Good afternoon everyone. Welcome to one of our caring conversations sponsored by the Amherst Senior Center. So this caring conversation is a series that we've designed to help people through a sort of a challenging time that we've come across with COVID and assisting us with planning and making sure that our wishes for our medical care end of life and just making sure that the people that matter to us know what our wishes are and that they are documented. So this pandemic has really focused our attention with the older adult community on this topic of preparing and planning and making sure that medical care decisions are in fact a set in place and that they're made known. So today's special wonderful guest is Dr. Erin Salvador. Dr. Salvador is a palliative care doctor and she has agreed to help us walk through some of the challenging decisions that individuals face with regard to making sure that the people who matter to us most know what our wishes are and making sure that we document them. The prior conversation was with with Dr. Rebecca Starr and she had a really made the great point of people have wishes but they don't always document their wishes. And so this is going to be an opportunity. It's going to be interactive. So if you are listening or you are participating make sure that you have a pen and paper with you because she's going to walk us through how to have the hard conversations of making sure that the people who matter to us know what matters to us. So I want to welcome Dr. Erin Salvador and I am going to shift her to being the host of this event and here we go. So hopefully this will work out. It's always new with this technology so thank you so much Erin and go ahead and introduce yourself and if you would share your background. Yeah sure. So thank you Mary Beth and thank you for having me here to be part of these conversations. It's really my pleasure and privilege to help people think about these things and thank you to the folks who have joined us this morning. I do want to let you know that it may sound a little intimidating that it's interactive and we're going to talk about these things but it's really going to be just personal things that you're writing down on your own. So nothing that you'll have to share. So I am a palliative care clinician so let me tell you a little bit about myself personally first. I grew up in Iowa and then now after many, many moves and different things in my career I live right here in Amherst in Echo Hill with my husband and my two teenage children. So and we've really enjoyed being here and it's such a unique and lovely community and I think the wisdom and the spirit that comes with the older folks that live here is really a treasure for me and my family. So after Iowa I moved to Cambridge Mass. I played basketball at Harvard and I studied on the side I say and then medical school took me to Baltimore. I went to Johns Hopkins Medical School and I met my husband Doug there. We got married a few weeks before graduation and then after medical school you go on to do what's called a residency which is learning in a hospital mostly about the specialty that you're going to go into. So we moved to Rochester, New York and I initially was a physician an obstetrician gynecologist so learned to deliver babies and all the things that go along with women's care. At the end of those four years about a week before that those ended we had our first daughter Ingrid and then moved to the South Shore of Boston where I began my private practice which was wonderful. I very much enjoyed my work and especially bringing new life you know there when new life started. It was it was very much a privilege and then when my kids were young and my second parent had died when I was 33 I decided you know I want to be home with my kids a little more and coach them and volunteer and things like that because my husband and I both had very busy jobs as physicians so I actually stayed home with my children for about 10 years while they were growing. Took us to from the South Shore to the coast of Maine just south of Portland and then about six years ago we moved here and once we got back here I and they got settled in school I said it's time for me to go back into medicine and when I decided to go back into medicine I wasn't sure what specialty I would want to do. I had ruled out obituary and because the lifestyle that goes along with that is not you know delivering babies was my passion it doesn't leave a lot for other things. So I initially volunteered at Bay State Hospital on what's called an ACE unit acute care for elderly it's a specialized unit that Dr. Starr talked about I don't know if you guys were did you see the Dr. Starr's presentation as well so that's where I met Dr. Starr and I started as a volunteer patient advocate to be with patients and families to make sure they understood things and to make sure they were understanding what care they were getting etc and after a couple of meetings where the palliative care team and I can talk about what that means had a meeting with the patient and their family members and their other doctors to sort of talk about what's really going on here what decisions do we need to be making how to best care for you. I decided wow that's really what I want to do so I've spent my time in that field since since then yeah. Wow so I take it that in terms of the care that you provide and the services that you provide with palliative care that you are around a lot of families sometimes finding themselves in crisis a medical crisis and perhaps the discussion about medical care choices haven't occurred and I think that one of the important pieces around inviting people to this conversation is helping them to understand why it's important to have the conversation which can be I think culturally challenging or I think a lot of people resist having these conversations so I always like to provide here's the why of why we're doing this so is there anything you could share either anecdote or from the perspective of the the medical provider or watching family members or even the person who might be struggling with a chronic illness or end of life if they haven't had those conversations what's sort of the drawback of not proceeding down that