 But as I said, the purpose of my being here today is to present the 2014 McLean Center Prize to Dr. Susan Toll, who is the Cornelia Hayes Stevens Chair in Healthcare Ethics and Professor of Medicine at Oregon Health and Sciences University, OHSU. Now the McLean Prize is awarded annually to an individual whose scholarly and policy contributions have changed the direction of clinical medical ethics and have improved the health care and outcomes of patients. The prize of $50,000 is one of the largest, if not the largest medical ethics prize in the world. I should quickly mention that Dr. Toll has requested that the prize award of $50,000 will be given not to her personally but to the Center for Ethics in health care that she directs. So that's a... Susan received her MD from OHSU and completed internal medicine residency at the University of California, San Diego. She then was recruited back to OHSU to join the Division of General Internal Medicine and Geriatrics and in 1988 and 1989 she trained in the McLean Center as an ethics fellow in the program. This was one of the... This was actually the first group of ethics fellows that Mark directed. So Susan has a number of very interesting recollections and remembrances of those days. They're very interesting to read about. She has written to us about them. The origin of her coming here was that Mark actually approached her after she presented a paper at the Society for General Internal Medicine and he invited her and she agreed to spend a year at the McLean Center to take a fellowship in the recently funded Pew Kaiser Mid-Career Leadership Award which was aimed at training future leaders in clinical medical ethics. Now Mark had at the time very ambitious and I would have even thought maybe unrealistic expectations of the fellows and he let's say encouraged them very strongly but under his guidance things really worked very well and the initial group was John Lantos, Steve Miles, Carol Stocking, Steve Tollman and Dudley Goldblatt and of course Susan and the fellowship class learned ethics, philosophy, law, research methods, the practical aspects necessary to fund and direct an ethics program and during that year Susan published nine papers and she secured three grants. So really remarkable. She then left Chicago on June 30th, 1989 and returned to Oregon and she opened the doors of the Oregon Center for Ethics and Healthcare the following day on July 1st, 1989. So since that time the Oregon Center for Ethics and Healthcare has trained 67 fellows, remarkable accomplishment and has raised three endowed chairs. More than any other U.S. ethics program Dr. Toll has been entrepreneurial in mobilizing widespread community support to support her center's growth and recently the 25th anniversary celebration of the center was held at the Portland Art Museum and more than 300 supporters attended and at the celebration the OHSU leadership announced a new $15 million campaign for the ethics center so that's a terrific accomplishment. Over the past two decades Dr. Toll has remained an active clinician and has published more than 150 peer reviewed papers and has become a nationally recognized leader in promoting system changes to support more respectful and compassionate care of die. Her work has driven health policy changes. She's best known for her role in developing and disseminating the physician orders for life sustaining treatment program or PULST which is now in use or in development in 44 states including Illinois. And we learned the other night that it's in other countries as well and they're even introducing it in China. PULST is an Oregon creation that in 1991 began under Susan's leadership at the OHSU Center for Ethics and the groundbreaking program allows seriously ill patients who are nearing the end of life to make clear what treatment they want and do not want and where they want to be treated at the home or in the hospital. Based on research done by Susan and her team and published this July in the Journal of the American Geriatric Society PULST orders work and patients receive the care they want in the care setting that they choose. So for her many outstanding accomplishments as a scholar, as a national leader in clinical ethics, an entrepreneurial builder of a distinguished ethics center and national founder and leader of the PULST program that is improving end of life care for all Americans. I'm really delighted to present this award to Susan Tull and the 2014 McLean Center Prize which is now a wonderful tradition and you are maintaining the highest standards and the highest quality of that prize. So congratulations. It's a pleasure and a privilege. I came from a city on the northern Oregon coast at town of 300. To be here and receiving the McLean Prize meant I had some pretty powerful mentors. We all know what a mentor Mark Siegler can be. He can be awesome and inspiring and open doors of opportunities and he can push you very hard. Now when they talked about the publication they forgot the story about the clipboard Mark because every three weeks Mark would come and stand over my desk and say what do you have to add to the center's CV. He told all of us that we were supposed to have 10 papers and two grants. I was really poor and I moved one of the papers over to one of the grants but you are awesome and an inspiration. There are other people here who also served as amazing mentors and deadly goldblad and what we have done in states and helping them with their regulations and statutes wouldn't have been possible without what she taught us. But someone else who often doesn't get quite as much acclaim is Carol Stocking. Who taught me how to do research and how to improve the quality of the polls program in states all over the United States. And Carol taught many of the fellows and so many of us owe a great gratitude to you. You need to get another Carol Mark. You owe it to the current fellows. I would like in the next few minutes to share several things. One is fairly quickly where we've been and there's some lights and things happening for just a