Bioethics with Sandra Shadley, LMFT, HEC-C and Dr. Ryan Howard, M.D.

[00:00] Michelle: In my working days, I was a member of my institution's Bioethics committee. I'm now a retired nurse and continue to serve as a community member. Constantly impressed by this committee's work, I wanted you to meet two of these brilliant minds. So I recently sat down with Sandra Shadley, a licensed marriage and family therapist and our committee chair, as well as Dr. Ryan Howard, our hospice and palliative medicine physician. Sandra holds a unique certification, the HEC-C, or certified healthcare ethics consultant. She explained that Bioethics is guided by four principles: respect for autonomy, beneficence, nonmaleficence, and justice. But despite the solidity of these principles, bioethical issues are still quite nuanced. Now, that's all fine and good, but what exactly does a bioethics team do? Well, they develop and implement policies, educate the hospital community, review research, and provide consultations with those patients facing end-of-life decisions. The committee consists of various social workers, physicians, nurses, critical care leaders, risk management, chaplains, and community members. It's a diverse group with diverse perspectives. Doctor Howard is gifted at having difficult conversations. He approaches patients with curiosity and humility, providing truly patient-centered and individualized end-of-life care. I left this interview feeling joyful. It was inspiring to witness these two individuals, whom I deeply respect, engage in a dialogue about their shared passion for Bioethics. 
In the five-minute snippet: Excavators, chainsaws and bonfires, oh my! Well, good afternoon, Sandra. Welcome to the podcast.

[02:33] Sandra: Thank you, Michelle. Glad to be with you.

[02:36] Michelle: I have wanted to talk to you for a while. You and I serve on the, well, I'll say I serve on the Bioethics committee here at this institution and you are the Chair. And we've known each other for quite a while. I started serving on the committee in 2012 and then I retired in 2022, so for ten years. And then you guys so graciously asked me if I could stay on as a community member, which I'm very, very honored and happy to do in my retirement. So thank you for that.

[03:16] Sandra: We're very grateful to have you. Thank you for doing it.

[03:19] Michelle: So I'm here today to talk to you and also Dr. Ryan Howard, who is the Hospice and Palliative Care Medical Director. And so he'll be here in a little bit and we can include him in this conversation, but I just want to start with an introduction from you. Who is Sandra Shadley? What is your story?

[03:45] Sandra: Well, thank you. Well, I am honored to be a long-term hospital employee here. It will be my 24th year starting soon, and my daily work is with the Palliative Medicine service. Helped to develop that over the last 1012 plus years. Working daily with patients and families in our care who have serious illnesses, helping them identify their goals of care, manage their symptoms, and make plans for their future, which may be an uncertain one for which they'll need ongoing support. So we work closely together as a team. We have a wonderful team of social workers, chaplains, nurses, nurse practitioners, and physicians, Dr. Howard being our Medical Director there, as you mentioned. So that work sort of puts me in a position to often also deal with patients and families, providers here in our system, where there may be different perceptions about what's best to do in the care of a patient or disagreements between family members or others in the care. And that sort of leads into the other big part of what I do is the Bioethics committee, chairing that, which is really a wonderful group of people, including you, hospital employees, and community members, who come together to address issues related to Bioethics that come up in healthcare, right? So we always try to do our very best for patients and families, and then there are often differences of opinion about how we can best serve. There's also a need for policy development and structural provisions to ensure that we're aligned with ethical principles in the care that we provide and have mechanisms for addressing the needs of patients and families as they emerge in the context of bioethical and healthcare issues. So our committee meets quarterly. I chair that and try to keep abreast of national and international bioethics issues. Work with our wonderful committee to address policy and other structural developments that may be needed.

[05:38] Michelle: Yeah, you do so much. You're one busy woman. Thank you for that introduction. So my first loaded question is, what is Bioethics?

[05:51] Sandra: Well, Bioethics is a field of study in which people from various disciplines come together to understand and develop mechanisms for ensuring that we care for patients in the healthcare system, particularly within the principles of Bioethics, the known Bioethics principles. There are four of them. They are respect for autonomy, beneficence, meaning do good, nonmaleficence, meaning do no harm, and justice, meaning we should ensure that every service we deliver is equally available to all people who may need it or benefit from it. So those are four guiding principles in Bioethics, whether they're applied to healthcare or other systems or other interactions between individuals. And so within our system, we ensure that our policies and our practices are aligned with those principles. And when there's a question about that or conflict around one of those, we offer a consultation service through our bioethics committee where we can bring together the appropriate parties and say, okay, what is the issue? What are you concerned about? If you're concerned about is the care we're providing is beneficial or harmful, right? Given the expected outcomes, we address that. We talk about autonomy, and decision making. Often we'll deal with patients who are unrepresented, meaning they are unable to speak on their own behalf, but due to the severity of their illness and or they have no one to speak for them. You've been a great help to us because we have a process where we come together and assemble a team to very thoughtfully care and think through what are the options available, and then make recommendations to the physician for how to best proceed. Always looking for surrogates, you know, continuing that search in case someone does come along who knows the patient better, can speak on their behalf. I think one thing that people think about the bioethics process in the healthcare system is that people bring a problem to us and we tell them what to do. That's not at all how it works. And so for some, that's frustrating because they want a clear, direct answer. But Bioethics is very nuanced, you know, and there are no real absolute rights or wrongs. There's really more of what is ethically permissible in the context of these four, you know, four principles of autonomy, beneficence, nonmaleficence, and justice. So we analyze that very carefully and then make a recommendation to whoever's brought the concern to us. Ultimately, then, it's a physician's decision to take whatever course of action, if it's a physician or others. But we do make a recommendation and hope that that's helpful because it's been very well considered in the context of the principles that I just outlined.

