 the panel. Dr. Agarwal, it's the director of the Georetic Fellowship Program, Banner University Medical Center in Phoenix. He's a great mentor. He actually takes care of some of my residents out there at Banner and we welcome him here. Thank you. Are there any questions from the audience? Hi, my name is Sharon. I'm a PA. I work in western or the western valley in the Goodyear area. So I know Dr. Castro very well. So my question is to the last talk. So I just a case comes to mind where we had that you know you have the shared decision-making. The patient's very clear. The patient I'm thinking of in particular has advanced heart failure. He's not tolerating guidelines directed in medical therapy because of hypotension. He also has multiple sclerosis and he's been bedbound for years. And he's in that quasi, yes I have advanced heart failure but I'm quasi stable. I don't have cardiogenic shock but he doesn't really want to do anything. He wants to go home. He was on hospice but he has a wife, actually an ex-wife who is his power of attorney who he lets make all the decision even though he's very capable of making decision and he is very clear and every time I see him he just wants to go home and go back on hospice but she wants everything done. How do you? So this is a very common scenario and this is where we really have to deploy those interpersonal negotiation skills and therapeutic communication and really outlining for the spouse the patient's wishes, the patient's desires, what the patient wants and then also outline for the spouse. This is a conversation we have in the advanced heart failure clinic all the time. When we set up patients for palliative care and for hospice it is as much for the patient as it is for their caregiver because patients like to say sometimes to let's cross that bridge when we come to it and sometimes we have to say we are at the bridge we need to make these decisions and so that's where you deploy interpersonal negotiation and you really have to be authentic and have an open conversation with the patient and their family member about the trajectory of the care, where you expected to go, where you've seen it go in the past and how that might look specifically in this situation and if you're effective hopefully they understand and they go along with the patient's plan. Sometimes that doesn't happen. Sometimes they say I want everything and you end up with a patient who spends their last moments in the hospital in a terrible setting in a terrible excruciating situation and unfortunately we can't always prevent that. Sometimes I will enlist my colleagues from palliative to deploy therapeutic communication for me. If I really think the conversation is not going well I get another party involved to also have that conversation in the hopes that reinforcing it over time multiple times from multiple specialties will eventually make sense and I also remember that behavior comes from a place. So the spouse's behavior in trying to keep their partner alive can come from a place of anxiety, fear of abandonment, fear of loss and I try to address that with the patient too and make sure as much as we're caring for the patient and their needs we're also caring for that spouse and making sure they are getting all the support that they need to. That's a great question. So as a generation this is something we see all the time right like the patient is not the patient by himself it's a diet the patient and the caregiver right. In this situation the ex-wife is the caregiver for the patient. The concept that Dr. Doe explained she did really amazing work on that. If you have to think about life expectancy first this patient does he have life expectancy more than two years or one year considering that he has already lived more than one to two years and the disease the terminal disease itself I don't know the details of it. Let's say he's in the middle category right that's a patient priority scare category. The thing that we kind of jump into is what are your goals but I think a step before that is what are your values and I think maybe considering that with the patient and his family member would be important. An example of exploring values is John I see quite a few patients every day and when I speak with them there are certain values which are really important to them. An example would be some patients may feel health is really important to us. We want to know every single answer why is the symptom happening and find the reason for that. Some patients may feel that connecting with family and being at home is really important to them and some patients may feel that it's really important for them to be able to function go to church be able to go to their daughter's wedding. I know these values are all important to for all of us right but if I had to ask you and this is a tough one if I had to ask you to pick one most important one what would that be once we have done that prioritization of those values that can guide your conversation with the patient and the caregiver to move forward to identify goals make trade-offs identify the apprehensions they have just like the stepwise approach that was given to really guide them on what this treatment holds for them so that would be my approach there. Other questions? So I did I love that actually I did everything you said we got probably the care involved I for the wife explored what this would look like if we went down this road and I also explored like what were his symptoms like what is actually the most bothersome to you he doesn't have any shortness of breath he doesn't have any of these things so I and I approached advanced heart failure team to see you know if he were to come to you would he be a candidate for anything and the answer was no so we went back and she still had a very hard time accepting that but we're kind of at the point where we are doing what we can for him which is what she wanted to know that we were doing everything we could for him but I just because a lot of times the families don't want what the patients want and so I just kind of wanted to hear how you guys would approach it and it was very helpful thank you thank you and I have just a follow-up on that so sometimes we don't know what the what the anticipated benefits of therapy would be and in this case when someone who is advanced age multiple comorbidities so they feel bad for many different reasons and we'll just look at say cardiac amyloidosis now so heart failure and then you're looking at something like drug therapy which could be very involved particularly in terms of the finances and what it takes to to actually complete a course of therapy how does one approach that when you're kind of when you when there may be some uncertainty in what the outcome or what the expectations would be when you when you speak to the patients in that in that second second step there that that when you tell the patient what you what can be expected and