lane. Right so I certainly in medicine and especially in palliative care have seen the perils and the suffering and the emotional toil things take on both patients and families who are nearing the end of life and needing to make critical decisions who haven't had any conversation about what's really important what's a quality of life for my mom that she would want or wouldn't want if I put her on a ventilator and she came off but she'd have to be in a nursing home would that be acceptable to her or not those kinds of things and one of my positions was actually working with patients and families who came into the hospital on the ACE unit who hadn't had these conversations and they were finding themselves in crisis and what I find is that when you have these conversations almost almost a hundred percent of the time people feel a lot better afterwards it gives the patient a sense of power and control and the conversations really clarify what's important to them right till the end of their life right what's quality of life mean to them and thinking about what medical decisions that might mean in the future you know just for instance I remember one family who this patient was 96 years old and she was in for her like ninth hospitalization and in a very short period of time with different things going on she was still like active and her mind was perfect and all of this and I called her daughter in who was her healthcare proxy to talk and then we talked for about an hour and then the last few minutes her other daughter got on from California and we talked about you know really what was important to her and what we what I'm not sure everyone understands is that really the what should happen is the root of the care you receive both now and especially when decisions get really tough should be coming from what matters to you right what you want your life to be now and if things happen and if you don't have those conversations you end up in crisis the people you may not understand what decisions need to be made and also very often towards the end of life we're not able to make our own decisions whether our thinking is not clear or we're so sick we're you know sleep too sleepy or too in too much pain or whatnot and we need to really rely on our healthcare proxies which might be family loved ones other important people in our life to talk to the doctors at that time and say what decisions to make and I can tell you if conversations about what you would want haven't excuse me haven't happened the the person that's had asked being asked to make those decisions is it's a very stressful position for them and they don't really know the right thing and they and they have a lot of guilt afterwards after dying oftentimes whether they made the quote right decision or not they didn't know what the right decision was so it really complicates their grief afterwards whereas when people have these conversations it it usually brings a closeness and a connections it clarifies things and you know we're all going to pass away sometime and most of us won't pass away suddenly with a heart attack or in our sleep so there's going to be time when we live with a serious illness and time when we make decisions about certain care so if we've had this conversation when the healthcare proxy needs to speak up I literally say to them if your mother was sitting here in this room with us during this meeting what would she say about this decision you know so it takes it off of them and really says brings your voice back into the picture and that takes the burden off of them and it also really helps us know what you would want I definitely have seen some situations where patients and families suffer greatly from not having had these conversations ahead of time um so I was just talking about the 96 year old patient just quickly in a one hour conversation with her and her daughter who was her healthcare proxy and the other daughter we kind of that you know went through her life history in a story and it really told me what mattered to her we talked about her medical situations and the doctor's job is to find out what's important to you because you're the expert on you make sure you we explain what the medical situation you're facing is and what it might look like ahead and how that might affect your life and then putting those pieces together to really come up with a plan that helps you live your best days right till the very end so these conversations are key to making that happen and unfortunately the way our medical system is set up now oftentimes it's the patient or the family member who has to bring up to the doctor I really want to talk about this ahead of time it's not built into our medical system so as much as lay people might say well my doctor's going to ask me about that we'll have that conversation when it's right it's so not true we've looked at studies and more than half of the time the patient brings up these conversations and that's for various reasons time some doctors aren't comfortable with it etc but it's it's you're right and the way you're going to feel that sense of power and control to have these conversations with important people in your life and physicians Wow thank you so much that really is a powerful reason to engage in this I think that you really laid out a great sort of synopsis for people to understand that it's not only about yourself but it's it's also ends up being a gift to your family and it's their sort of guilt about having to make hard choices if they should have to be in that position and and I found it so interesting when you talked about the way in which it complicates grief thereafter if that conversation hasn't been had so thank you and and that's one of the reasons I've so enjoyed speaking with you before this opportunity to share the conversation with others is you really have a wonderful way of wrapping around compassion and understanding people and when I speak with you it's often like you're putting together a puzzle of a person and their desire and how they live their life and how that should be reflected even as they age and the medical decisions that are made so thank you it's a really wonderful sharing for people so given that we've said like come on join us in this