[08:29] Michelle: I've really enjoyed being a part of the multidisciplinary team looking in. It's interesting to see all the many issues that are so complicated. And you mentioned unrepresented individuals, and have you seen an increase in years past of unrepresented patients?

[08:55] Sandra: Yeah, you know, it feels that way, but I don't have the statistics to back that up. But I think that our little community, you know, I remember being living here many years ago when we had one homeless person. We all knew who he was.

[09:10] Michelle: Exactly.

[09:10] Sandra: We were all worried about him. We all tried to help him. He told us to leave him alone, and we ultimately did. And so now I look at our community, and I see just the vast numbers of individuals who are unhoused and who seem to have very minimal support, significant mental health needs, living on the street. And those people, obviously, often don't have well-managed healthcare, seek treatment only under crisis, and might be too ill at that point to speak on behalf. So it feels like there are more of those people needing our care. I don't know if I have the numbers to support that, but I know that the hospital, we all have a deep commitment to recognize the vulnerability of those folks, to be sure that whatever we do to care for them, we do it in the most thoughtful way. And if we can't find someone who knows them better than we do to speak on their behalf, we are sure to come together in the way that you described, through a multidisciplinary team process, engaging all the right people to hear what the options are and, you know, offer the best recommendation we can for care. 

[10:10] Michelle: Well, let's talk about those people. Who are the players on the bioethics team, the disciplines?

[10:19] Sandra: So we welcome anyone within the hospital system who wishes to participate. Typically now we have social workers, physicians, nurses, our risk management, department of patient experience. People participate, and leaders of our critical care area participate. We're glad to have her there. And we have chaplains, of course, you know, spiritual support folks and community members, because we always want to bring into the discussion people who may not work here anymore. We did once, as you did, but who have a perspective, you know, from the community, living in our community, and can bring that together. We try to have it be a diverse group of people, bring in diverse perspectives. And I always, you know, there's sort of sometimes a conception that if there's a problem, you'd take it to ethics, right? And it's kind of a serious thing. It's a very serious process. But it's never as though we're punitive or in any way critical of the situation. We just try to best understand what's happening, consider it through the principles that I eliminated, and then help make the best recommendations we can. So we have a wide variety of folks to help us do that, and it's a really great group.

[11:35] Michelle: I will say your team of social workers is so thorough at trying to find surrogates for unrepresented individuals. They turn over every rock and look in every cranny, and they're so well connected they know their resources so well. I'm always impressed when I hear of all the ways that you've tried to contact any kind of family, any friends from our unrepresented population.

[12:09] Sandra: Thank you for that. And those people are a group of hardworking medical social workers, and we're actually working right now to even kind of deepen our due diligence search process, you know, and to structure it so that it's as consistent as possible every time, and that everybody knows everywhere to look, even though I think they already are quite adept at it, as you said, it's sort of to tighten it up and give them a frame of reference. So deeply committed to that, and they do a fantastic job. I agree with you.

[12:36] Michelle: It's so touching to me as looking in now, I'm still a nurse, but I'm a community member, at just the dedication and the compassion of the people on the team that really want to reconnect people. They want people to know that their loved one is going through this crisis, need. They need to make decisions and so forth. It's like, I feel so good knowing, like, if you guys treat people like that's your family like you would want that person, that's your brother or, you know, your sister, cousin, or whatever, that you would want them to represent them in that way. And I love that.

[13:26] Sandra: Thank you, Michelle. You're a big part of us, really, keeping that focus, you know? And I can remember a few cases where, try as we may, you know, we couldn't find anyone. The people were so disenfranchised and separated from their families that the only people with them, you know, as they died sometimes, were us. And. And what I love about this system is the people who work here, is that if that's the case, they're never left alone, right? The nurses.

[13:54] Michelle: No one dies alone.

[13:55] Sandra: Or that formal program that we have. Yeah.

[13:57] Michelle: So amazing.

[13:58] Sandra: Yeah. We just don't want that for anyone. So I thank you for that. And that is a deep commitment.

[14:06] Michelle: Oh, yeah, I see that.

[14:08] Sandra: Yeah.

[14:09] Michelle: Okay, well, what are some of the common bioethical issues that are addressed that are brought to the committee?

[14:17] Sandra: Okay, well, one, of course, is this issue, as we've been talking about unrepresented patients and how we can best ensure their care needs are met. There are times when a family, on behalf of a patient or a patient themselves, may be requesting a type of medical care that the physicians involved in the case feel is ineffective and is not likely to help them achieve their goals or their wishes, as we understand them from having talked about them, with them. And there's concern sometimes on the part of the physician that they will cause undue harm or pain or suffering. So those come to us sometimes as a discussion around what we call medically ineffective care, where the medical team feels like what we're offering is not going to be effective in achieving the goals. And that's important. It's not just, we don't think we should do it, or we don't want to do it. That's never the case. It's we think carefully, what are you hoping to accomplish? And what we're offering is not going to get you there, right, and could cause undue suffering. So we talk about those things. We never mandate or force things. We help. Sometimes people understand what the limits are to what we can and can't do, and help people find alternative care if they wish. But that's a very careful and important process that gets brought to the bioethics consultation process. We often, always, not always, I would say most of the time, ensure that a palliative consultation has been involved, because, as Dr. Howard will speak when he joins us, that's a critical part of the process to really, at the deepest level possible, understand the goals and preferences of the patient and the family and to determine if, once we know those, do we feel we can help you achieve them through the medical interventions that are available here or elsewhere. So palliative consultation and bioethics consultation are often kind of quite joined and collaborate together really well to ensure the best care possible, which is what we're all striving for. 

[16:21] Michelle: Okay, let's see. So you have a very special certification, and it's called the HEC-C. It's a healthcare ethics consultant. So talk about that.

