{"scheme":"http://www.blogger.com/atom/ns#","term":"hospital"},{"scheme":"http://www.blogger.com/atom/ns#","term":"icu"},{"scheme":"http://www.blogger.com/atom/ns#","term":"JAMA Internal Medicine"},{"scheme":"http://www.blogger.com/atom/ns#","term":"palliative care"},{"scheme":"http://www.blogger.com/atom/ns#","term":"pottash"},{"scheme":"http://www.blogger.com/atom/ns#","term":"The profession"}],"title":{"type":"text","$t":"Comfort Care, Whatever Does That Mean?"},"content":{"type":"html","$t":"\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-BWieu9MS_T8\/XM3I0FwQEgI\/AAAAAAAAARU\/XfcP01G77XobeI2pZU8914DNMveKmUrSgCLcBGAs\/s1600\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup%2B%25282%2529.png\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" src=\"https:\/\/2.bp.blogspot.com\/-BWieu9MS_T8\/XM3I0FwQEgI\/AAAAAAAAARU\/XfcP01G77XobeI2pZU8914DNMveKmUrSgCLcBGAs\/s320\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup%2B%25282%2529.png\" width=\"320\" height=\"320\" data-original-width=\"800\" data-original-height=\"800\" \/\u003E\u003C\/a\u003E\u003C\/div\u003Eby Michael Pottash (\u003Ca href=\"https:\/\/twitter.com\/mpottash\"\u003E@mpottash\u003C\/a\u003E) \u003Cbr\u003E\u003Cbr\u003E\u003Ca href=\"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/fullarticle\/2698147\"\u003EComfort Care, whatever does that mean?\u003C\/a\u003E This is the important question asked by my colleagues Anne Kelemen and Hunter Groninger in the September 2018 issue of JAMA Internal Medicine. The term is ubiquitous and its interpretation influences how patients with end stage illness are cared for at the end of their lives. In their article they argue that the language of Comfort Care is confusing and easily misunderstood. They suggest improving the understanding around end of life care and moving to a less ambiguous term for care of the dying. I worry that any term to describe dying care will always be problematic.  \u003Cbr\u003E\u003Cbr\u003ESo what is Comfort Care? One common definition comes from \u003Ca href=\"https:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMra1411746\"\u003EBlinderman and Billings, writing in the New England Journal of Medicine\u003C\/a\u003E, defining it as “the most basic palliative care interventions that provide immediate relief of symptoms in a patient who is very close to death.” Another is from the \u003Ca href=\"https:\/\/www.nia.nih.gov\/health\/providing-comfort-end-life\"\u003ENational Institute on Aging, describing Comfort Care as “care that helps or soothes a person who is dying ... to prevent or relieve suffering as much as possible and to improve quality of life while respecting the dying person’s wishes.”\u003C\/a\u003E Both definitions are simple enough, and yet lack any specifics or direction for clinicians. This leaves the practice of Comfort Care up for interpretation. \u003Cbr\u003E\u003Cbr\u003E\u003Ci\u003EKelemen\u003C\/i\u003E points out the pitfalls in operationalizing this vague term. First, it promotes a dangerous misconception that clinical care is binary and that patients must choose between focusing on comfort or not. Second, \u003Ci\u003EKelemen\u003C\/i\u003E \u003Ca href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22495795\"\u003Ecites a study demonstrating that while the term is ubiquitous, clinicians don’t actually know what it means.\u003C\/a\u003E This leads to ambiguity around what kinds of medical interventions constitute Comfort Care and to a wide disparity in which medical interventions clinicians apply under the circumstance. Worse, some seem to think that it means methodically titrating up an opioid infusion: “Nearly half [of surveyed physicians] expressed a belief that Comfort Measures Only care is itself an indication for more aggressive opioid administration than for other patients, regardless of clinical condition. This is of concern because it seems to obviate the critical need for nuanced assessment that drives symptom management.” Administration of inappropriately high dose opioids will hasten death; this is at best bad medicine and at worst euthanasia. \u003Cbr\u003E\u003Cbr\u003E\u003Ci\u003EBlinderman\u003C\/i\u003E agrees:  \u003Cbr\u003E\u003Cbr\u003E“However, the term is often used in a misleading or imprecise manner — for example, when such care is automatically considered equivalent to a do-not-resuscitate order and, perhaps even without discussion with the patient, is extrapolated to mean the exclusion of a full range of palliative measures appropriate for a dying patient. Rather than simply writing orders for “comfort care” (or “intensive comfort measures,” the term that we prefer), the medical team should review the entire plan of care and enter explicit orders to promote comfort and prevent unnecessary interventions.” \u003Cbr\u003E\u003Cbr\u003EA \u003Ca href=\"https:\/\/www.pallimed.org\/2016\/07\/against-euphemisms-part-1-comfort-care.html\"\u003EPallimed post by Drew Rosielle from 2016\u003C\/a\u003E made a similar protest: \u003Cbr\u003E\u003Cbr\u003E“One, it amplifies the already irksome and unnecessary dichotomy we have set up in medicine between 'cure' and 'comfort’... What we are trying to do in palliative care is to reduce the gap between the two, to help our patients feel better as they live longer… Two, it's confusing for patients and should never be said in front of them.  I've seen it lead to stupid miscommunication many times. Like someone asking a patient 'Do you want comfort care?' 'Do you want us to focus on keeping you comfortable?' and the patient saying 'Yes of course' not realizing that the clinician was actually saying 'Should we stop efforts to prolong your life and *only* provide ongoing interventions to alleviate symptoms\/provide comfort?'” \u003Cbr\u003E\u003Cbr\u003ETo summarize: Comfort Care is confusing to patients and families, no one knows how to provide it, and it can be harmful.  \u003Cbr\u003E\u003Cbr\u003EHere is the kicker from \u003Ci\u003EKelemen\u003C\/i\u003E:  \u003Cbr\u003E\u003Cbr\u003E“End-of-life care plans must be specific to the patient and family, reflecting their values and goals for that critical event and universal experience. To highlight this, we coach colleagues and families to consider every therapeutic intervention—for example, each medication, laboratory test, imaging study—and evaluate whether that intervention promotes the goal of alleviating symptom burden during the dying process. If it does (eg, oxygen administration in hypoxia), we continue it; if not (eg, the ubiquitous statin therapy), then perhaps it could be discontinued after reassuring communication with patients and families.”  \u003Cbr\u003E\u003Cbr\u003ELet’s treat dying patients as we would treat any patients: as thinking clinicians. Continue treatments that meet the goals of the patient and family, and discontinue treatments that do not. If the goals of the patient and family are to prioritize symptom management over life prolongation then ask the question of every test, intervention, or medication: Does this promote quality of life? Some life-prolonging interventions can be continued without impacting quality, if the patient so chooses. This will all depend on the patient’s preferences and the clinical context. That is why it is impossible to create a Comfort Care algorithm, bundle, or pathway - clinical reasoning is still required.  \u003Cbr\u003E\u003Cbr\u003EWhile my colleagues believe that we should use clearer language or work towards a unified understanding of Comfort Care, I would argue that we should get rid of it altogether. Do we need a term for taking care of dying patients in the hospital? If it does not indicate a clinical pathway or answer an urgent clinical question, then what is its benefit? Rather, in my experience, I have only seen it cause confusion, miscommunication, and unethical medical practice. \u003Ci\u003EKelemen\u003C\/i\u003E has identified a crucial blind spot in our collective medical practice, one that I fear is a symptom of a general misunderstanding and discomfort with how to care for the dying. Let’s teach our trainees to continue reasoning through clinical decisions to the end of a patient’s life, and to provide good medical care even if all that entails is sitting at the bedside to hold their patient’s hand. \u003Cbr\u003E\u003Cbr\u003EDisclosure: Anne Kelemen and Hunter Groninger are dear friends and colleagues. \u003Cbr\u003E\u003Cbr\u003E\u003Ci\u003EMichael Pottash MD MPH is a Palliative Medicine Physician at MedStar Washington Hospital Center and Assistant Professor of Medicine at Georgetown University School of Medicine.  He is currently very curious to know who will end up sitting on the Iron Throne.\u003C\/i\u003E\u003Cbr\u003E\u003Cbr\u003E\u003Cb\u003EReferences\u003C\/b\u003E\u003Cbr\u003E\u003Cbr\u003E1 Kelemen AM, Groninger H. \u003Ca href=\"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/fullarticle\/2698147\"\u003EAmbiguity in End-of-Life Care Terminology - What Do We Mean by Comfort Care?\u003C\/a\u003E JAMA Internal Medicine. 2018 \u003Cbr\u003E\u003Cbr\u003E2 Blinderman CD, Billings JA. \u003Ca href=\"https:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMra1411746\"\u003EComfort Care for Patients Dying in the Hospital\u003C\/a\u003E. New England Journal of Medicine. 2015. \u003Cbr\u003E\u003Cbr\u003E3 National Institute on Aging. \u003Ca href=\"https:\/\/www.nia.nih.gov\/health\/providing-comfort-end-life\"\u003EProviding Comfort at the End of Life\u003C\/a\u003E. Accessed 2018. 4 Zanartu C, Matti-Orozco BM. \u003Ca href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22495795\"\u003EComfort Measures Only: Agreeing on a Common Definition Through a Survey\u003C\/a\u003E. Am J Hospice and Palliative Care. 2013 \u003Cbr\u003E\u003Cbr\u003E\u003Cmeta name=\"twitter:card\" content=\"summary\" \/\u003E\u003Cmeta name=\"twitter:site\" content=\"@pallimed\" \/\u003E\u003Cmeta name=\"twitter:title\" content=\"Comfort Care, Whatever Does That Mean?\" \/\u003E\u003Cmeta name=\"twitter:description\" content=\"Clinicians use the term 'Comfort Care' like we all understand what that means, but could we be more clear?\" \/\u003E\u003Cmeta name=\"twitter:image\" content=\"https:\/\/2.bp.blogspot.com\/-BWieu9MS_T8\/XM3I0FwQEgI\/AAAAAAAAARU\/XfcP01G77XobeI2pZU8914DNMveKmUrSgCLcBGAs\/s1600\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup%2B%25282%2529.png\" \/\u003E\u003Cmeta name=\"twitter:url\" content=\"https:\/\/www.pallimed.org\/2019\/05\/comfort-care-whatever-does-that-mean.html\" \/\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/3355110906847263552"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/3355110906847263552"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2019\/05\/comfort-care-whatever-does-that-mean_4.html","title":"Comfort Care, Whatever Does That Mean?"}],"author":[{"name":{"$t":"Pallimed Editor"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/11358791266969988517"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/2.bp.blogspot.com\/-BWieu9MS_T8\/XM3I0FwQEgI\/AAAAAAAAARU\/XfcP01G77XobeI2pZU8914DNMveKmUrSgCLcBGAs\/s72-c\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup%2B%25282%2529.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-3515235906973648543"},"published":{"$t":"2019-02-11T14:33:00.000-06:00"},"updated":{"$t":"2019-03-10T13:02:19.939-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"annals of internal medicine"},{"scheme":"http://www.blogger.com/atom/ns#","term":"hospice"},{"scheme":"http://www.blogger.com/atom/ns#","term":"hospital"},{"scheme":"http://www.blogger.com/atom/ns#","term":"journal article"},{"scheme":"http://www.blogger.com/atom/ns#","term":"outpatient"},{"scheme":"http://www.blogger.com/atom/ns#","term":"pain"},{"scheme":"http://www.blogger.com/atom/ns#","term":"rosielle"}],"title":{"type":"text","$t":"Goodbye to Compounded Analgesic Creams"},"content":{"type":"html","$t":"\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/3.bp.blogspot.com\/-6eXOSNVbeQg\/XGHbKkvGJtI\/AAAAAAACgEA\/dckv3BvSmQsL-_vGu1QRZuQVAQ6z73HYQCLcBGAs\/s1600\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup.png\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"800\" data-original-width=\"800\" height=\"320\" src=\"https:\/\/3.bp.blogspot.com\/-6eXOSNVbeQg\/XGHbKkvGJtI\/AAAAAAACgEA\/dckv3BvSmQsL-_vGu1QRZuQVAQ6z73HYQCLcBGAs\/s320\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup.png\" width=\"320\" \/\u003E\u003C\/a\u003E\u003C\/div\u003Eby Drew Rosielle (\u003Ca href=\"https:\/\/twitter.com\/drosielle\"\u003E@drosielle\u003C\/a\u003E) \u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"https:\/\/annals.org\/aim\/fullarticle\/2724041\/compounded-topical-pain-creams-treat-localized-chronic-pain-randomized-controlled\"\u003EAnnals of Internal Medicine has just published one of the better trials of compounded analgesic creams\u003C\/a\u003E I've yet to see, and unfortunately it's pretty damning.   \u003Cbr \/\u003E\u003Cbr \/\u003EIt's a randomized, double-blind, placebo-vehicle controlled, intention-to-treat, 3 parallel armed study of 3 different compounded creams for adult patients (median age ~50 years, ~50% women) with localized chronic pain (the 3 groups had neuropathic, nociceptive, or mixed pain syndromes). It took place at Walter Reed. Each arm had about 130 subjects (which, for this type of research, and compared to many other investigations of compounded creams, is quite a lot). Patients needed to have chronic pain (longer than 6 weeks), rated at least 4\/10, and localized to a body area or two extremities. Broadly speaking about half the subjects' pain was incited by an injury or surgery. Pain was classified as nociceptive vs neuropathic vs mixed based on a pain physician's assessment, more or less. About 20% of patients were on systemic opioids.  \u003Cbr \/\u003E\u003Cbr \/\u003ESubjects were prescribed one of 3 compounded creams (or the placebo\/vehicle cream which was PLO) and asked to apply it to their painful region three times a day:  \u003Cbr \/\u003E\u003Cul\u003E\u003Cli\u003E\u003Cb\u003ENeuropathic\u003C\/b\u003E: 10% ketamine, 6% gabapentin, 0.2% clonidine, and 2% lidocaine\u003C\/li\u003E\u003Cli\u003E\u003Cb\u003ENociceptive\u003C\/b\u003E: 10% ketoprofen, 2% baclofen, 2% cyclobenzaprine, and 2% lidocaine\u003C\/li\u003E\u003Cli\u003E\u003Cb\u003EMixed\u003C\/b\u003E: 10% ketamine, 6% gabapentin, 3% diclofenac, 2% baclofen, 2% cyclobenzaprine, 2% lidocaine\u003C\/li\u003E\u003C\/ul\u003E \u003Cbr \/\u003EThe primary outcome was average pain score after 1 month of treatment. They presented several prespecified secondary outcomes too. The study had 90% power to detect a pain reduction of 1.2 (out of 10) points with 60 patients per treatment arm, which they met.  \u003Cbr \/\u003E\u003Cbr \/\u003EBasically there weren't any statistically, let alone clinically, meaningful differences between the groups, regardless of pain type. For all groups, pain was reduced at a month by around 1-1.4\/10 points on the 0-10 NRS, regardless of receiving active drug or placebo cream. Secondary outcomes including patient judgement of a positive outcome (ie, the percent of patients who reported they considered the cream a success) were the same between all the groups too (around 20%). Health related quality of life did not differ either between groups at a month.  \u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/4.bp.blogspot.com\/-e7n3JF1Skz8\/XGHbwCD_pZI\/AAAAAAACgEQ\/lV54pGv8NSA7a_NpA-09uTlZRlLDMMCKwCLcBGAs\/s1600\/m182736ff2_figure_2_pain_outcomes_over_the_study_period_stratified_by_treatment_group.jpeg\" imageanchor=\"1\" style=\"margin-left: 1em; margin-right: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1201\" data-original-width=\"1024\" height=\"320\" src=\"https:\/\/4.bp.blogspot.com\/-e7n3JF1Skz8\/XGHbwCD_pZI\/AAAAAAACgEQ\/lV54pGv8NSA7a_NpA-09uTlZRlLDMMCKwCLcBGAs\/s320\/m182736ff2_figure_2_pain_outcomes_over_the_study_period_stratified_by_treatment_group.jpeg\" width=\"273\" \/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EThis study is one of the largest and best-designed study I'm aware of of these creams, and the findings are pretty clear: such creams benefit patients via placebo mechanisms, aka they don't work.  \u003Cbr \/\u003E\u003Cbr \/\u003ENote that there is a separate body of research on some other topicals which should not be confused with this study. Eg, the 5% lidocaine patch for post-herpetic neuralgia, topical capsaicin for a variety of neuropathies, and at least some topical NSAIDs for osteoarthritis, and topical opioids. I'm not broadly endorsing those either - it's complicated - however they weren't tested here and the take home point is we should stop making our patients pay exorbitant out of pocket costs for these compounded analgesic placebos, not necessarily those others.   \u003Cbr \/\u003E\u003Cbr \/\u003EParticularly for painful axonal neuropathies, many of us struggle with how to control those adequately, especially chemotherapy induced ones which don't respond well to most systemic drugs, and I've ordered plenty of fancy creams in the past for my patients, most of whom paid out of pocket for them, and I think it's time to stop doing that.  \u003Cbr \/\u003E\u003Cbr \/\u003EFor more \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/journal%20article\"\u003EPallimed posts about journal reviews.\u003C\/a\u003E\u003Cbr \/\u003EFor more \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/rosielle\"\u003EPallimed posts by Drew click here.\u003C\/a\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ci\u003EDrew Rosielle, MD is a palliative care physician at the University of Minnesota Health in Minnesota. He founded Pallimed in 2005. You can occasionally find him on \u003Ca href=\"https:\/\/twitter.com\/drosielle\"\u003ETwitter at @drosielle\u003C\/a\u003E. \u003C\/i\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EReferences\u003C\/b\u003E\u003Cbr \/\u003E\u003Cbr \/\u003E1 Brutcher RE, Kurihara C, Bicket MC, Moussavian-Yousefi P, Reece DE, Solomon LM, et al. \"\u003Ci\u003E\u003Ca href=\"https:\/\/annals.org\/aim\/fullarticle\/2724041\/compounded-topical-pain-creams-treat-localized-chronic-pain-randomized-controlled\"\u003ECompounded Topical Pain Creams to Treat Localized Chronic Pain: A Randomized Controlled Trial.\u003C\/a\u003E\u003C\/i\u003E\" Ann Intern Med. [Epub ahead of print ] doi: 10.7326\/M18-2736 \u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cmeta name=\"twitter:card\" content=\"summary\" \/\u003E\u003Cmeta name=\"twitter:site\" content=\"@pallimed\" \/\u003E\u003Cmeta name=\"twitter:title\" content=\"Goodbye to Compounded Analgesic Creams\" \/\u003E\u003Cmeta name=\"twitter:description\" content=\"All the compounded creams in the world just don't live up to the hype. Dr. Rosielle reviews the research.\" \/\u003E\u003Cmeta name=\"twitter:image\" content=\"https:\/\/3.bp.blogspot.com\/-6eXOSNVbeQg\/XGHbKkvGJtI\/AAAAAAACgEA\/dckv3BvSmQsL-_vGu1QRZuQVAQ6z73HYQCLcBGAs\/s1600\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup.png\" \/\u003E\u003Cmeta name=\"twitter:url\" content=\"https:\/\/www.pallimed.org\/2019\/02\/goodbye-to-compounded-analgesic-creams.html\" \/\u003E     "},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/3515235906973648543"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/3515235906973648543"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2019\/02\/goodbye-to-compounded-analgesic-creams.html","title":"Goodbye to Compounded Analgesic Creams"}],"author":[{"name":{"$t":"Drew Rosielle MD"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/04345646798042773615"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"32","height":"32","src":"\/\/3.bp.blogspot.com\/-sdxTTBPb3Kw\/UddApiGn9-I\/AAAAAAAABLE\/mriu5xh44dA\/s113\/ea37b7645cd78e7867d246cd755bc8d4.jpeg"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/3.bp.blogspot.com\/-6eXOSNVbeQg\/XGHbKkvGJtI\/AAAAAAACgEA\/dckv3BvSmQsL-_vGu1QRZuQVAQ6z73HYQCLcBGAs\/s72-c\/SQ%2B-%2Bpallimed%2Bwriters%2Bgroup.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-2127087734987940920"},"published":{"$t":"2018-10-01T11:24:00.002-05:00"},"updated":{"$t":"2018-10-03T05:34:49.489-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"communication"},{"scheme":"http://www.blogger.com/atom/ns#","term":"documentation"},{"scheme":"http://www.blogger.com/atom/ns#","term":"family"},{"scheme":"http://www.blogger.com/atom/ns#","term":"goals of care"},{"scheme":"http://www.blogger.com/atom/ns#","term":"hospice"},{"scheme":"http://www.blogger.com/atom/ns#","term":"language"},{"scheme":"http://www.blogger.com/atom/ns#","term":"miles"},{"scheme":"http://www.blogger.com/atom/ns#","term":"social work"},{"scheme":"http://www.blogger.com/atom/ns#","term":"stepfamily"}],"title":{"type":"text","$t":"Challenges Faced by Blended Families at End of Life"},"content":{"type":"html","$t":"\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/4.bp.blogspot.com\/-0C_ykPSqDSY\/W7I-rq9asoI\/AAAAAAACbu4\/RjopVdj52egceRm8sHoz__of5RXtKH7DACLcBGAs\/s1600\/Challenges%2BFaced%2Bby%2BBlended%2BFamilies%2Bat%2BEnd%2Bof%2BLife.png\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"800\" data-original-width=\"800\" height=\"320\" src=\"https:\/\/4.bp.blogspot.com\/-0C_ykPSqDSY\/W7I-rq9asoI\/AAAAAAACbu4\/RjopVdj52egceRm8sHoz__of5RXtKH7DACLcBGAs\/s320\/Challenges%2BFaced%2Bby%2BBlended%2BFamilies%2Bat%2BEnd%2Bof%2BLife.png\" width=\"320\" \/\u003E\u003C\/a\u003E\u003C\/div\u003Eby Lizzy Miles (\u003Ca href=\"https:\/\/twitter.com\/lizzymiles_MSW\"\u003E@lizzymiles_MSW\u003C\/a\u003E)\u003Cbr \/\u003E\u003Cbr \/\u003EAs with \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/miles\"\u003Eall my articles\u003C\/a\u003E, I need to acknowledge that I’m still learning always.