conversation how do we begin this conversation of trying to figure out what's important is there are there some steps that you could help us walk through to figure out what is important to me and then how do I share that yeah so that's what we're going to do today and I know that the hour is a very short period of time but what I'd like to do anytime you're going to talk to someone else about what's important to you you need to have thought about that first and so in our society that often falls on the patient themselves to be proactive I'm going to give you a resource that you can go to that will walk you through the steps ask you the questions give you a little pamphlet about okay these are the questions you want to think about and then it walks you through okay who do you want to talk to when do you want to talk to them what do you want to make sure you say but it really starts with what matters to you and especially when you're facing a serious illness and then it will give you the steps to talk to your your healthcare proxy your physician etc and fill out any documents that would show these these preferences and goals that you would like but I really want to get into that first part today what matters to you and I do want to say that there are a lot of resources out there on the internet to help people go through these thought processes I'm going to use just one today and I'll point you right to where you can find it on the web and it has really everything you need to get yourself going and to the point all the way toward toward toward the end of having everything lined up yeah great okay so you want to take it away I thought you was a host I've hopefully done the technology appropriately so you can begin to walk people through or if there's anything you want to screen share in terms of helping people to understand what's important to them if they develop a serious illness or COVID or you know how how somebody should begin that conversation sure so I'm just going to give a little bit of background on sort of what we're talking about why we're talking about it we've touched on many of things already you may also be asking what's a palliative care doctor and what do you do so palliative care is a field that specializes in in in focusing in on patients that are going through a serious illness and their family members and providing an extra layer of support it's a it's a team usually a palliative care team social worker physician chaplain an extra layer of support as you go through that serious illness you can see palliative care doctors they can help you with symptom management if you're having a lot of pain or shortness of breath they can help you with conversations that really say what is the quality of life we're looking for and let's go down those paths and it's important to know that it can it's a specialty that can be part of your care it doesn't take over your doctor's care your specialist care we work with them to coordinate when you're still going through any curative things so people sometimes ask do I not do I have to not be going through my cancer therapy or no palliative care is to be there along with you to provide extra support and expertise in managing those kinds of things but today I'm not talking to you necessarily as a palliative care doctor I'm talking just to you as someone who's had a lot of these conversations and trying to bring what you can do yourself to you so I think you know just for a big picture we've already talked about you know why having these conversations is important and then we also I'm going to just quickly address the elephant in the room which is COVID right which we're all scared of and we're all living in and I hate to say it but we're not done with so a lot of times people think about these issues that we're going to talk about when they have a serious illness maybe they have end stage COPD or heart failure or cancer or dementia but those serious illnesses usually last a while and you have some time with COVID unfortunately you can get suddenly quite sick so having conversations like this in anyone that's you know higher risk you're older you have medical conditions to think about if COVID hits me and I get seriously ill and need to be hospitalized what are the things I'm going to want okay so that's sort of the elephant in the room and why this is it's not a conversation that we would have in the course of a long series illness but it's a proactive conversation about what would I do and what if I did get COVID. Can I just ask because I know that some of your work has been COVID related has because of the rapid way in which it might progress has that sort of also brought an urgency to this discussion to have the discussion while you're still well before you should happen to have a diagnosis or an exposure or you know some kind of a risk. Yeah exactly so that's why this is a proactive discussion now especially in people who are higher risk because it can come on you can develop COVID and have most people will have a mild to moderate illness you know maybe fevers cough headaches sore throat some nausea you know a combination of a number of symptoms but can stay home and hydrate and rest and be well and support themselves there and get through it like other viruses but we do know that there's a certain set of patients that instead of over you know a week or so getting better that they actually get sicker and sometimes that can happen quite suddenly often they might have symptoms for a few days three four five days and then start to develop trouble breathing and when if you develop trouble breathing with COVID it's time to call 911 because and then people go to the hospital and sometimes very shortly after you get to the hospital you can be making some decisions about I mean they'll give you fluids and they'll give you oxygen but if you're young and healthy often times even if you need to be hospitalized even if you need to have a ventilator you're usually going to come off of that and go home the concern is is that if you're older and we know that patients over 80 are at highest risk or you have pre-conditioned pre-existing conditions that make you higher risk diabetes high blood pressure COPD asthma things like that that there's a chance that