[16:36] Sandra: Okay. Well, it is kind of a neat thing, and I'm proud to have been able to pursue it and have the hospital support to do it. It is a certification that was developed through the American Society for Bioethics and Humanities, ASBH. It's kind of the national organization that oversees bioethics policy development conferences, research, kind of the clearinghouse, really, for all things bioethics related. In about 2017, they decided to develop a training program and a mechanism through the testing process to determine certain basic competencies that were important to have for anyone who works within the bioethics consultation process, especially those who lead those processes, right? Such as me, as the chair of our institutions' policy. So it involves a study and an exam that asks a person to really learn and address, you know, all aspects of the history of bioethics, kind of what the key issues are in current bioethical healthcare, particularly practice, deeply understand how to process issues related to medical decision making for patients and families. We talk about the four-box method, which you might have heard. We talk about a lot in our work, where we do our ethical analysis through that mechanism, where we look at four key issues in any case, one being the medical indications, what's happening medically. Secondly, what are the known patient preferences or family preferences on behalf of the patient? What's the anticipated quality of life? Knowing that quality of life is a very personal matter, right? That no one can really decide for another person what makes a quality of life that's acceptable. But that's what we strive to understand, is what is acceptable and would be okay for a person based on their values and their wishes. And then we consider contextual features like, what are the factors in this individual's life? If we're making, helping to make medical decisions or make recommendations about medical decisions, that would, you know, impact it. Do they have caregiving? Are they unhoused? That doesn't change what we do. We just have to consider it as we offer what would be a recommendation. So there's a lot of training on that in this certification process and how to be sure to really apply these principles or these considerations and perspectives in the context of the bioethics principles. So, yeah, studied for quite a while. It was a pretty grueling test. I'll almost say that I walked out thinking, wow, I thought I knew this stuff. And it turns out I did because I did pass. But it's really kind of a part of a movement within healthcare, with bioethics and healthcare, where we're kind of saying, okay, for many years now, bioethics committees and institutions such as ours and others have been comprised of, you know, really great people, well-intentioned, working hard, but not necessarily people who've had much formal training in the bioethics realm. Exactly. Yeah. And since that is getting, you know, more evidence-based, more research coming into play, and more articles being written about training, and there are many more now training programs, you know, at institutions around the country. There's sort of a, we're sort of upping our game a little bit, I think, in the bioethics world. And this certification is, you know, a step toward that for those who are interested. It doesn't have to be pursued. But I found it to be very. It just was validating, you know, for me, I kind of feel like, okay, it actually says on the paper, I know what I'm doing when I kind of felt I did. But, you know, it helps. It helps in that way. And it's being considered, you know, more and more kind of a standard, you know, for leaders, particularly in bioethics. So I think we'll be seeing more and more people pursuing it, more and more people getting it. And I think it's great. I think it's just a way of really, you know, validating the knowledge we have and challenge our, challenging ourselves to keep growing all the time, because it's always changing.

[20:35] Michelle: Yeah. And there's so much more. There are so many layers. Like you said, Bioethics is so nuanced that there's nothing really cut and dried about it. And I got on the certification website and they had a few sample questions.

[20:48] Sandra: What'd you think?

[20:49] Michelle: And I thought, you know what? I've been doing this for about ten years. I probably know. Oh, my gosh, no. I was, like, so embarrassed. I didn't do well at all. But I was so interested in it. I thought this is so interesting. I would love to learn more about it.

[21:07] Sandra: Yeah. And, you know, it's certainly doable. And I have the textbooks and the training program, and they're actually now re-evaluating the training program for the certification. So that's right now happening. And I, they may change some of the training mechanisms and the competencies associated with them, but it's very doable. And I thought, you know, I felt that way when I walked out of the exam. I felt like, wow, I thought I knew this stuff. And then I realized that I really did. And I think you do, too, because, you know, and I think most people who are committed to learning it, appreciative of the nuanced nature of it and the complexity of it, really have what you need, you know, to contribute meaningfully in bioethics setting, whether or not a person has a certification, you know.

[21:54] Michelle: Yeah. And I know many nurses that have taken certification exams and nine out of ten, they say when I walked out, I thought I totally bombed it. And they passed. You know, there's so much information that's floating around in your head, and obviously you have studied for it, you know, very intensely. And then just the whole testing, you know, the process is kind of intense as well. And some people aren't good test takers, you know, so all those are considerations. But it sounds like you would recommend this to anybody who's, like, really interested in pursuing any kind of work in bioethics.

[22:35] Sandra: I would really, just as a way of kind of, you know, expanding knowledge and anchoring yourself or anyone's into the kind of the principles and the processes and the latest information. Also, membership in the American Society of Bioethics and Humanities is a great thing because what they have is a wonderful listserv where you can get love listservs.

[22:57] Michelle: They're so great.

[22:58] Sandra: Yeah. You can get information about free virtual webinars from all over the world, really, and just be able to then hear, you know, things that you, you know, would not see people and hear experts speak that you would otherwise have the opportunity to. Yeah.

[23:14] Michelle: Just broadens your world.

[23:16] Sandra: Yeah. Yeah.

[23:17] Michelle: Well, do you think nurses, you get out and about in the hospital and I'm sure you get on the units and you see nurses and do you think that they know about the Bioethics committee? What do you hear about it from them?

[23:37] Sandra: Yeah.

[23:37] Michelle: Do they have questions about it? Like, I'm curious, what do you guys do?