\u0026nbsp; Because of the nature of my job as a float social worker, every patient and family is new to me every day. I have to rely significantly on others’ charting and I have to make sure my own is tip top. For patients who are new to hospice, I make it a special point to learn the nuances of their family dynamic so that I can pass the information on to the care team. There is a fine line between with getting the details and not getting mired down in detail. Ultimately, the key is really paying attention to language.\u003Cbr \/\u003E\u003Cbr \/\u003EThese days it is common to work with families in which both the patient and spouse are on their second marriage and both have children from previous marriages. Blended families can be beautiful as they can represent a fractured family becoming whole again in a new way. Remember the Brady Bunch? Double the family, double the love.\u003Cbr \/\u003E\u003Cbr \/\u003EHowever, when blended families have conflict at the end of life, it can complicate everything from caregiving to funeral planning.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EON LANGUAGE AND RELATIONSHIPS\u003C\/b\u003E\u003Cbr \/\u003EFor blended families, there are “technical” relationship identifiers and “perceived” relationship identifiers. You may wonder why you would need to clarify the difference, and there are a couple of different reasons.\u003Cbr \/\u003E\u003Cbr \/\u003E1.\u0026nbsp; If there is no designated health care power of attorney (POA), \u003Ca href=\"https:\/\/www.americanbar.org\/content\/dam\/aba\/administrative\/law_aging\/2014_default_surrogate_consent_statutes.authcheckdam.pdf\"\u003Estate laws for surrogate decision-making focus on biological relations\u003C\/a\u003E, and by default step-family are further down the line or even excluded. Even if there is POA, many funeral homes often depend on next-of-kin hierarchy.\u003Cbr \/\u003E\u003Cbr \/\u003E2.\u0026nbsp; The step-relationship may come in to play in regards to caregiving support these family members choose to offer.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: Be cautious when referencing a relationship as it was previously identified in charting. Other clinicians don’t always make the distinction.\u003C\/b\u003E\u003Cbr \/\u003E\u003Cbr \/\u003EThe clinician may have charted “Dad” when the family member is actually “stepdad.” Alternatively, the clinician may have charted “step-sister” without acknowledging the family uses the “sister” label.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/4.bp.blogspot.com\/-BR5K4lTvwSM\/W7I_sZe-VMI\/AAAAAAACbvA\/_JWQDPXWF1okJ89V_hn6uLp3W1HDccThQCLcBGAs\/s1600\/hope-house-press-leather-diary-studio-767323-unsplash%2B%25281%2529.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1067\" data-original-width=\"1600\" height=\"213\" src=\"https:\/\/4.bp.blogspot.com\/-BR5K4lTvwSM\/W7I_sZe-VMI\/AAAAAAACbvA\/_JWQDPXWF1okJ89V_hn6uLp3W1HDccThQCLcBGAs\/s320\/hope-house-press-leather-diary-studio-767323-unsplash%2B%25281%2529.jpg\" width=\"320\" \/\u003E\u003C\/a\u003E\u003C\/div\u003EI had one daughter who referred to both her dad and her stepdad as “dad.”\u0026nbsp; No other clinician understood that the primary caregiver “dad” was technically a stepdad.\u003Cbr \/\u003E\u003Cbr \/\u003EPerception of “step” may vary within a family. Sometimes feelings about relationships are not mutual.\u003Cbr \/\u003E\u003Cbr \/\u003EThe age of the sibling might affect their use of the label. I’ve seen older children from the first marriage identify younger step-siblings with the “step” label, while younger children only ever knew and talked about the older ones as “siblings.”\u003Cbr \/\u003E\u003Cbr \/\u003EOn the subject of grandchildren, a daughter-in-law once “assisted” my conversation with a patient by asking how many grandchildren she had. I never ask the question because numbers challenge the memory. The patient gave a number that only reflected her biological grandchildren which angered the daughter-in-law who had children from a previous marriage. I then was a helpless witness to a 20 minute argument in which the patient was adamant that the step-grandchildren didn’t “count” and the daughter-in-law was visibly upset.\u003Cbr \/\u003E\u003Cbr \/\u003EA step-mom may consider her step-children as “children” but if the children are still connected to their biological mom, there is a possibility that the feeling is not mutual.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: In your own documentation, be clear and distinct with family preferences for labels.\u0026nbsp;\u003C\/b\u003E\u003Cbr \/\u003EFor example, you could say something like, “The youngest two are technically step-sisters, but family members do not use the “step” identification.”\u003Cbr \/\u003E\u003Cbr \/\u003EBe sure to also chart any sensitive areas on the topic, as with the example about the grandmother.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: Use language the way they do.\u0026nbsp;\u003C\/b\u003E\u003Cbr \/\u003EIf you’re talking to someone who clearly delineates within the family, reference “step-sister” or better, yet, use the person’s name. If a child thinks of their stepdad as “dad” then use the word “dad.”\u003Cbr \/\u003E\u003Cb\u003E\u003Cbr \/\u003E\u003C\/b\u003E\u003Cb\u003EON CAREGIVING AT HOME AND BLENDED FAMILIES\u003C\/b\u003E\u003Cbr \/\u003EOne cannot make assumptions about how a person will be a caregiver based on their familial relationship to the patient. In a best case scenario, we would see the whole family supporting one another and equally sharing the burden. Unfortunately this is not always the case. A few years ago I wrote about how to \u003Ca href=\"https:\/\/www.pallimed.org\/2016\/01\/navigating-hospice-care-with-reluctant.html\" target=\"_blank\"\u003Enavigate working with a reluctant caregiver\u003C\/a\u003E. At the time, though, the dynamics of blended families weren’t completely on my radar.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cdiv class=\"separator\" style=\"clear: both; text-align: center;\"\u003E\u003Ca href=\"https:\/\/3.bp.blogspot.com\/-V2bE3Sjo8hU\/W7I_0b7bo4I\/AAAAAAACbvE\/iqoiiE7TmAAYQcDXVfm11avVNufHuMoKQCLcBGAs\/s1600\/alex-6723-unsplash%2B%25281%2529.