you may need to go on a ventilator to breathe and despite that you may die on the ventilator or you may go on a ventilator to breathe you may be on it for weeks and we know there's the isolation factor too with COVID in the hospital and even if you get off the ventilator between long-term effects on your lungs and the the difficulty of going through rehab and getting stronger you may actually never get back to the quality of life that you think is acceptable so that's why it's really important to talk about this great so I think we scaffolded and scaffolded why this is important I just want to go through the steps that you would take and you know the first one is showing up to something like this which is awesome I'm so glad you're here because the steps really are you need to think about what matters most to you you are the root of what medical decisions should be for your care you have that you need to decide who's going to speak for you if somebody needs to and you can't so next week Mary Beth and Anita are going to be doing a session on healthcare proxies and that that is naming your healthcare proxy and documenting that and then you need to have the conversations with your healthcare proxies with other family or important people in your life so they know what you're thinking and with your doctors or advanced practitioners etc when I say doctors I mean anybody that you go to for your primary care or your specialty care and and then you need to fill out any documents and again healthcare proxy is like everyone over 18 should have a healthcare proxy Mary Beth will talk about that and then there's some documents if you've decided with your doctor I want I don't want to have some life-sustaining treatments like a ventilator or which is a breathing tube or you know CPR if I were to pass away you document those in a medical order which she'll also talk about next week it's called the most so let me I think I've talked about COVID a little bit you know the most important thing just in talking about COVID you guys probably all know this is you know the thing the best thing you can do is take care of yourself and try not to get it so I'm sure you're following all those preventive measures and I don't need to go over there like I said most people develop a mild or moderate illness and don't need to be hospitalized and and and do just fine some go into the hospital some need life support treatment some come off of that life support treatment some don't and we really want to think about what it would mean for you if those situations came up so what I want to do now is hopefully I've laid the groundwork I'm going to share my screen and this is when I'm going to have you answer a few questions and this is just to get you started on thinking about what matters to you and if you wouldn't mind to playing along with me each having a piece of paper and a pen to just write down the answers to your questions I'm not going to ask you the answers and you'll keep that with you and you can do with it what you'd like so I'm in a screen share and you guys just give me a thumbs up when you have your paper and pen it's already everybody's good okay awesome thank you so so the way this starts out so the preface of all of these questions is think about what you would want if you became seriously ill with COVID so it says like I've said people who are older or have chronic medical conditions are more likely to become very sick if they get COVID-19 some will recover with hospital care but even with ventilator support some will die think about what you would want if you became very sick at this time so this is just a the starting picture is about I haven't asked you anything you need to write down yet but this is just says you know good day start with good talk you know having these conversations is how you can ensure that good days are ahead and so you can live your best life so this is all from a document that I'm going to point you to online this is called being prepared in the time of COVID three things you can do now the first one pick your healthcare decision maker you're going to talk to Marybeth about that next week talk about what matters most to you but it's listed as number three think about what you would want if you became seriously ill with COVID we're going to do that today and then you can follow up with those other three on your own time so the first question is if you became seriously ill with COVID what would be most important to you so if you can just write down on your paper most important and then put some things that come to your mind and I'm going to give you a couple minutes you know they gave examples here being comfortable or trying all possible treatments other things people might say is stay in my home not suffer not go to a nursing home um still be able to be around my loved ones you can take your time but if you want to just give me a thumbs up when you when you're done with that one just let me know um and also you can add more later but take your time okay awesome so going on to the next question what are you most worried about so if you got COVID-19 what do you worry about could happen they give examples here being alone being in pain being a burden but there are many others being separated from family members not being with my cat the financial burden the people I leave behind what are you most worried about so just write worried above this just so you know what your answers are in regards to and just give a thumbs up whenever you're ready to go to the next question but take your time great okay next question what is helping you through this difficult time this is certainly a difficult time and we all have things that bring us strength or support samples given my friends my faith my cat could be exercise meditation the senior center Mary Beth specifically so just give a thumbs up if you're ready to move on take your time everybody doing all right so far okay you're good students if you became very sick with COVID-19 would you prefer to stay where you live or go to the hospital so if you became very sick with COVID-19 and you the decision came that you were so sick would either need to stay home you would either need to go to the hospital and have more aggressive treatment