[23:42] Sandra: Or, you know, they do, and I'm so glad you brought that up because, you know, nurses are the eyes and ears. Right. They're at the bedside. They see the patient and the family and have a connection with them that really almost nobody else might have over the course of this day. So they're the best, you know, among the best people, really, to help identify when there's a need that we could offer some support for. But I think, and historically, and it's interesting you say that because our director is a wonderful person, and really committed to enhancing the understanding among the nursing team of what bioethics is and what it can do and how it can support them and how any member of the hospital system, any nurse, any time who has a concern can bring it to us and we can evaluate it with them. Right. Yeah. So it's not as though you have to have an order or a physician or somebody in the hierarchy, you know, who requested anyone can. So I have a little PowerPoint and every chance I get, I mention it and I talk about it and I'll continue to do that. And I always encourage nurses to join the committee. Right. It's hard, you know, when they are working and to step away from the bedside. But I think we can certainly do a better job of letting the nurses know what a resource it is to them. And, you know, one of the things we try to support, too, is being sure that when, you know, in the course of care, there sometimes can be situations where caregivers experience moral distress. Right. Are conflicted about what we're doing and is it right? And can we do more or should we do less? You know, and we want people to have support in that. Right. Because if we don't address issues of moral distress or moral injury, they get cumulative and they impact how people feel and how they struct, how they manage their day-to-day work and their lives. So we don't want anyone to be suffering with that. So we, you know, we, Bioethics can be a source of consultation. A nurse could say, I'm just worried about this patient. Can we do a consultation? Right. Absolutely. Right. We can absolutely do that. We have other mechanisms, you know, within our system. We have Schwartz rounds where people can come and, you know, talk about a topic of interest and need support and compassion, you know, interaction with one another. But bioethics really, I think it's underutilized, maybe in the sense that people think you have to have a big, big problem and a big, big conflict to go to bioethics. Right. Or ask for consultation from bioethics, because that's really the mechanism is to request a consultation. The meetings we have quarterly are administratively focused. Right. We talk about policy, procedure, national events, and incidences, if we need to, certainly. But we step aside and have a consultation on a one-to-one or team-to-team basis whenever that's needed.

[26:31] Michelle: Yeah, I think that's so important to get the word out there, like at the grassroots level with the nurses who have their boots on the ground and to say it's not some big scary thing. Here's what we do. Here's, you're welcome to access us. You know, at any time, all you have to do is say the word. I know that many nurses left the profession during and post-COVID for some of those very reasons that they were really suffering that moral distress and that cumulative caretaking trauma, and with no outlet, really, to talk about it or to find out more about things that could be done. I mean, I think it's very important for every institution to have a bioethics committee, if only for that reason. I think that would be great. What can nurses and other healthcare professionals do at their institution if they do not have a Bioethics committee? How can they bring one there? How can they start one?

[27:42] Sandra: Yeah, good question. There are, there are some really clear strategies for that, and various agencies, including the American Society of Bioethics and Humanities, have some information about that. So that is www.asbh.org. But, you know, it used to be that the Joint Commission mandated Bioethics committees, now, they make a recommendation, just recently changed their standard to say that there needs to be a mechanism for patients and families and staff to resolve conflicts. They're not saying it has to be in this particular structure, that it has been traditionally established with a committee. And, you know, the things that are in place in most institutions that have been around a while, but it's still a recommendation by them and essentially a requirement. And so there are some, there is some information with the joint commission on how to start one and how to, you know, develop one. But basically, you know, it's, I think it takes just, you know, an understanding of a little bit of research on what our bioethics committees, what do they do? It's all available in those resources I mentioned and others, and then bringing together the right folks, you know, the people that care about these issues that, and in a blend, certainly a blend of clinical people, bedside focused physicians, nurses, administrative, you know, people with illegal notions, mentality, risk management folks, and, you know, administrative level people who can help policy development and implementation right across settings. I think one, you know, I just say an example, like, of one way that we thought carefully in our bioethics committee discussion about how we support the timely and appropriate assessment of a patient's capacity. Right. It's important that we do that. There are evidence-based practices for doing that. So we realize that's important. We think about that. There may be some ways we can strengthen our process around that. Where are we, how are we functioning in the con, in the, you know, in this process? Right. And could we offer anything to our team to help strengthen it or inform them of updates or changes or that sort of thing?

[29:49] Michelle: There were a couple of terms, well, probably a lot of terms, that when I started on the committee that I wasn't familiar with. So being a pediatric and neonatal nurse my entire career, I had never heard of a POLST.

[30:03] Sandra: Okay.

[30:04] Michelle: Yeah, I had heard of, like, advance directives, you know, from myself being a patient. However, we didn't have advance directives for neonates or pediatric patients. So that was all new to me. But can you just briefly explain those?

[30:20] Sandra: Sure. And they are important to the Bioethics process because if we have conflict or if we have need for clarity about who are the decision-makers, those documents often guide us. Right. And help us establish care plans for going forward. So an advance healthcare directive. Advance healthcare, sometimes people say advanced with a d. It's not a d. I have to always remind them of that. So advance Healthcare directive is really an advance care planning document that anyone can complete over the age of 18. That allows you to do really two important things, and that is to establish a surrogate, someone who would speak on your behalf if you were unable to speak for yourself at any point, and then also to state some preferences you would have for your healthcare what you would want or not want. Right. The state of California has a standardized document that we have available on our intranet that we and the Joint Commission does require that we ask everyone upon admission, do you have an advanced directive? If not, would you like information about one? There's a lot of support for the development of that. And then we support people in completing them if they wish to, during their healthcare stay or later. And once done, it's then scanned into our medical records so that anytime the person comes into the hospital, we can quickly say, okay, these are the people they designated, right? People can also develop their advance care plans. Even if they don't fill out the document, they can verbally state their preferences to their attending physician upon admission. And those are and their surrogates a preference. And that's good for 60 days or the duration of the admission. So you don't have to complete a paper. But the benefit of having the paper completed is that if you're unable to speak on your own behalf, we have ready information about who speaks for you. People can change that at any time. They can modify it at any time. So it's not permanent or edged in stone. And the POLST is kind of a complement to that. And it's, POLST stands for physician order for life-sustaining treatment. It's a bright pink document, always pink if you have the official document here at the hospital. And it's an order, a physician's order that allows people to specify their wishes in three important areas, resuscitation status, type of treatment they wish to receive. And the third area is whether or not they would elect to have artificial nutrition, should it be at some point indicated. It's a complex process. Dr. Howard, who just came in, speaks about the POLST with patients in the best way I've ever seen anyone do it. And it's not really something that every person has to fill out. It's really more for people with serious illnesses who are likely to move between care systems. Right? So if you say you leave the hospital and you're going home, right, and you're in an ambulance, the POLST is a way of making it clear to even the ambulance transport folks what your preferences are. And it's an order so they can follow it. Right. In the absence of that order, they would have to offer full treatment. And that wasn't what you wanted, right? If you didn't want to be resuscitated, you're in a different position. So it just helps clarify and tighten it up. And you're here now, so you can say it better than me, probably. Hi, Dr. Howard.