moment. It's kind of magical in the development where we are now in dissemination and expanding education and what it takes to actually make a system's transformation. And then to look at where are we going in the future. What will add further to true availability of recording, eliciting, honoring patient wishes all across this country and some of the amazing fellows out of this program are carrying this around the world. Why was polls developed? Because advanced directives were not enough. Advanced directives serve a couple of really wonderful purposes and they are important and useful. But they are of little use to emergency medical personnel in the field. The net result is that people who don't wish hospitalization often cannot carry their wishes from one setting of care to another. We have a need to take a program that works well and reach a very broad public. One of the things I've never shared in this conference before is the challenge of doing public education and how that can be done and be done well and reach a large amount of people because written materials often are not enough, particularly for those with lower levels of health literacy. The freedom to say how much medical care you want when you are very sick. But if you are very sick, you may not be able to speak for yourself. Here is one thing you and your doctor can do to help make sure your wishes are followed. A post is a form your doctor can fill out for you. It is actually your doctor's orders. It tells other people how much medical care you want if an emergency happened today. How do you know if a post form is for you? It can help if you have a serious medical problem that can't be fixed. It is for people who are getting worse and worse or weaker and weaker. Now your health and your wishes can change. You and your doctor can change your post form at any time. Doctors sometimes use confusing words. This video is to help you understand your choices so your doctor knows what you want. If you don't know what all the words mean, that's okay. Just ask your health care team to tell you more. The post form has three parts. Let's start with the middle part. It asks how much medical care you want if you got much sicker. You'll choose between three options. One option is comfort measures only. This means you only want treatments that help keep you comfortable where you live. It means you don't want to go back to the hospital even if you get sicker. This choice allows death to happen naturally. You'd be taken to a hospital only if you can't be kept comfortable where you live. Another option is basic treatment. Choosing basic treatment on a post form means that you do want to go to the hospital. You also do want things like IV medicines, antibiotics and fluids, but you do not want machines to do the breathing for you. If you do also want breathing machines and intensive care, you'd choose full treatment on the post form. That's the third option in the middle part of the form. Now let's talk about the bottom part of the post form. This choice is about nutrition. It asks if you want a tube in your stomach if you are too sick to eat. This tube could stay in your stomach forever. Finally, let's talk about the top part of the post form. It asks if you want CPR if your heart stops beating. You've seen CPR on TV. That's when they push on your chest and put a breathing tube in you to try to bring you back to life. CPR is used because you have died. Your heart and lungs have stopped working. On a post form, you'll say yes or no to CPR. If you choose no CPR, this is sometimes called a DNR order. Remember, the post form helps you get the medical care you want or don't want if you got much sicker today. We hope this video helps you talk with your doctor and decide together if this is the right time to fill out the post form. Is what the post program looked like in 2007. You'll note West Virginia where Woody Moss, one of the fellows from the McLean Center, is leading the program in West Virginia. How does dissemination happen? You can look at this group. You can look at fellows at the McLean Conference and know that they are an important part of dissemination. People like Julie Goldstein and her team here in Illinois are working hard to advance the post program here in Illinois. Art Darcy is working hard in Wisconsin. Many others have been involved in some aspect of advancing goals of care conversations because the post program is only as good as the conversation you are recording as medical orders. I am grateful to colleagues and I'm grateful to all of those who through their private philanthropy have helped advance the dissemination of the post program. One specific funder to acknowledge is the Retirement Research Foundation based here in Illinois who gave us another grant yesterday. This is what the national post program looked like in 2012, in 2013, and in 2014. Post is also being implemented in multiple countries and I learned here on this visit that my list of four was short, that in addition to Germany, Canada, Australia, and Singapore that post is being implemented in China. Let's look at one of the most powerful studies new since I had the privilege of being here last year and see why the post program may be a more effective tool than any tool developed thus far to assure that wishes to have or to limit treatment are respected. Eric Fromey is the first author on this study. It was published in July in JAGS. It looks at the association between the first two years of operation of the Oregon Post Registry, forms in that registry matched with death certificates from those who died in Oregon with their pulse forms so that we can look at what you ordered and where you died. We had 18,000 death certificates, about a third of those who died those two years. And what we found was this question seemed important to us. If you marked that you wanted to go back to the hospital, we would assume your odds of dying there would be much greater than if you said you wanted comfort measures only and wish to remain in the current setting of care. I had speculated