or would you prefer to stay where you're at and focus on being there and bringing care to you that would provide you comfort and supportive care but but you may pass it on thumbs up everybody for a little more time okay if you did choose to go to the hospital would you want to receive intensive care in the hospital so you may have decided in the previous question I would want to go into the hospital to get treatment to try to get me better from COVID when you get to the hospital there's a couple of choices you can have as much treatment as they can give you whether that be medicines should they develop that are very helpful fluids and other things but mostly it's supportive care and trying to support you to keep you hydrated and and comfortable and give you some oxygen to help you with breathing would you want to do that and say if I don't get better let's focus on my comfort and maybe getting me home kind of thing or if you went to the hospital would you say if you were supporting me and my breathing got so bad that just regular oxygen through my nose or through a light mask didn't work and the only way to continue to treat me to keep me alive was to put me on a breathing machine on a ventilator and go to the ICU which includes you know being hooked up on monitors having the breathing tube in being sedated is this something that you would want people to try or would you say I wouldn't want to be going through that just to explain this question a little bit only a few more this is an extra box list any other questions or concerns that you might want to bring up with your family friend healthcare provider healthcare proxy when you talk to them this could include anything but certainly who would take care of my animals who would take care of you know there's some financial things that are outstanding I need to talk about there's some people I want to talk to before I pass or some unfinished business I have or that something could help you when you got sick please call you know a rabbi or a priest or any other form of religious leader that's supportive for you things like that make sure to bring me chocolate ice cream things you know the important stuff that would be on my list thumbs up ready to move on or need a little more time okay great so you've completed the questions I'm going to ask you so I'm hoping that none of those raised your blood pressure too much and that it was something that you know you were in control of and there was no pressure because this is the root of where things start so I'm proud of you and thank you for going through that because it's not necessarily easy for people to do but so important so you've done number three you've thought about what you'd want if you became seriously ill with COVID next week you're going to marry Beth and Anita are going to talk about picking the person to be your healthcare proxy or persons you can put a couple two or three which is often nice to have more than one so people can share the burden or not burden but responsibility responsibility and then you're going to need to have conversations because it's nice that you wrote this stuff down but if we write things down or we fill out a healthcare form or we make something with a doctor and we never share it with anybody they don't have the information to act on it and to take the best care advocate for the care you would want so really important to have the conversation and then make sure you're documenting things in certain ways which Mary Beth will go into detail next week so this is a resource I'm sorry some of it might be cut off because of all of our smiling faces this morning but this is the one resource I would point you to it's called the conversation project and if you just type that into your browser if you have one or your phone you'll come up to a page that looks a lot like what's on the left there and it will take you everywhere you want to go and it will provide you supportive documents along the way to get you there so if you went to this page you see right there there's a brand new guide specific to COVID-19 that's what that's what we just went through those questions but on the other side of it there's information about COVID some of which we talked about as well as how to choose a healthcare proxy and you can open up a link that shows you the guide on who should I choose what would matter and what should matter and someone that I would choose and then it will also take you through a larger what's called a conversation starter kit that asks you more in detail questions about what matters to you as you think about things including how much say would I want in my medical care or would I want others to mostly speak for me where would I want to be what am I most worried about if I had to you know balance between a little more pain but being awake and alert to meaningfully interact with people how would I work with that so this is just go to this resource and it will take you through all of that I will also have the resources including this guide for COVID-19 a handout that talks about how to pick the healthcare proxy the healthcare proxy forms and those bigger starter kits printed out for the senior center so if you need hard copies and then those are things you take with you to have conversations and like I said in these books it talks you through where do you want to have the case conversation who do you want it with etc and I forgot I had added on some extra credit questions so before we just wrap up I just wanted to go back to your paper and a few more extra credit questions one is who I you may have a healthcare proxy already but if you don't I want you to write down who might I choose to be my healthcare proxy you don't have to make the hard decision today or maybe it's an easy decision for you but if you write down a couple people some of us have more people we think of than others but most of us if we think hard enough might have a family member might have a neighbor might have a religious leader that we can talk about what's important and we can trust that they will speak on our behalf everybody good with that one the next extra credit I have to use my glasses to see what I wrote here sorry who should I talk about talk to about my wishes and what's important