[33:20] Michelle: Dr. Howard's here.

[33:22] Dr. Howard: So sorry I'm very, very late.

[33:25] Michelle: That's okay. Better leave than never. So Sandra has brought me all up to speed on everything, but I want to know a little bit about you. So why don't you introduce yourself?

[33:35] Dr. Howard: Dr. Ryan Howard, the medical director of both the hospice service and then also the palliative medicine service. I'm board-certified in family medicine, my first specialty of medicine I did a residency in at the University of Arizona. But then I went on to do advanced training and a fellowship of Hospice and palliative Medicine.

[34:01] Michelle: How did you get involved in that? Like, what was the pull for you? What was the attraction?

[34:05] Dr. Howard: A few things. I kind of feel like everything in life has been a bit of a stepping stone for me. I was an EMT in undergrad, so I was running, you know, I got trained in emergency medical treatment and ran around then in between undergrad and medical school on an ambulance in the northern part of Florida. Saw a lot of bad outcomes. Frankly, very uncomfortable. Borderline like unnecessary, because it's. We know it's not going to have a good outcome. Traumatic, uncomfortable things happen. Right. And so I think that was part of the reason why when I was training in family medicine in the hospital, and I would see people that had chronically progressive and irreversible disease processes, I was more than happy to go talk to them about what they would want, what are their wishes. And so I think that was, again, foundational during residency. And so then when I actually became a hospitalist and was taking care of patients here, it was almost just like a natural progression that I should continue having those conversations. There were very frequently major factors in how we move forward with caring for that person. Right. You hate to say like a game changer, but it was very significant after you had that conversation that it was going to change the trajectory of how we care for them. And it was very consistent with what they wanted, which was a beautiful thing, I think, engaging people on these topics. None of us are assuming what they want. We actually meet them where they're at, find out what's most important to them, and then try to facilitate care that helps them achieve those, you know, those goals.

[35:56] Michelle: I feel like you both are very special people in that you seem fearless about having those difficult conversations. I think a lot of people would really shy away from that. And so it's like, where does that come from? You know? How do you become such a strong patient advocate? I feel like nurses are very strong patient advocates, but I feel like sometimes in that realm of the direct confrontation about what do you want to happen to your life? You know, I think we kind of pull back a lot, and so I respect that in both of you. And where do you think that comes from?

[36:39] Dr. Howard: I would say trying to keep everything as patient-centered as possible. You know, the fact of the matter is there are, everybody is different. And when you think about patient-centered care, it needs to be individualized. And so when I approach, it's always with curiosity, humility, like totally acknowledging that I don't know what they're going to say and what they're actually going to want. And sometimes I'm surprised by what they want. And sometimes it seems consistent with what I'd heard from various other people. But I think when I approach, I'm not fearful because my heart is truly in it to hear from them about what's most important. And, you know, how if they had all the control over what comes next, what would they want? How would they envision that going? And so it feels low stress to me because I think because my heart is truly just wanting to know what do they want. And then knowing I can pivot and provide and go down whichever path they choose sort of thing. So it feels right.

[37:52] Michelle: Where do you think that comes from?

[37:54] Sandra: You might want to cut this out, but we've talked about this old souls, right? We both kind of grew up with mothers who were hairdressers, and we eavesdropped on the conversations in the beauty shop. And you hear everything there, right? And you learned that people can talk about everything, you know, and that there's. There's safety in that. There's, you know, warmth and love and care in that. And I think for me that just, you know, I just. I believe that to be true, that no matter what we have to talk about, if we talk about it, as you said, Dr. Howard, with an open heart and a genuine desire to really understand at the deepest level what's most important to these people we're talking to. Right. And then to do our best to try to help them achieve that or understand what the limits to that might be. Right. You know, I think, Ryan, I just think that it's an old soul, open heart kind of thing. And this is an old soul right here. I'm so proud and honored to...

[38:54] Dr. Howard: Let the record say she was talking about me and not Michelle.

[38:56] Sandra: Yeah.

[38:56] Dr. Howard: Yeah.

[38:57] Sandra: She's talking about both of you.

[38:59] Michelle: That's so true. Is that a skill that you think can be honed if somebody doesn't have that skill, is that something that they can work on to have those difficult conversations?

[39:12] Sandra: I think so. I think a person has to first recognize they need to grow in that area and not think that they are doing it well unless they really have evidence that says they are. I think what's really been fascinating to me in the palliative medicine field over the last 10-15 years is that communication has become much more of an evidence-based practice. Right. There are people who study the words to be used and the ways to use them to affect the most positive outcome for patients and families, allowing them to feel most understood, most heard, and most clear about their preferences. So if a person's willing to invest in that time, the time and receive feedback from others that says, you know, and that's a big part of the fellowship training program. Right. And the certification processes for social workers and others in the palliative medicine field is a big process, getting feedback from others on the effectiveness of your communication. We often think of communication in palliative medicine as our primary procedure, one of the primary things we do, in addition, of course, to symptom management and those important things. So I think people have to say, I want to do it well, and I'm willing to study to do it well and learn and observe and share experiences with others to do it well.