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1112\" data-original-width=\"1600\" height=\"222\" src=\"https:\/\/3.bp.blogspot.com\/-V2bE3Sjo8hU\/W7I_0b7bo4I\/AAAAAAACbvE\/iqoiiE7TmAAYQcDXVfm11avVNufHuMoKQCLcBGAs\/s320\/alex-6723-unsplash%2B%25281%2529.jpg\" width=\"320\" \/\u003E\u003C\/a\u003E\u003C\/div\u003EOne blended family challenge is the situation in which a patient is part of a couple that is on their second marriage and patient and caregiver each have children from prior marriages. You could have a combined total of ten children and still no one helping the spouse. The children of the caregiver don’t feel an affinity towards the patient, and the children of the patient do not feel that they need to be the ones to relieve the caregiver. These may seem like stereotypes. They are, and they do not apply to all blended families. This article, however, is addressing situations in which the family system is not working smoothly and is an attempt to explore how we, as professionals, approach these situations.\u003Cbr \/\u003E\u003Cbr \/\u003EAlternatively, in some blended family situations, it is one or more of the children who are the primary caregivers and the second spouse is the one who is the reluctant caregiver.\u003Cbr \/\u003EWhile you want to have an awareness of family dynamics, you do not want to have a position on them. It would be very easy to side with the caregiver who is involved and complaining about others who are not involved. But you don’t know the history of the family and their relationships.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: First of all, stay out of the mud slinging\u003C\/b\u003E\u003Cbr \/\u003EProvide supportive listening, but do not take sides. Who is right or wrong is not our place to say.\u003Cbr \/\u003EDon't say, “What a jerk!” Do say, “It sounds like you’re disappointed that he is not more involved in the care.” Document objectively any family dynamics that could affect care.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: Be solution focused\u003C\/b\u003E\u003Cbr \/\u003EWhile we want to provide supportive listening to a family member who is frustrated with a caregiving situation, we also need to redirect focus to the reality of the situation at hand and what we can actually do to ensure the patient is getting good care and the caregiver is supported.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: Complete HCPOA\u003C\/b\u003E\u003Cbr \/\u003EIf the patient is still oriented and does not yet have a health care power of attorney, encourage them to complete this document. Ask them who they want their primary decision-maker to be. Do not assume it will be their spouse. Be clear with patient and family that without the document, though, the spouse is the primary decision maker in the event patient is no longer able to speak for themselves. When a patient has only been married a few years or less and the children are well into middle age, the spouse’s authority can sometimes be a point of conflict.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: Have a family meeting focused on goals of care\u003C\/b\u003E\u003Cbr \/\u003EIf family members are involved but disagree on care, encourage everyone to get together at the same time to discuss goals of care. This should be centered on what the patient wants. In an ideal world, the meeting would involve the patient, the whole hospice team and all involved family members. For families providing care at home, at a minimum, the nurse and social worker should both be there. There might be medical questions for the nurse to answer, and social workers have more training in group dynamics and facilitation.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EIntervention: Assist with communication and language\u003C\/b\u003E\u003Cbr \/\u003EAssist the primary caregiver with phrases that he or she can use to ask for help. Sometimes the family can get so caught up in the dynamics of a relationship that they don’t know how to ask for what they need. They may have a habit of accusing someone of not being around enough, but complaining in itself isn’t effective.\u003Cbr \/\u003E\u003Cbr \/\u003EI always tell caregivers that it is easier for others to agree to help them if they are specific in their request. I would work with them to find out what their biggest needs are and then help them phrase the “ask.”\u0026nbsp; \u0026nbsp;I might suggest they say something like, “It would be helpful to have a weekly two hour block of time that I can count on to run errands. I don’t feel comfortable leaving [patient] alone. Is there a time when you might be able to come over to relieve me?”\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003EAdvice for you: Help with what you can, let go of the rest\u003C\/b\u003E\u003Cbr \/\u003EAs you are working with challenging families, you may find yourself frustrated by situations that you can’t fix. If this happens and you find yourself having an adverse reaction to a family situation, take a step back to explore your response.\u003Cbr \/\u003E\u003Cbr \/\u003EFor more articles by \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/miles\"\u003ELizzy Miles, click here\u003C\/a\u003E. For more articles about \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/communication\"\u003Ecommunication, click here\u003C\/a\u003E. For more articles about \u003Ca href=\"https:\/\/www.pallimed.org\/search\/label\/social%20work\"\u003Esocial work, click here\u003C\/a\u003E. \u003Cbr \/\u003E\u003Cbr \/\u003ELizzy Miles, MA, MSW, LSW is a hospice social worker in Columbus, Ohio and author of a book of happy hospice stories: \u003Ca href=\"https:\/\/www.amazon.com\/Somewhere-Between-Chocolate-Shared-Experience-ebook\/dp\/B005GGGYQ2\/ref=asap_bc?ie=UTF8\"\u003ESomewhere In Between: The Hokey Pokey, Chocolate Cake and the Shared Death Experience\u003C\/a\u003E. Lizzy is best known for \u003Ca href=\"http:\/\/deathcafe.com\/what\/\"\u003Ebringing the Death Cafe concept to the United States\u003C\/a\u003E. She is currently funding \u003Ca href=\"https:\/\/www.kickstarter.com\/projects\/lizzymiles\/hora-fugit-postcard-reminders?ref=4ye25s\"\u003Eher fourth Kickstarter campaign Hora Fugit\u003C\/a\u003E which seeks to send willing participants gentle postcard reminders of their mortality. You can find her on Twitter \u003Ca href=\"https:\/\/twitter.com\/LizzyMiles_MSW\"\u003E@LizzyMiles_MSW.