to me so this would include your healthcare proxy should be like the number one this should include anybody else and you might have that first conversation just with that one person or with that one person and your closest family member but eventually anybody you think will be important when that when the time comes to really be thinking about you and caring about you that you want would want to be in on decision making and supporting you is great to have so for instance if you have four kids and you get along with all of them maybe only two of them are named as your healthcare proxy but ideally you want to sit down or in this time have your tablet there and have a video conversation or even just a phone conversation about these things to everyone and it's also a good time to say I've named so and so and so and so as the healthcare proxies because they're older they're in the medical field they were always my favorite whatever no just kidding but um and to say but I want all of you to help take care for me and make decisions for me at the end of your life this really makes folks feel good so the next one is when would I want to have this conversation and where would I want to have this conversation if I think about it this is a little harder in COVID because of the difficulty with getting together but like I said there's video and audio abilities and also if people are local you can go into your backyard stay way more than six feet apart and have these conversations but where would I want to do this and when would I want to do this Erin can I ask a question about that from from the opposite perspective of being an adult child of an older adult um do these conversations always have to be initiated by the older adult or do you find in your practice an experience that sometimes adult children might approach parents to say you know geez mom or dad um you know you're getting on in years and we would really like to be a part of that process and help to generate that conversation if the older adult is resistant to having that conversation so I just wanted to flip that script because there certainly will be some who'll say I'm in and I want to lead it and others where it might be being led from from adult kids yeah so I think that's a great point Mary and Beth and I think it starts with the fact that in our society both in the medical arena and just in our personal lives culturally we don't have these conversations usually so anybody who wants to start it is great so if the patient themselves says I'm going to be proactive I want to tell people I want to start this awesome and you might be people like that because you're here and you're thinking about it but you know if you were 30 years younger you might be you might have your parents alive and say you know I really want to know what's important to them and I see that they're getting sick or older or I'm worried that they might get COVID I want to bring this up and so you can if you're one of those folks you can use these same resources the conversation project which will help you talk to your family members about this and you know it would be ideal if the doctor has brought it up but again in our society it's not like that and I think some people who are trying to bring it up with maybe their older family member or you know their neighbor if they're very close and it's really the two of them connected because they're worried they may find you may find resistance to begin with this can often be a scary thing to talk about and it's not talked about in our culture you know we have this culture that oh you know we don't really think about death it's not really going to happen and that sort of thing you know it's just but to say um so if you meet resistance say you know I'm really coming from a love you know make sure it's a loving standpoint I really want to know about you and what's important I want to make sure the rest of your days are good days and I want to know how I can help and I want to speak for you and you know you best so I want to hear that story and those things from you it's also important to know that this isn't necessarily going to happen in one conversation so you may bring it up that this is something I want to do um maybe we could have coffee or talk over zoom and just ask one question or something or give you know send them the resource in the mail to look over um and they can fill out this little booklet there's really just questions that you circle and then maybe the next one call you talk about the first page or the next page um but I do think it's important to understand that it's very anxiety provoking for a lot of people and to come at it from a point of love and how you can help them best and also it is important for people to know that it's helpful for you that it's providing you some stress to know not know what you would want and it would be a relief and a privilege for them to know this so they could act and speak on your behalf and know that all your wishes right till the end are going to be fulfilled even if you're not able to speak for yourself so those would be some things I would think about great thanks sure um and then the last step is a section next steps and if you can just list there the next steps you're going to take so one might be do more work on this list go to Mary Beth's session go on the web and look at these other resources call my healthcare proxies or loved ones or neighbors that are really important in my life and talk to them about this and get the conversation started and another might be I'm going to give you my in contact information so this is my email and my cell phone and I live here in the community and though I work at base state as a palliative care clinician and I work on the mass coalition for serious illness to come up with new initiatives um and um I work in teaching serious illness to people all over the country one of the things that's important for me is to act locally and help people here so I am going to make myself always available for questions and I'm actually available for if you want to have this conversation with someone else or you don't know where to go next I'm happy to help help guide you and I'm actually happy to be there on the conversation through the