[40:30] Michelle: How do you think working in this field has influenced you in terms of your own wishes for a good death, your family, you know, advice that you would give to your family members or loved ones about be sure and have an advance directive?

[40:51] Dr. Howard: Write it down.

[40:52] Michelle: Yeah. How has that influenced both of you?

[40:56] Dr. Howard: I think I have had this conversation a lot with family, and I really encourage folks to write that down and then proceed to distribute it to the local medical centers that you might be taken to, because, you know, we engage with a lot of different families, and there's variable degrees sometimes, of acceptance or understanding about what the patient would want. And I. I know that can be a huge burden on a loved one's shoulders, you know, or several loved ones. And. And so, you know, I find it heartwarming when I see an advanced record that actually even states, I don't want the burdens of these decisions to be made by my family or cause any guilt or shame or strife amongst the, you know, and I'm just like, how well worded, you know, like, what a wonderful thing to sign, you know, and make known. So I think when it comes to, you know, communicating my own wishes for what I would find to be acceptable for my future care plan or quality of life, you know, or what I talk to families, my own family about, it's. It's really just encouraging and trying to empower them to know that this is worth doing. And then it's. It's especially worth doing as long as you make sure it gets on file at your doctor's office, at your kind of local hospitals that you might be taken to.

[42:20] Michelle: Yeah.

[42:20] Dr. Howard: It sits in a drawer or in a locked. Yeah, you know, locked file. Right.

[42:26] Michelle: No good.

[42:26] Dr. Howard: It's no good at all. It's worked.

[42:28] Michelle: So we can't just tattoo on our chest, DNR? That's not acceptable?

[42:35] Sandra: I hear some nurses say they would like to do that.

[42:38] Michelle: Oh, so many. So many. Or like, if I come in and this doctor is working, please don't.

[42:43] Sandra: Yeah, stuff like that. That's really cool.

[42:49] Michelle: Okay.

[42:50] Dr. Howard: There are some interesting things that I sometimes show. I'm gonna have you, Michelle, look at my phone. And I'm not just showing off my wife and fur-child, but I am having you look at this because your face is not my face. Oh, yeah. Do you know about this little emergency tab down there?

[43:08] Michelle: Yeah.

[43:09] Dr. Howard: Medical ID?

[43:10] Michelle: I have it.

[43:11] Dr. Howard: Yours is filled out?

[43:12] Michelle: Yes, it is.

[43:13] Dr. Howard: Does it almost look like an advance directive? Where it tells you about who would be your surrogate decision-maker? What would be your code status?

[43:23] Michelle: Yeah, I will update. Yours is very, very detailed.

[43:28] Sandra: Okay.

[43:29] Michelle: I didn't know I had to put that much detail in.

[43:31] Dr. Howard: I just wrote it like a note, you know, like, if you want to know about my family history, it's right there. If you want to know about my social history, it's right there.

[43:40] Michelle: That's awesome. I will definitely update mine. So you guys handle a lot of really heavy, heavy things. And how do you manage that heaviness? Like, what do you do to kind of offload some of that?

[44:00] Dr. Howard: I like joking around a little bit. If the situation calls for it, I like to. I don't know. Sometimes patients are the funniest, you know, I mean, there's times when they share a story and you. And they're actually, they're just crying, laughing or, you know, like they're cutting up and I'm willing to go there too. And you don't have to be a total stick in the mud and expect everybody to cry in every situation or, you know, so I definitely try to, again, we call it, like, meeting them where they're at. You know, there's some situations in some rooms you come into, and it's like trying to be humorous and to cut up would be totally unprofessional and inappropriate. But other ones, I feel like it's totally unprofessional and inappropriate if you don't crack a smile or, you know, go along with the joke that clearly the whole family is enjoying, you know, and, like, be supportive of that.

[44:54] Michelle: The humor dynamic.

[44:56] Sandra: Yeah, for sure.

[44:58] Michelle: How about you, Sandra?

[45:00] Sandra: Well, you know, I've, in recent years, I've sort of developed gratitude practice and that's so helpful, I find, because, you know, we witness things that most people would do anything to avoid having to even think about, not, not to mention see and talk about. So I always, I'm grateful for that in the sense that I feel like I'm not going to be surprised no matter what happens in my life or the lives of the people I care about. It's going to be hard to surprise me because I've seen a lot of things that are, you know, would be unimaginable. But I always try to, you know, in, after a hard day, I think about sometimes I, you know, do mindfulness activities. Sometimes I pray for the people that I'm still worried about, and then in my own unique way, do that. And then I always think about, and what am I grateful for in the context of this you know, I think about these moms who have to let their children, you know, even their young adult children go, and I'm driving home fussing about this or that. I gotta pay this fee for him. And I think these mothers would give anything to have that be the problem, or the dads, you know? And that just brings me right to where I need to be. Not to diminish what, you know, other stresses might be at play, but just to recognize what really matters.

[46:15] Michelle: No, those gratitude practices are so important. Exactly like you said, you know, after some of the calls that I've been a part of with the multidisciplinary teams and hearing, you know, people's stories, I just hang up the phone and say thank you that my problems are so small and an offer of prayer for them, too, and, and also a prayer of thankfulness for the team, I see so much dedication in the team. I love being on the calls because every time Dr. Howard speaks, he says, this is Dr. Howard here. Yeah, Dr. Howard here. And it's so funny because I have your voice memorized, probably we all do. But it's just. No, it's a sign of respect. I love it. It's just like a sign of respect but every time I just chuckle inside. So I'm like, you say Dr. Howard here, so I had to tell you.