that if we had perfect respect for wishes, we would have about 5% of people who wanted comfort measures only and didn't want to go back to the hospital, transferred to the hospital, because there are times we cannot manage comfort in the current setting of care. They will not stop seizing. They fell and broke a hip. That the something about the situation at home is such that the patient must be moved. So I didn't think the number should be zero. But I was amazed to see it was 6.4%. If you marked a post form, comfort measures only, the smallest bar of which there were over 11,000 matched with death certificates, the odds of death in the hospital, ultimately, all across the state, all settings of care, 6.4%. If you have no post form at all in my state, all comers, all ages, you have a 34% chance of death in the hospital. Oregon overall has a lower rate of in-hospital death than many states. If you said you wanted to go back to the hospital and have the easy things fixed but avoid intensive care and ventilator support, you had a 22% chance of dying in the hospital. Obviously, if you return there, complications may occur, and you may die there. But lower than the rate with no post form. If you said you wanted full treatment, that's not saying I would like to die in the hospital. It is saying I wish to continue to pursue treatments to extend my life, including ventilator support and intensive care. But the odds of dying in the hospital are higher than if you had no post form at all. Now, it's not random who completes a post form, and it's not random who chooses full treatment. And when one marks comfort measures only and decides that's the path where they want to follow, often there is a substantial infrastructure that goes with that, including the majority of these patients would have enrolled in hospice and have a backup plan of who to call in a crisis. So it's about more than the post form that would give you those numbers. Let's talk about the future. Where do we go from here? Assuming that a post form is associated with better respect for wishes than anything that's ever been developed. One of the things we'd like to do is share it more broadly. The Institute of Medicine published a report in September, and in recommendation 14 gave the first federal endorsement of the post program, encouraging states to develop and implement the physician orders for life sustaining treatment program in accordance with nationally standardized core requirements. Those are available on the website, and they talk about things like you cannot say, do not transfer, because sometimes the comfort could not be managed, and we would not be proud of the care that was given. Two innovations to share that are on the horizon. One is the development of an ePost system that is more easily shared nationally with colleagues across competing health systems than the smart phrases that some are developing within their health system, so that polls can be completed electronically. The other is developing registries and how those registries function and work. The first core element of a registry's success is very broad penetration in a post program. You don't build a registry and have the EMS call it when you have just 1,000 post forms in your state, because most of the time they'll call, and they won't have a post form, because you're not penetrated enough. Only two states are penetrated such that in any region in the Dartmouth Atlas that you might wish to choose. The majority of hospice programs in that region, long-term care facilities, and hospitals are using the post program in every single catchment region. And only two states have that now, Oregon and West Virginia. But others are developing quickly. My prediction would be that California will be next within the next two years. Once you reach that level, you're ready for a conversation about a registry. We recommend that only post forms be used because they're what's needed by EMS quickly in a time of crisis. The post program needs to remain completely voluntary. Completing a post form needs to be voluntary. And how you fill it out needs to be voluntary. Oregon has a mandate on the signer to submit a post form to the registry, solving problems with HIPAA and privacy protections about transfers of records, and allowing submission without an additional consent form to be signed. Patients can opt out of the registry and about one person in 500 does so. The registry is statewide. And it's incredibly helpful if it's integrated into a health care system, that it's not freestanding. There are a number of freestanding advanced directives to registries. They're infrequently used. The state of Washington had a registry for four years. It was completely independent of health care freestanding. And in a period of four years time, they had 4,000 total forms, including post forms and advanced directives. And the system simply was not looked at, called upon, or utilized in a consistent way. And it is no longer funded by the Washington legislature. So making sure that it's in home base. Ours is actually on the speed dial of EMS because it's inside the statewide trauma system. So that was already a 24-7 system and made a very efficient, from a cost perspective, but even more, it's already on the speed dial of EMS. We have a vision for the future about e-polls. It's a system that would allow inside initially OHSU's epic system, where we hope over the next couple of months to pilot test this, that we would be able to complete a post form, automatically submit to the registry, print a form, let the patient take it home. And in the third phase of development, be able to directly query the registry, learn that two weeks ago in a competing health system, a post form was completed and see what it looked like. That's a more advanced phase. And if that all happens, what we are developing would be able to be plugged in to the systems of any other epic record and eventually other systems than epic. We're working with National Epic to figure out how to integrate this. You can imagine the efficiencies of being