\u003C\/a\u003E \u003Cbr \/\u003E\u003Cbr \/\u003EPhotos via \u003Ca href=\"https:\/\/unsplash.com\/\"\u003EUnsplash\u003C\/a\u003E- Ink by rawpixel; Dad's Keys by Hope House Press; Mugs by Worthy of Elegance       "},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2127087734987940920"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/2127087734987940920"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2018\/10\/challenges-faced-by-blended-families-at.html","title":"Challenges Faced by Blended Families at End of Life"}],"author":[{"name":{"$t":"Lizzy Miles"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/06871018407337559011"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/4.bp.blogspot.com\/-0C_ykPSqDSY\/W7I-rq9asoI\/AAAAAAACbu4\/RjopVdj52egceRm8sHoz__of5RXtKH7DACLcBGAs\/s72-c\/Challenges%2BFaced%2Bby%2BBlended%2BFamilies%2Bat%2BEnd%2Bof%2BLife.png","height":"72","width":"72"}},{"id":{"$t":"tag:blogger.com,1999:blog-13495125.post-8381506043320918661"},"published":{"$t":"2018-07-30T05:00:00.000-05:00"},"updated":{"$t":"2018-08-07T20:33:05.491-05:00"},"category":[{"scheme":"http://www.blogger.com/atom/ns#","term":"hospice"},{"scheme":"http://www.blogger.com/atom/ns#","term":"miles"},{"scheme":"http://www.blogger.com/atom/ns#","term":"ninjutsu"},{"scheme":"http://www.blogger.com/atom/ns#","term":"perseverance"},{"scheme":"http://www.blogger.com/atom/ns#","term":"social work"},{"scheme":"http://www.blogger.com/atom/ns#","term":"social worker"},{"scheme":"http://www.blogger.com/atom/ns#","term":"spiritual"}],"title":{"type":"text","$t":"End-of-Life Learning from the Philosophy of Ninjas"},"content":{"type":"html","$t":"\u003Ca href=\"https:\/\/3.bp.blogspot.com\/-6weZppbZS5A\/W1zwl0qjxbI\/AAAAAAABW7s\/oZZ7iBO1yVUDxHTuZB2hcRJccx5sXpHDACLcBGAs\/s1600\/Ninjutsu%2Bfor%2Bthe%2Bhospice%2Bpatient%2B%25281%2529.png\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"800\" data-original-width=\"800\" height=\"320\" src=\"https:\/\/3.bp.blogspot.com\/-6weZppbZS5A\/W1zwl0qjxbI\/AAAAAAABW7s\/oZZ7iBO1yVUDxHTuZB2hcRJccx5sXpHDACLcBGAs\/s320\/Ninjutsu%2Bfor%2Bthe%2Bhospice%2Bpatient%2B%25281%2529.png\" width=\"320\" \/\u003E\u003C\/a\u003Eby Lizzy Miles\u003Cbr \/\u003E\u003Cbr \/\u003EIf you had told me there was a parallel between the study of ninjutsu and hospice a year ago, I wouldn’t have believed you. But I have now realized that there is much to be learned from the ninja philosophy that can be applied to hospice.\u003Cbr \/\u003E\u003Cbr \/\u003EIt was a patient who helped me make the connection.\u003Cbr \/\u003E\u003Cbr \/\u003EThe chaplain and I were doing our initial assessment with a cancer patient who was younger than both of us.\u0026nbsp; I will call the patient “John.” I started the visit like I usually do, by asking \u003Ca href=\"http:\/\/www.pallimed.org\/2017\/11\/defining-dignity-at-end-of-life-one.html\"\u003Ethe dignity question\u003C\/a\u003E.\u003Cbr \/\u003E\u003Cbr \/\u003E“What do I need to know about you as a person to give you the best care possible?”\u003Cbr \/\u003E\u003Cbr \/\u003EHis response was calm.\u0026nbsp; “I learned in the military, you can gain a lot of strength through suffering. It can help you see through to the other side.”\u003Cbr \/\u003E\u003Cbr \/\u003EI looked over at the chaplain, intrigued. I could tell he was intrigued too.\u003Cbr \/\u003E\u003Cbr \/\u003EI asked John if he had any worries or concerns. He said it he didn’t. I had heard that one sister was having a particularly tough time, so I asked John if there was anyone in his family that he worried about.\u0026nbsp; Again, in a slow, calm voice, he said, “I hope when I’m gone nothing changes, but a shift in the system can cause disarray.”\u003Cbr \/\u003E\u003Cbr \/\u003EI suppose my feelings of surprise were because his manner and presence were so much calmer than patients usually are when they’ve been referred to hospice with a short prognosis. I looked over at the chaplain again and we locked eyes. Craig, our chaplain, has a PhD in Philosophy. I could tell that he was also curious and impressed with John’s demeanor.\u003Cbr \/\u003E\u003Cbr \/\u003EI turned to John and told the patient as much. “The chaplain and I are looking at each other because you are a lot calmer and more at peace than most patients we meet. What’s your secret?”\u003Cbr \/\u003E\u003Cbr \/\u003EJohn told us that he had studied ninjutsu.\u003Cbr \/\u003E\u003Cbr \/\u003EThough I only met John that one time, his strong presence at that visit affected me. I was so curious about ninjutsu because I really knew nothing about it except what I had seen in movies and television, which couldn’t be more misleading. I searched online, and found an \u003Ca href=\"https:\/\/blackbeltmag.com\/arts\/ninjutsu\/ninjutsu-training-tips-anyone-can-use\/\"\u003Earticle\u003C\/a\u003E that introduced me to the spiritual component of ninjutsu training. I then checked out several books from the library and dug in.\u003Cbr \/\u003E\u003Cbr \/\u003EAccording to Dr. Masaaki Hatsumi, the last surviving grandmaster of the ancient art on ninjutsu, there are multiple theories of the evolution and origin of ninjutsu. Going back almost 1,000 years there was a time in Japan where feudal lords ruled through terror. Ninjutsu was created as a martial art focused on self defense against oppressors. Along with the physical training, there was a focus development of mental fortitude (Hatsumi, 1988 p. 19-21).\u003Cbr \/\u003E\u003Cbr \/\u003EFirst and foremost: “The ninja are not members of a circus. Nor are the ninja robbers, assassins or betrayers. The ninja are none other than persons of perseverance or endurance.” (Hatsumi, 1988 p. 77)\u003Cbr \/\u003E\u003Cbr \/\u003ESecondly, “…true ninjas began to realize that they should be enlightened on the laws of humanity. They tried to avoid unreasonable conflicts or fighting…The first priority to the ninja was to win without fighting, and that remains the way.” (Hatsumi, 1988 p.23)\u003Cbr \/\u003E\u003Cbr \/\u003EWhat was of greatest interest to me in the books was the details of mental training that went along with the physical training in ninjutsu. Much of what we see in hospice goes beyond the physical as well, and I saw many parallels.\u003Cbr \/\u003E\u003Cbr \/\u003EHere are the gems I found:\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"https:\/\/3.bp.blogspot.com\/-C5iwlARCMJ0\/W1zvLzElG9I\/AAAAAAABW7g\/uHtIBqxdD68Og2r3Jp3Ken5L6MRxFcgMwCLcBGAs\/s1600\/philip-brown-542157-unsplashcrop.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1192\" data-original-width=\"1600\" height=\"148\" src=\"https:\/\/3.bp.blogspot.com\/-C5iwlARCMJ0\/W1zvLzElG9I\/AAAAAAABW7g\/uHtIBqxdD68Og2r3Jp3Ken5L6MRxFcgMwCLcBGAs\/s200\/philip-brown-542157-unsplashcrop.jpg\" width=\"200\" \/\u003E\u003C\/a\u003E\u003Cb\u003ENinja philosophy:\u003C\/b\u003E “The objectives of the ninjas are: first, to use ninjutsu to infiltrate the enemy’s camp and observe the situation.” (Hatsumi, 1988 p. 111).\u003Cbr \/\u003E\u003Cb\u003EHow it applies to hospice:\u003C\/b\u003E Everyone involved in a hospice situation, including the patient, their loved ones, and the staff, are observing everyone else.\u003Cbr \/\u003E* The patient often can be stuck in a role of observation whether they chose to or not because they may be too tired to interact, or the family will talk in front of them to staff.\u003Cbr \/\u003E* The family is often on high alert, watching the patient for symptoms or watching the staff and timing our responses.\u003Cbr \/\u003E* The staff members are observing the patient for signs of pain or distress and watching family for signs of psychosocial distress.