[47:15] Dr. Howard: That I just really love it.

[47:17] Sandra: Yeah.

[47:18] Michelle: Okay, so one of the last questions. How do you both stay up to date on all the emerging bioethics information out there?

[47:29] Dr. Howard: I feel like I probably don't, in all honesty, and I could do a lot better, but I'm thankful to have my, to be surrounded by an excellent colleague here. I'm pointing to Sandra, who I think is able to keep up, probably more with the bioethical issues in her daily life and practice and study. I do know that a lot of the basic framework of bioethics was combined into my fellowship. You know, palliative medicine. It's ingrained into that practice. By no means do I think that everybody who comes out of a palliative medicine fellowship is ready to be a healthcare like certified consultant and bioethicist. But I'm very thankful to Sandra because she usually keeps me pretty up to date on things, sharing a lot of primary literature and making sure that I'm in attendance at, you know, meetings and also the regional bioethics conference that's coming up soon.

[48:31] Sandra: Yeah. Yeah. So you're politely not calling me a nerd, but we do.

[48:35] Dr. Howard: I was waiting for her to call herself a nerd because we're total nerds.

[48:39] Sandra: Oh, yeah. Yeah. And I appreciate that about you, that we could just sort of, we have that interest, you know, one or the other of us is always paying attention to something important, to sharing it and offering it back. That's great that you have each other's back.

[48:53] Michelle: Well, if anyone in our audience wants to contact you, how do they find you? And can I put your email address in the link?

[49:02] Sandra: Yeah.

[49:02] Michelle: Okay.

[49:02] Sandra: Because I'm fine. Absolutely. Yeah.

[49:05] Dr. Howard: They're all published online and things anyway, so they're right there. If ever somebody in the audience felt like they needed a consult for palliative services, the best thing to do is ask the nurse, who can then make sure to get the message to the doctor. And same thing for Bioethics consultation. So if there's need or a perceived need, I think it's, we're just a phone call away. And again, nursing staff would connect with a doctor who is in charge of their loved one's care and could engage the Bioethics committee that way.

[49:40] Michelle: Yeah, I think you guys have made it very easy to access your services and also getting the word out on what you do, like what is the Bioethics committee and making it not so scary. Like, oh, this is just a bunch of stuffy people that sit in a room talk about death all day. Yeah. So you guys have really, really made a lot of strides on that.

[50:04] Sandra: That's great. Thank you.

[50:06] Michelle: Well, I'm so happy that we got to talk today. Thank you so much. Thank you so much for coming, Dr. Howard.

[50:12] Dr. Howard: No, I'm so sorry I was late as well. And your patience is very much appreciated because I wanted to be a part of this. So thank you, Michelle, for making it possible.

[50:21] Michelle: I'm so glad. Well, now you get to be part of the fun. So at the end of my episodes, I do this thing called the five-minute snippet.

[50:31] Dr. Howard: Okay.

[50:31] Michelle: And it's just five minutes of fun. And because there are two of you today, we're doing like a version of the Newlywed Game. Oh, how well do you know each other? As it's all, it's all like there's no R-rated stuff.

[50:51] Sandra: Okay. What we can do here?

[50:53] Michelle: So we're going to start with Sandra. Sandra, what is one of Dr. Howard's pet peeves?

[51:40] Dr. Howard: Oh, one of them.

[51:43] Sandra: Yeah, just one. Give me the top five, very loud noises.

[51:48] Dr. Howard: Oh, I thought you were going to say that.

[51:50] Sandra: And too many emails.

[51:52] Michelle: Too many emails.

[51:53] Dr. Howard: Easily distracted by noises in the office. Yeah, yeah.

[51:57] Michelle: And is this your office?

[51:58] Dr. Howard: Primarily, I come over here to get away from the noise in the other office.

[52:02] Michelle: Well, I'll tell you, the AC would drive me nuts.

[52:04] Dr. Howard: I've gotten used to that. It's kind of like a white sound, but I was worried about it with the recording.

[52:10] Michelle: It'll be fine.

[52:11] Sandra: And one thing I learned about him very early is if he, and I tease him about this, he has like wolf hearing. He can hear. I could be on my phone and he can hear what the person is saying on the line.

[52:23] Dr. Howard: It's true.

[52:26] Sandra: I don't know where it comes from, but it's incredible.

[52:29] Michelle: Okay, Dr. Howard, whose office is tidier? We're in your office. Right?

[52:38] Dr. Howard: This is like two out.

[52:40] Michelle: There are no visuals. This is pretty.

[52:42] Dr. Howard: Are you saying me or Sandra? Yeah, me.

[52:46] Sandra: His is only messy because I brought stuff in here.

[52:52] Dr. Howard: Give me another 15 years.

[52:54] Sandra: That's right. You'll accumulate.

[52:57] Michelle: Okay, Sandra, Dr. Howard has the day off. How does he spend it?

[53:02] Dr. Howard: She'll get this.

[53:03] Sandra: He's up in the hills tearing it up with his, what is that thing you drive?

[53:09] Dr. Howard: Mini excavator?

[53:11] Sandra: Mini excavator.

[53:12] Michelle: Really?

[53:12] Dr. Howard: Chainsaws.

[53:13] Michelle: Wow.

[53:14] Dr. Howard: Bonfires.

[53:15] Sandra: I stopped worrying about him a long time ago because I figured he knows what he's doing. But he's very into that.

[53:22] Michelle: You like to dig things up.

[53:24] Dr. Howard: Yeah. We have a little bit of property in Three Rivers and I'm out there roughing it and having a good time and it's very centering.