video or whatnot not just not acting as a doctor and giving you advice on what you should do or that but to sort of mediate the discussion with you and your family members so please do reach out if I can help you and that's all I have Mary Beth that is fantastic so again you can be reached doctor Erin Salvador can be reached at Erin Salvador at me.com and her cell phones<PHONE_NUMBER> if anybody has any vision problems with any of the slides or the screen that's in front of you and thank you so much for making yourself available to the community to assist in this endeavor I have to say from the moment I met you you were so enthusiastic about this community conversation and the need for healthcare proxies to be documented and signed and and and a way in which wishes are shared and conversations can unfold in a way that supported and I love when you use that word scaffolding because I think that that's what you've done a beautiful job today of sharing is here's some scaffolding resources so I just also want to share with individuals if there's any follow-up you can also contact us at the Amherst Senior Center our number is 259-3060 and the resources that Dr. Salvador referenced we will make sure that that we make them available to you we will mail them out to you if you want to come and stop by we meet people outside and we can hand documents out to people and we will be doing more conversations around healthcare proxies in the medical order for life sustaining treatment which is also known as most and thank you so much Dr. Salvador you are a treasure in our community and we are most grateful for your help especially in this time of COVID which as you explained has really laser focused our attention on the need to plan and to have these conversations in a way that's loving and compassionate so thank you so much you're welcome it's been my pleasure thank you for coming today and listening and I hope I see you around town and I hope you do take me up on contacting me and letting me help you if you find the need great thank you thank you so much and we'll end the recording and we look forward to having people a part of this conversation and continue to have good talks and making sure that people know what matters thank you Dr. Salvador have a good day you too bye bye now


So my name is just Nisheli. I work at Doctor on Demand. So what is Doctor on Demand, the rest of the talk will not make a heck of a lot of sense if you don't know what the product actually does. I could explain it to you myself. But shortly after we launched, we got a bit of free publicity that we could never have hoped to have asked for in a million years. We got picked up by the Colbert show. So before I start, I will let him explain exactly what we do. It was like a free advertisement. Oh. The side wasn't working. And you can kind of tell when this was released because of the reference to a not working. No, it wasn't working. Jim, this consultation with a real board certified licensed physician who can diagnose you and prescribe medication. The cancer talk is one of about 1,000 doctors nationwide treating vacations via app. This is a major breakthrough, medical expertise with the convenience of a smartphone. Why waste time getting an exam?  Got a little sunglasses, isn't that cool? You face time with a doctor from your computer, smartphone, or tablet, which is great news for anyone with an iPhone, an Android, or a public library where they can press their junk up against a web fan. I'm not safe from this. This app is going to revolutionize medicine. It's designed to modernize the health care system by using mobile technology to make a simple doctor's visit stress-free for patients and doctors alike. Yes, it's less stressful for everyone.  Now he can watch you doing yourself. If you get really good at it, I know a sign that'll pay you $40 to do it on camera. You can even upload photos for them to examine. In fact, the only thing you can do is set a stool sample. Learn that one the hard way. Rune a perfectly good headphone jack. There is the future of modern medicine. And we'll just cut that off right now, because it automatically goes to the next one. On our website, this is what it actually looks like. You go in, put in symptoms, fill out a few basic pieces of information, like you were at a doctor's office, and the system connects you with a doctor in minutes if everything is working correctly, which it normally does. So that clip was actually a little bit scary, because we're on the West Coast. And all of a sudden, we had friends on the East Coast calling us up and being like, hey, did you see we're on the Colbert show, and we're like, what? What happened there? But it turned out to be a really good thing. And it's a lot easier than me trying to explain it, because he does it much better than I ever could. Doctors get paid per call. So lots of stuff with the website is the same, as you might expect. We have all of the same issues that any web app has. You have data that people need to access. Lots of it is static or custom. People, after they have visits, they have charts associated with those visits. We have access controls. We have all of the standard stuff. But when I was looking at DjangoCon, I was like, oh, hey, they're still accepting proposals.  You should talk about that.  Just not accept me? No, the worst that they could do is accept me. So there's lots of cool stuff. There are lots of other talks about how to make that stuff work well, and frameworks, and APIs. That is not what I'm talking about today. Not everything is the same. The biggest thing that is different is the fact that we have to keep track of where people are in the call process. So people want to initiate this matching process. And you don't know exactly how long it's going to take, because you don't know exactly which doctor is going to pick up, and you don't know if one of the doctors is asleep at the wheel, and you have to call other doctors to make sure that it connects appropriately. So we also have to deal with the fact that regulations say that I can't just route you to any licensed physician in the US. Oh, no. No. My life would be much simpler if we had one indivisible country that did not involve states. Instead, what I have to deal