\u003Cbr \/\u003E\u003Cb\u003EInterventions:\u003C\/b\u003E Be deliberate on the task of observation. Imagine taking the bird's eye view. Sometimes we can be so focused on what we need to do or say that we forget to check in. Make a mental note for yourself to \u003Ci\u003Eobserve\u003C\/i\u003E before you speak or act.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003ENinja philosophy:\u003C\/b\u003E “In ninjutsu this is no fixed or permanent, ‘this is what it is’. Forget the falsehood of fixed things.” (Hatsumi, 2014, p.46)\u003Cbr \/\u003E\u003Cb\u003EHow it applies to hospice:\u003C\/b\u003E This is already my favorite insight with hospice. The longer I’ve been doing hospice, the more I keep learning what I don’t know. I’ve written about \u003Ca href=\"http:\/\/www.pallimed.org\/2014\/08\/we-dont-know-death-7-assumptions-we.html\"\u003Eassumptions \u003C\/a\u003Ethat we have about dying, how the dying \u003Ca href=\"http:\/\/www.pallimed.org\/2018\/06\/dont-ask-dying-man-if-he-wants-bacon-or.html\"\u003Emay not want to be in control\u003C\/a\u003E, and \u003Ca href=\"http:\/\/www.pallimed.org\/2017\/12\/the-emotions-of-dying.html\"\u003Ethe emotions the dying might be feeling\u003C\/a\u003E. Still, I keep discovering more and more variations in the way that people die – both in timing and symptoms.\u003Cbr \/\u003E\u003Cb\u003EInterventions:\u003C\/b\u003E Be mindful of any time you find yourself feeling certain about a patient’s condition or what will happen. Reflect on the times you have been wrong about what you thought you knew.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"https:\/\/3.bp.blogspot.com\/-AbOO1IgmRSs\/W1zyRfvoU9I\/AAAAAAABW78\/TRmDQw00Ozg8Lk0-dcfzN7z84f99tGNxACLcBGAs\/s1600\/asoggetti-528311-unsplashcrop.jpg\" imageanchor=\"1\" style=\"clear: left; float: left; margin-bottom: 1em; margin-right: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1600\" data-original-width=\"1399\" height=\"200\" src=\"https:\/\/3.bp.blogspot.com\/-AbOO1IgmRSs\/W1zyRfvoU9I\/AAAAAAABW78\/TRmDQw00Ozg8Lk0-dcfzN7z84f99tGNxACLcBGAs\/s200\/asoggetti-528311-unsplashcrop.jpg\" width=\"174\" \/\u003E\u003C\/a\u003E\u003Cb\u003ENinja philosophy:\u003C\/b\u003E “First, forget your sadness, anger, grudges, and hatred. Let them pass like smoke caught in a breeze” (Hatsumi, 1988 p. 123).\u003Cbr \/\u003E\u003Cb\u003EHow it applies to hospice:\u003C\/b\u003E It is not uncommon for patients to go through a life review process in which they may have feelings of anger, guilt, or shame. Sometimes they take out their emotions out on us. Friends and family too may have memories of past hurts that come up during this time. Hospice staff are sometimes put in the position where we have to wear a mask to hide whatever might be happening to us outside of work.\u003Cbr \/\u003E\u003Cb\u003EInterventions:\u003C\/b\u003E Work on your awareness of when your feathers are getting ruffled by a patient. Recognize that their attitude towards you may reflect on their own internal state of mind rather than a defect of your own. Be mindful of your reactions to stressful situations.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-5kttbezOrIU\/W1zlYVGrM4I\/AAAAAAABW68\/ub57sKP-YA0nwLo2ZeQx_XYF6Lk8suA1QCLcBGAs\/s1600\/nathan-dumlao-264909-unsplashcropped.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1481\" data-original-width=\"1600\" height=\"296\" src=\"https:\/\/2.bp.blogspot.com\/-5kttbezOrIU\/W1zlYVGrM4I\/AAAAAAABW68\/ub57sKP-YA0nwLo2ZeQx_XYF6Lk8suA1QCLcBGAs\/s320\/nathan-dumlao-264909-unsplashcropped.jpg\" width=\"320\" \/\u003E\u003C\/a\u003E\u003Cb\u003ENinja philosophy:\u003C\/b\u003E “We say in Japanese that a presentiment is ‘a message conveyed by an insect.’ For example, when someone is dying, his family or close friends he really loved, can feel something is happening. We say than an insect has conveyed a message to them. It makes us believe that one can communicate through the subconscious” (Hatsumi, 1988 p. 72). \u003Cbr \/\u003E\u003Cb\u003EHow it applies to hospice:\u003C\/b\u003E\u0026nbsp;If you have been working in hospice long enough, you have to acknowledge there are unusual coincidences, synchronicities, signs, and moments of instinct. There are stories where patients have predicted the timing of their own death, stories about someone dying just when a loved one arrived or left, and stories about spirit presences in the room.\u003Cbr \/\u003E\u003Cb\u003EInterventions:\u003C\/b\u003E Be open to the idea that there are forces beyond what we understand. Remember that patients and families may have belief systems different from our own.\u003Cbr \/\u003E\u003Cb\u003E\u003Cbr \/\u003E\u003C\/b\u003E\u003Cb\u003ENinja philosophy:\u003C\/b\u003E\u0026nbsp;“The first important aspect of ninjutsu is to maintain calmness in the body, and endurance in the heart” (Hatsumi, 2014 p.169).\u003Cbr \/\u003E\u003Cb\u003EHow it applies to hospice:\u003C\/b\u003E The connection with this one to hospice seems obvious to me. How many patients do we have with anxiety? From my experience, this feels like one of the most common symptoms across diagnoses, and understandably so. The mind\/body connection is most apparent with COPD patients who are short of breath and then feel anxiety about being short of breath and then become even more breathless. We know that they are creating their own cycle, but sometimes we have difficulty helping them find their calm.\u003Cbr \/\u003E\u003Cb\u003EInterventions:\u003C\/b\u003E Start the conversation with patients about anxiety at a time when they are not anxious. Ask them how they calm themselves when they are feeling anxious. If they don’t know how to answer that question, then encourage them to think on it for a while. I sometimes joke with patients that I am giving them “homework.” This goes for staff too. Do you know what brings you calm? How can we be educators if we don’t practice what we preach?\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Ca href=\"https:\/\/2.bp.blogspot.com\/-oQObVQT2h-g\/W1zoGlk9HnI\/AAAAAAABW7I\/af1PTvJUddoGcIRBBdvUwSCvIqUj5DhCACLcBGAs\/s1600\/clayton-caldwell-382402-unsplash.jpg\" imageanchor=\"1\" style=\"clear: right; float: right; margin-bottom: 1em; margin-left: 1em;\"\u003E\u003Cimg border=\"0\" data-original-height=\"1067\" data-original-width=\"1600\" height=\"132\" src=\"https:\/\/2.bp.blogspot.com\/-oQObVQT2h-g\/W1zoGlk9HnI\/AAAAAAABW7I\/af1PTvJUddoGcIRBBdvUwSCvIqUj5DhCACLcBGAs\/s200\/clayton-caldwell-382402-unsplash.jpg\" width=\"200\" \/\u003E\u003C\/a\u003E\u003Cb\u003ENinja philosophy:\u003C\/b\u003E\u0026nbsp; “Nothing is so uncertain as one’s own common sense or knowledge. Regardless of one’s fragile knowledge one must singlemindedly devote oneself to training, especially in times of doubt. It is of utmost importance to immerse and enjoy oneself in the world of nothingness” (Hatsumi, 1988 p. 65-66).\u003Cbr \/\u003E\u003Cb\u003EHow it applies to hospice:\u003C\/b\u003E Patients and families do not get to a point of acceptance of death overnight. For patients and families to reach acceptance they need to sit with the uncomfortable feelings. Slowly, they get used to the idea that this is really happening. When patients start sleeping for longer periods of time, both the patient and the family are learning to separate from one another.