able to pull in all the demographic data and other things and actually improve a problem we've had for many years, which is many forms are not dated. And if it's not dated, it's not valid. Epic would take care of that problem for us. So we'll keep you informed about the progress with that, but it's where we'd like to see things go in the future. There are a lot of places you can get any of the materials I've shared, whether it's maps, whether it's the video. The video was designed to be fifth grade education and for those who are primarily visual learners, we're happy to give it to you as a drop box and help in any way that works in dissemination. We have found that a number of people going out in home health hospice have loaded it on their computers and do education in the home, off their laptop. And have found that it's been well received in the next few months. We will create one also in Spanish. I would like to thank you for inviting me and I welcome the opportunity for questions. Thank you very much, yes. Hi Susan, Kristi Kirschner from Schwab Rehabilitation Hospital. A lot of my patients have chronic disabilities that are progressive, so neuromuscular diseases for instance, and this instrument is a beautiful instrument for people I think who are trimly ill or elderly, but for young patients who are trying to anticipate what they may or may not want, I find it really challenging, like the ventilator for instance. You know, a lot of my patients are very interested in non-invasive ventilation and they may want a middle ground. Yes. When you talk about staying in your own home, many of my patients, that's a very high priority, but you've got to have the resources and the caregivers to stay in the home. So I think the idea of the nuance and the time limited trials of treatment and making sure that those resources there support, people are a real challenge. You are correct about several very important things. First of all, POST was not designed for people with chronic stable disabilities. Those individuals eventually will be POST-eligible as they near the end of their lives. But they may have decades where POST is not appropriate for them and there are some misinterpretations just because people have limitations. The other thing you brought up was age. POST is not about your chronological age. It's about the chapter of your life. We have babies born dying who have POST forms. There aren't very many. It's less than 1% of the POST forms in the Oregon POST Registry are under age 18. It's about 600. But there are people for whom it is appropriate because they are progressing in their illness, nearing the end of their lives and are appropriate to have a form. But you're quite right. If you set limits and you want to stay at home, you can't just check this and say, okay, I've made a plan to stay at home, but I have no plan for anything else. So when the crisis comes, what am I gonna do? There needs to be infrastructure and we have built pretty good infrastructure in my state for many things. And one of them is we can usually get hospice into the home within 24 hours. So are we talking about then POST being appropriate for people who would qualify as terminally ill? We don't use the word terminally ill for a number of reasons in any of the POST literature. First, it often is linked to a six month prognosis or less. And we encourage healthcare professionals to reach out and offer this to patients for whom they would not be surprised if the patient died in the coming year. We don't make them sign an attestation about that. And there are certainly people with advanced frailty that are likely to live several years but feel quite strongly about not wanting ICU care. You probably noticed or maybe it went too quickly that CPAP-IPAP is under limited additional interventions so that intervention could be occurring for someone who did not wish to be intubated or have ICU care. This is a small point, but I think it's important when we're developing widespread educational materials to open caption for people who are deaf and hard of hearing just to keep the flexibility for people to access it. Absolutely, we certainly need all kinds of connections and we actually have special things on our forum for persons with disability and how that decision making process should go. And it's actually on the form itself. Thank you. September, I learned so much from you. I'm trying to follow in your footsteps here. Thanks for all of your work in this area. I've learned so much from you in fact because when I started doing the When We Are Ask program and filming all across the country, I used you as an example, you and Kugler Ross, right? Of just going out in the community and asking them as a part of the Oregon Health Care Plan development and those things. I wanted you to be aware because you'll be in California shortly that in several consultations that I've done in the broader community, not just hospital based, what I've discovered is that as people are being checked into SNF level care, skilled nursing facility care, that there is a specific demand that's being put in by sort of the corporate skilled nursing facility that there'd be a pulse form, which in a way kind of contradicts some of this dialogue here. Of course we want pulse forms to be used but literally having to figure out how to do that when someone is coming out of acute rehab or coming out of these sort of things. So it's really important to actually sit down with people and I have people read aloud or I read aloud to them exactly each of those things because Part B right now looks really good for that limited interventions but including some basic airway stuff that would not be there before and comfort care but it is being policy-ized in ways that are kind of knee-jerky and I think that that will eventually... Are you seeing that? Or you guys have built that in already in Oregon? We are well aware that when you have something that works well and has the eye-catching feature of a category of a large number of people choosing comfort measures only and avoiding a