and ask them if they want to participate what how do you deal with uncertainty that you may have as as a clinician in terms of what you can reasonably um ask the patient to anticipate if they do pursue therapy I'll start but it'll be a really quick pass to Nimit so honestly when we think about shared decision making we have to get to a place where we understand that we are co-collaborators and coming up with a treatment decision and plan and sometimes that involves trial and error and discussing openly this is what we think here the here's the data that I have here's what I think in context of you but we may not be right every single time and that's what makes it really challenging but it also adds a layer of humility between the patient and the clinician because we are working together to figure it out and that goes back to self-determination theory and being invested in treatment what you described there is exactly that middle group right you don't have the answer and he doesn't have the answer the first group is the group where someone has a life extended more than 10 years they may be eight years old but they still have a life extended more than 10 years they are fit they're not frail they are climbing mount Everest you would apply guideline based therapy on that patient right that's an easy one right and then you have the extreme where life extended less than one to two years and you would really not offer treatment in that case because you know that the benefit from that treatment will not occur during the lifetime right so putting in treatment that would not be beneficial so you would recommend a palliative supportive care for that patient right the beauty of the middle group is that there is it's fraught with uncertainty and you don't have an answer right and in that situation really that is why the patient priorities come in and that is why you follow that to the three-step approach where you first identify the values if you have not identified the values and you go to the goals you're gonna be in trouble because the goals are really on a day-to-day basis right the values of people don't usually change if you know the values then you can connect those goals the trade-offs that they have to make and keep on aligning them back to the values and that is a step we commonly miss thank you are there other questions from the group I have a question here just a quick comment I think it's very hard to really know where the patient sits in terms of life expectancy like we all have heard about you know different models and prediction and and you know it's just it's really hard to say that this patient is going to die in the next one to two years and I think we could do better like we could use those prediction models you know actually put them in our note but I think as clinicians are sort of a bias that okay this patient has an opportunity and so you know I think it's it's harder than it than it looks to to bucket those patients in that final category absolutely I have a question for Dr. Singh regarding the dashboard so what how has been the perception of the clinicians when when this is presented to them do they see this as a useful tool or is this just another impediment to their day and to their daily care how how has that been incorporated because I'm sure that they have other dashboards and projects that they that they work with as well how how do they value it or what what what perceptions have you had so far I think a lot of the feedback so far is there's a little bit of a learning curve in terms of operating the dashboard getting getting on board with kind of how the workflow is going to go I can speak for personal experience myself that it took me a little bit of time to get used to it but once I was able to play around figure out what workflow adaptations that I need needed to make for myself it's pretty streamlined pretty well now we haven't necessarily spread it too much into or disseminated too much into other clinics other than the clinicians that are helping to work develop the dashboard so far so we're waiting to see what other people think but there is a little bit of a learning curve that's associated thank you just with respect to the dashboard congratulations on a great amount of work in it and you know a great product so far the one thing I would say is to the point that was just sort of made you know when we put an iPad or something like that in front of like a two-year-old they can figure out how to use it right pretty quickly I think you know even in my own dashboard work part of this is is not just what's the information but really how do you distill it down so that it's an actual piece of information that doesn't require you to actually understand anything that it just kind of tells you what you need and that that really is the challenge I think so one part of dashboard sort of development is is the technical side of stuff right but what I found in my work is that there's a design element too and this is kind of the the apple approach to things which is how much does the person actually need to see in order to make a change or to you know for them for themselves on behalf of the patient or for a patient to even see themselves right so I think that piece I would I would echo what what you said earlier is that you know the intuitiveness of this is really sort of going to drive how much people actually uptake it in clinical practice and I think unfortunately everybody in the world has their own dashboard or their own wearable that they want everybody else to pay attention to but the results for any individual person is that there's just the deluge of data that we don't really know exactly how to integrate things so I think that's a really important piece I think I would add to that that you can have an incredible tool but if you don't have a health system where the infrastructure supports implementing the data from the tool then you're going to have a real problem so when you implement these dashboards you really have to make sure that you have a strong multidisciplinary team you have a strong infrastructure present and it's able to support all of the data that you're receiving and take the patient through the entire care cycle it's more than just making the diagnosis it's ensuring that they are able to seamlessly transition through the entire care cycle. Great thank you let me just poll the audience can you just raise your hand if you use dashboards currently in your in your daily management of patients how many of you have them so just the front row okay so I think that this is a trend that is going to be coming and it's going to certainly be more more available to all of us to use and this is this is how these these tools are generated and it's very important that there's feedback both on both ways. Let me just ask I think we're getting a little bit short on time are there any other questions that we have for the for the panelists well thank you