\u003Cbr \/\u003E\u003Cb\u003EInterventions:\u003C\/b\u003E Be patient with the time it takes for our patients and families to come to acceptance. Realize that for some of them, the introduction of hospice may have been the first time they truly contemplated mortality. They haven’t trained for it like we have. Those who work in hospice and see death and dying on a regular basis can forget what it feels like to be in this situation.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cb\u003ENinja philosophy:\u003C\/b\u003E “Ultimately the responsibility for your training is your own” (Hoban, 1988, p. 172).\u003Cbr \/\u003E\u003Cb\u003EHow it applies to hospice:\u003C\/b\u003E Remember not to project your own ‘right way to die’ onto a patient. Consider this: some people actually do want to die in a hospital setting! Some patients do want a room full of people there with them. Some people want the television on to Fox news.\u003Cbr \/\u003E\u003Cb\u003EInterventions:\u003C\/b\u003E Ask the patient about their preferences, rather than assuming you know what they want because it’s what you would want. Self-reflect on suggestions you make to patients and families to ensure you're not projecting your own belief system.\u003Cbr \/\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003EReferences\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003EHoban, J. (1988). \u003Ci\u003ENinpo: Living and thinking as a warrior.\u003C\/i\u003E Chicago: Contemporary Books.\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003EHatsumi, M. (1988). \u003Ci\u003EEssence of ninjutsu: The nine traditions.\u003C\/i\u003E Chicago: Contemporary Books.\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003EHatsumi, M. (2014). \u003Ci\u003EThe complete ninja: The secret world revealed.\u003C\/i\u003E New York, NY: Kodansha USA.\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u003Cbr \/\u003EPhotos via Unsplash. Some photos have been cropped.\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003EMoon via \u003Ca href=\"https:\/\/unsplash.com\/@fortheking\"\u003EClayton Caldwell\u003C\/a\u003E\u0026nbsp;\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003EOwl via \u003Ca href=\"https:\/\/unsplash.com\/@nebirdsplus\"\u003EPhilip Brown\u003C\/a\u003E\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003EButterfly via \u003Ca href=\"https:\/\/unsplash.com\/@nate_dumlao\"\u003ENathan Dumlao\u003C\/a\u003E\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"font-size: x-small;\"\u003ESmoke via \u003C\/span\u003E\u003Ca href=\"https:\/\/unsplash.com\/@asoggetti\" style=\"font-size: x-small;\"\u003EAlessio Soggetti\u003C\/a\u003E\u003Cspan style=\"font-size: x-small;\"\u003E\u0026nbsp;\u003C\/span\u003E\u003Cbr \/\u003E\u003Cspan style=\"background-color: white; font-family: \u0026quot;helvetica neue\u0026quot; , \u0026quot;arial\u0026quot; , sans-serif; font-style: italic;\"\u003E\u003Cbr \/\u003E\u003C\/span\u003E\u003Cspan style=\"background-color: white; font-family: \u0026quot;helvetica neue\u0026quot; , \u0026quot;arial\u0026quot; , sans-serif; font-style: italic;\"\u003ELizzy Miles, MA, MSW, LSW is a hospice social worker in Columbus, Ohio and author of a book of happy hospice stories:\u0026nbsp;\u003C\/span\u003E\u003Ca href=\"https:\/\/www.amazon.com\/Somewhere-Between-Chocolate-Shared-Experience-ebook\/dp\/B005GGGYQ2\/ref=sr_1_1?ie=UTF8\u0026amp;qid=1473000768\u0026amp;sr=8-1\u0026amp;keywords=somewhere+in++lizzy+miles#nav-subnav\" style=\"background-color: white; border: 0px; color: #1f5a09; font-family: \u0026quot;helvetica neue\u0026quot;, arial, sans-serif; font-style: italic; margin: 0px; padding: 0px;\" target=\"_blank\"\u003ESomewhere In Between: The Hokey Pokey, Chocolate Cake and the Shared Death Experience\u003C\/a\u003E\u003Cspan style=\"background-color: white; font-family: \u0026quot;helvetica neue\u0026quot; , \u0026quot;arial\u0026quot; , sans-serif; font-style: italic;\"\u003E. Lizzy is best known for bringing the\u0026nbsp;\u003C\/span\u003E\u003Ca href=\"http:\/\/deathcafe.com\/what\/\" style=\"background-color: white; border: 0px; color: #1f5a09; font-family: \u0026quot;helvetica neue\u0026quot;, arial, sans-serif; font-style: italic; margin: 0px; padding: 0px;\" target=\"_blank\"\u003EDeath Cafe\u003C\/a\u003E\u003Cspan style=\"background-color: white; font-family: \u0026quot;helvetica neue\u0026quot; , \u0026quot;arial\u0026quot; , sans-serif; font-style: italic;\"\u003E\u0026nbsp;concept to the United States. You can find her on Twitter\u0026nbsp;\u003C\/span\u003E\u003Ca href=\"https:\/\/twitter.com\/LizzyMiles_MSW\" style=\"background-color: white; border: 0px; color: #1f5a09; font-family: \u0026quot;helvetica neue\u0026quot;, arial, sans-serif; font-style: italic; margin: 0px; padding: 0px;\" target=\"_blank\"\u003E@LizzyMiles_MSW\u003C\/a\u003E\u003Cbr \/\u003E\u003Cul style=\"background-color: white; border: 0px; font-family: \u0026quot;helvetica neue\u0026quot;, arial, sans-serif; line-height: 20px; margin: 0px 0px 15px; padding: 0px;\"\u003E\u003Cdiv style=\"border: 0px; margin: 0px; padding: 0px;\"\u003E\u003C\/div\u003E\u003Cdiv\u003E\u003Cbr \/\u003E\u003C\/div\u003E\u003C\/ul\u003E\u003Cmeta name=\"twitter:card\" content=\"summary\" \/\u003E\u003Cmeta name=\"twitter:site\" content=\"@pallimed\" \/\u003E\u003Cmeta name=\"twitter:title\" content=\"End-of-Life Learning from the Philosophy of Ninjas\" \/\u003E\u003Cmeta name=\"twitter:description\" content=\"Insights into how to cope with illness and dying can from many different sources.\" \/\u003E\u003Cmeta name=\"twitter:image\" content=\"https:\/\/3.bp.blogspot.com\/-6weZppbZS5A\/W1zwl0qjxbI\/AAAAAAABW7s\/oZZ7iBO1yVUDxHTuZB2hcRJccx5sXpHDACLcBGAs\/s1600\/Ninjutsu%2Bfor%2Bthe%2Bhospice%2Bpatient%2B%25281%2529.png\" \/\u003E\u003Cmeta name=\"twitter:url\" content=\"https:\/\/www.pallimed.org\/2018\/07\/ninjutsu-for-hospice-patient.html\" \/\u003E"},"link":[{"rel":"edit","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/8381506043320918661"},{"rel":"self","type":"application/atom+xml","href":"https:\/\/www.blogger.com\/feeds\/13495125\/posts\/default\/8381506043320918661"},{"rel":"alternate","type":"text/html","href":"https:\/\/www.pallimed.org\/2018\/07\/ninjutsu-for-hospice-patient.html","title":"End-of-Life Learning from the Philosophy of Ninjas"}],"author":[{"name":{"$t":"Lizzy Miles"},"uri":{"$t":"http:\/\/www.blogger.com\/profile\/06871018407337559011"},"email":{"$t":"noreply@blogger.com"},"gd$image":{"rel":"http://schemas.google.com/g/2005#thumbnail","width":"16","height":"16","src":"https:\/\/img1.blogblog.com\/img\/b16-rounded.gif"}}],"media$thumbnail":{"xmlns$media":"http://search.yahoo.com/mrss/","url":"https:\/\/3.bp.blogspot.com\/-6weZppbZS5A\/W1zwl0qjxbI\/AAAAAAABW7s\/oZZ7iBO1yVUDxHTuZB2hcRJccx5sXpHDACLcBGAs\/s72-c\/Ninjutsu%2Bfor%2Bthe%2Bhospice%2Bpatient%2B%25281%2529.png","height":"72","width":"72"}}]}});