terminal admission at the hospital at the level of 6.4% that a lot of people start to love the Pulse program for more than a desire to respect patient wishes. If you follow me. I'm right with you. So the biggest problem Oregon is now having with the Pulse program is that it is overly loved. That a little is good, a lot is better. We have practices much to my dismay who think that you should hand this to everyone who's 65. We need to get out yet again with an educational intervention. This is for people with advanced illness and frailty. Well, if it works better than an advanced directive is the thinking then we should use it and the answer is no. An advanced directive is for a future health state. A Pulse form is for tonight found down. Now, if your health state is one that you would want to continue to explore what your prognosis would be because you don't have significant health conditions before setting limits then you're marked yes to everything on the Pulse form. And the one thing we've learned powerfully about advanced directives is that they lift a burden from those you love because it's written down what you want and don't want. So I'm gonna now hand the family a Pulse form that says do everything in the context of someone who's just had a massive stroke because someone thought it was a great idea two years ago to fill out a Pulse form saying I want everything. That will not lift a burden from that family. Right. The default of course is full treatment so I'm not sure what I accomplished by filling out the form and a healthy person saying you wanted everything. But we are seeing a lot of forces putting pressure on implementation including in California meeting there's a special place on the documentation and long-term care where only the state of California is doing this where they record whether or not you have a Pulse form. And there are some special challenges in California but they're moving fast and they probably will be developing a statewide registry. Yeah thank you. Hey Bill. Hi Susan I'm Bill Meadow from the University of Chicago. Susan tell me can you just expand a little more on how that EMS stuff works. I'm trying to figure it out. So somebody calls an ambulance and the ambulance then is hooked into the Pulse and the Pulse says we don't wanna come so the ambulance guys turn around and that's hard to believe. Here's our work. Frail elderly woman has a Pulse form and it says limited additional interventions and she collapses in the park. A friend says she has a Pulse form. They call online medical controls the trauma center and they are told what her orders are specifically limited interventions. If she were to arrest, she should be transported. So because of those orders she would be transported. So it depends on what the orders are, what they do. So we're gonna do two. So they would transport her to the hospital. In route she arrests, no CPR, no intubation. And when she arrives the information is already there for the emergency room department to make a plan. Should she be in extremis? Should she not go to the ICU? Those kinds of things. So it moves along all settings of care and slots the level you want. If this person is at home, we saw a scene at home. She's in intractable pain. A caregiver panics, calls 911 and it's the woman sipping the water at home. 60 pound weight loss, metastatic cancer. Then EMS would come in and would potentially even with online medical control give pain medication and would not transport the patient if the scene could be stabilized. If her comfort could not be managed they would move her for failure to control her suffering. Thanks. Julie Goldstein, Illinois Polst. So that's all I wanted to say. Even though it's a national crowd I know many of you are in Illinois and we're a very small getting toward fatigued group and we need always lots of help and are welcoming any of that. Christy in particular, we're having a hard time embracing the disability community although we have tried. So we welcome any of your help and any other communities that were not so obviously serving. You can reach me through Susan or Mark. You can also look at our local website which is postal.org, P-O-L-S-T-I-L.org and I just wanna thank you for your eloquence and your hard work and inspiring all of us. Thank you. I'm Todd Barrett from Cedar Sinai and LA. I was just wondering if there were any ways to assist community hospitals or hospital systems that are now joining together. For example, there's all these strange insurance products that are coming out in California now where there's now an ACO that's joining Cedar Sinai and UCLA for shared savings across the spectrum and we're now running into multiple situations where people are much more aggressive about getting advanced directives and pulse forms of both institutions because of this focus on end of life care and I'm filling out pulse forms at Cedars and then the patient has a hip fracture and gets admitted to UCLA and they fill out the forms and both of these systems need to be communicating with one another because they've had multiple negative outcomes where patients have been intubated at the end of life and they have a pulse form that we just don't know about at a hospital that we're now working closely with. On December 3rd, I will be in Sacramento working with your policy makers to explore the possibility of creating a statewide registry for the state of California, working with the California Health Care Foundation and with Judy Thomas, Judy Sikko Thomas, who is leading all of the coordinated efforts in California and linking in with Judy and the resources in your region and those who are leading the pulse program may be able to help but California is almost ready to launch a statewide registry and we're exploring funding with their legislature on December 3rd. In the meanwhile, has there been any work with Epic when now that there's some mechanisms to share information like on the last hospitalization in Epic, are there any hospitals that are currently sharing pulse forms via Epic that we could link into National