[53:34] Michelle: Yeah, that probably helps with all the heaviness of stuff too.

[53:38] Dr. Howard: It definitely helps.

[53:38] Sandra: And I'm glad. It's certainly an improvement upon surfing by yourself, which he used to do. And that worries me.

[53:45] Dr. Howard: Great white shark attacks. Yeah, I think I agree with you.

[53:48] Michelle: That's funny. Okay, let's see. Is it your turn? Okay. What would be Sandra's last meal?

[53:55] Sandra: No.

[53:58] Dr. Howard: Oh, Sandra, we've never discussed this. I have a joke.

[54:05] Michelle: Okay.

[54:06] Dr. Howard: She's always telling me, I wish he drank. You need a drink.

[54:16] Michelle: What would be her last cocktail?

[54:18] Dr. Howard: I was going to say Diet Pepsi.

[54:19] Sandra: Yeah, that's probably it. A lot of that. I would love to have one of your vegan meals.

[54:28] Dr. Howard: I was gonna say something more like chicken.

[54:32] Sandra: Yeah. Yeah.

[54:34] Dr. Howard: I don't know.

[54:34] Sandra: That's probably it.

[54:35] Dr. Howard: I don't know.

[54:36] Michelle: A nice dish from the Vintage Press?

[54:41] Sandra: That's it? Yeah, that would be it. That would be it.

[54:44] Michelle: Okay. Sandra, what keeps Dr. Howard up at night?

[54:48] Sandra: Oh, I think.

[54:50] Dr. Howard: Supposed to be fun.

[54:51] Sandra: Yeah. Yeah, yeah, yeah. Right. Wow. That part, seriously, what I appreciate about him is his integrity. So when he feels like something is not right, something is not. We're not doing our best in a particular area or we're falling short in meeting the needs of a particular situation, that sticks with you, worries you, keeps you awake and usually you come back the next day with a good suggestion solution about how to make it better.

[55:17] Dr. Howard: That's a cool guy. I try to be very solution-focused. You know, it's like if there's a problem you're there to solve it. So then I do sometimes take home those just difficult situations and try to think through how can we make this better a little better. Tomorrow may not exactly fix it.

[55:33] Sandra: All together but yeah.

[55:34] Michelle: Okay. Dr. Howard, what are you and Sandra most likely to argue about?

[55:41] Dr. Howard: She's laughing her head off. She's got something that immediately came into play. Most likely to argue?

[55:48] Sandra: Yeah.

[55:49] Dr. Howard: Well honestly, I think bioethical issues at times, you know, because that's the whole point is to come together in good faith and get like very inquisitive. Right. And there's not always a right answer. I think that the hardest thing about Bioethics and also the most interesting and sometimes fun thing is that two people can have the exact opposite perspective and kind of be right in their own way. And so I think the only time we get into it is when there's not a right answer and we're just trying to work through the list of possible right answers and then pick a course. And so that's what I would say.

[56:30] Sandra: I think that's exactly right. That's great.

[56:34] Michelle: Sandra, if Dr. Howard was on Who Wants to be a Millionaire,  who would be his phone-a-friend?

[56:42] Sandra: Good question. Your wife, she would say lovely.

[56:49] Dr. Howard: And we're very, we have our different expertise, which is a good thing.

[56:53] Sandra: Yeah.

[56:53] Dr. Howard: And so yeah, I would call her because she would know.

[56:56] Sandra: She definitely.

[56:57] Michelle: That's great. Everybody needs one, right?

[56:59] Sandra: Yeah.

[57:00] Dr. Howard: If I don't know it, she'll know it.

[57:01] Sandra: You bet.

[57:02] Dr. Howard: Yeah.

[57:02] Michelle: All right, last question. Sandra. Or is it Sandra's turn?

[57:07] Dr. Howard: I think you gotta ask me about her.

[57:08] Michelle: Yes.

[57:09] Sandra: Okay.

[57:09] Michelle: What is.

[57:10] Dr. Howard: You're leading by one.

[57:12] Sandra: Good. I like to win.

[57:14] Dr. Howard: Oh, score.

[57:15] Sandra: Oh, we're a little competitive. The two of us are competitive.

[57:18] Dr. Howard: That would be the other thing. Christmas, holiday, party games. That's what we get into it.

[57:23] Sandra: Oh man. Those are, those are ambitions.

[57:26] Michelle: Okay. What is Sandra's superpower?

[57:33] Dr. Howard: I mean her, I would say her heart, her willingness to go the distance no matter what the task and not give up until it's done. And she's a workaholic if I might say.

[57:46] Sandra: Yeah.

[57:46] Dr. Howard: I look over lovingly.

[57:48] Sandra: Yes, that's right.

[57:50] Dr. Howard: Yeah. She's willing to go the distance. It's like heroic at times. Or heroin. Female hero. No.

[57:57] Sandra: Yeah. Thank you. That's very sweet.

[58:00] Michelle: And Sandra, what is Dr. Howard's superpower?

[58:04] Sandra: He is one of the truly most compassionate people I know, and a most compassionate physician, particularly, that I know. And he communicates in a remarkable way, like, and his ability to read the room. We often talk about, you know, how critically important that is and the situations that we deal with. He's just magnificent at that and kind, you know, just deeply kind.

[58:34] Dr. Howard: Thank you so much.

[58:35] Sandra: I appreciate that about you.

[58:38] Dr. Howard: We feel the same about each other.

[58:40] Michelle: What a great team you guys are. Thank you so much for joining me today.

[58:44] Sandra: Thank you. It's been fun.

[58:47] Michelle: All right, have a good rest of your day.

[58:50] Sandra: You, too.

[58:50] Dr. Howard: Bye now.

[58:51] Sandra: Thanks.