Epic? We are in contract negotiations with National Epic and expect to have that resolved before the end of the year and this would allow better integration and access even without paying for a registry. If all of this comes to pass as we think it will, obviously this is all a pilot to make sure all of the pieces work as well as we think it should but there is tremendous interest in being better able to find these forms across settings. We are able to have people from Oregon who travel to other states have phone calls made to the registry and get forms. So we know things can be better integrated and effective and we've had over 2000 calls in a time of crisis just to the Oregon Post Registry in its relatively short history, guiding care in the field in addition to all the forms that are found on site. So a tremendous efforts can be made but California is poised to really move forward and National Epic is negotiating. Thank you, Susan. That was incredible what you've done over the years. So I was just a little surprised when you said that somebody had filled out a post form that said do everything and you would have done everything anyway so why fill out the form? And I would actually argue that that's a great result to have 100% including those who say do everything because sometimes families come in and it's so much easier for them to know what their loved ones wishes are. Granted wishes change and be great if people updated it but it would still be helpful I would think for families who really fret feeling sort of that the burden is on them because they really never did have these discussions. Well, Laney, you were quite right about the value of conversations and sometimes we make these a post or goals of care conversations an event and in an ideal world they're a step-wide process of actually having an advanced directive, someone getting sicker, revisiting the advanced directive, getting sicker, completing a post form, getting sicker yet, completing another post form often setting more limits over time and the more we're able to do that the easier it is on families who actually make it all the way down the path with us with guidance in the whole process. The less a family has had any clue what the individual wanted, no conversation, no written documents and the more they end up in the ICU making a decision to withdraw life sustaining treatment the more they suffer at two in the morning because they truly feel they made the decision it's on them, they pulled the plug as opposed to standing by what their loved one wanted and ensuring that their wishes and values were respected it's very different as far as burden. Right, no so my only point was conversation is the best but even without a conversation the fact that somebody filled out a form I think can be very useful for families and so I would actually argue we really should be going for 100% of the population filling out these forms. Thank you, I'm David Kososchek, I'm from the University of Iowa Hospitals and Clinics and we're in one of your developing states and we're trying mightily to do the education required in our hospital system to roll out post in a more meaningful substantial way that it currently is being used. One of the lively conversations we continue to have is the role post plays within an inpatient admission not even in the emergency room which is a different situation but for an inpatient we had a lively discussion about whether or not to scan a pre-existing post into Epic into their electronic medical record and if a post is created, signed during the inpatient admission all those different scenarios I'm wondering if you could say a few words about the intent, the purpose, how it relates to advanced directives which might also exist and goals of care, other decision-making guidance. Thank you and your state is moving forward rapidly. Post is designed to build on an advanced directive if one exists and to turn an advanced directive into action at the time it's now wanted. It's no longer a philosophical statement if I get in an accident and I'm in permanent coma I wouldn't want these things done. Maybe it's tonight, found out I would and would or would not want certain treatments. Now what we're up against in a situation like that is that people need to know better what their odds are at that, their current state of health and it's always designed for out of hospital. Post is an out of hospital document and so we focus very little in the video on section A of the post form and resuscitation. Why? What are the odds? Mark has rated it at 1% chance for a post-appropriate population, people with advanced illness and frailty of an out of hospital, unwitnessed arrest, successful resuscitation. So we're keeping in mind who should have a post form and the setting away from the hospital very different from a 50 year old who's just had a myocardial infarction is on telemetry and develops an abnormal heart rhythm. So we are encouraging post forms to guide the conversations as people are admitted to the hospital but some things change in the hospital including your prognosis for CPR. So that conversation does need to be evaluated as a starting place though, not zero. So we scan in all outside post forms we can find and we use them as a guide to decision making and we follow them as written in our regulations until or unless we have information to the contrary. So if they're all you have, they guide what you do. I wanna thank you, I wanna thank Mark. I wanna thank the Dean. I have two presentations for Susan. One is the certificate which reads the University of Chicago McLean Center for Clinical Medical Ethics awards Susan W. Toll, MD in the Oregon Health Sciences University Center for Ethics and Healthcare the McLean Center prize in Clinical Medical Ethics for contributions to clinical ethics, healthcare research and end of life care. Susan, congratulations. We hold that up again. The other minor presentation is in my book and it's a check made out as you requested to the Center for Healthcare and Ethics at Oregon for $50,000. Thank you.