with is the fact that Dr. A has licenses in these five states. Dr. B has licenses in these seven states. And I can only connect you with a doctor that is licensed in the state that you are currently located in, assuming you have never seen that doctor before. There are other rules if you have seen that doctor before. But if this is your first time, I have to connect you to a doctor that is licensed in your state. There are 52 cues in that case, because there's all of the US states. There's DC. There's international calls that can actually go to any doctor. And there are also some other territories. So there are over 52 different cues that you have to deal with. So one question you might ask is, this sounds like it's been solved before, right? Does this matching people who need help to people who can help them sound at all like an application anyone else has ever dealt with in the past? Maybe customer support? So why not just use an existing customer support system and do the routing that way? There are a number of reasons. Partly why I'm here is if anyone knows something that would mean that I built this system in vain and I don't have to maintain it or make it work better, please tell me. That would be awesome. But assuming that that is not the case, we looked at several different systems and none of them could meet the requirement that we had, where when patients are calling in, it actually has to be a video call for most purposes to satisfy state requirements for a legitimate telemedicine visit where a doctor could prescribe medication if appropriate. Actually, a lot of people ask if we're a pharmacy pill shop. We're not. There are a significant percentage of our calls that don't involve prescriptions. That's a question I get asked all the time. But in this case, it has to be a video call. So we would need something that can support iOS, Android, and web clients in terms of connecting their customer support routing system with the video technology that we use. And there was nothing that was flexible enough to drop in in that manner that I found. There seem to be mostly monolithic solutions for call routing where if you have a customer support system and you have a voice over IP or traditional PBX that they support, then they will do everything for you. They will handle all the scheduling. There are massive amounts of ways that you can configure it. But if you just need something simple and you just want to plug it in, not so easy. So I got the opportunity to look at a bunch of different things. And again, I may not be the unique snowflake that I think. And I would love for someone to tell me that I can just throw all this code out and never have to worry about it again. So without something off the shelf, what did I get to do next? I got the chance to use a lot of technologies that might be common in more Python back-ends development, but that you often see as kind of side notes in Django projects. So the first option that we needed to look at was, well, before I get into the first option of what I considered, the data that you need to keep track of for this is pretty straightforward. You have all of your patients that are calling in and what state they're located in. And then you have all of your doctors that are currently online and available and what their current status is. So to simplify things a bit, the current status is there are more than these in reality, but current statuses can be considered available for a call, currently being paged for a call, or actively in a call, and what states their license in. So that's all the data that you need to keep track of. And first option is to just use long-running HTTP requests. Now this has a number of issues. So one thing that it does work for is a very quick proof of concept. If you just need to get something running and show people how this is supposed to work, so this is actually the first thing that I did. You set the time out to be really, really long on your web server. You allow the request to go on for minutes at a time and assuming that you know that your doctors are generally behaving correctly, which they are in a proof of concept setting because it's all staged, then everything is fine and dandy. It's simple to implement. It's good for prototyping. You just use a database and check what's going on in terms of, so you have a visit object, and that has a status of whether or not it's been connected yet. You can use models for everything, and it's all fine and dandy when you have a few demo patients and a demo doctor. But it does not scale. And worse than that, even if it did, it's flaky and unreliable because if a client loses their connection, they don't necessarily have a way to get that status back. If they did, how would they find out the result? So you end up starting with something more like option two, where if the client's flaky anyway, you do need a way for them to recover from that and see where they are in the current match process and get reconnected to a doctor. So you might as well start having the ability for the patient's client to ask what its current status is and whether you've found a doctor yet. So Ajax polling. And then on the back end, because you don't have this long-running request for the match, what I did is use Celery, which is an asynchronous task queue written in Python. It integrates really well with Django. Another talk would be on all of the configuration options for it. I will not go into that. There are many. It works well out of the box, but there's lots of stuff you can do to tune it. And that fell naturally into this use case because I could have Celery, lots of workers running in the background. It scales really well as we have more patients coming in. They're just able to check the status of the doctors and page a doctor one at a time. We have a built-in business requirement that if the first doctor that's called doesn't answer within a minute, then you start paging another one and another one and another one. And these can just go on for as long as they need to with some arbitrary timeout. And so that's all great. So the pros for that asynchronous task, you don't have to worry about request timeouts. Cons for polling. It's no longer real time in the way that your long-running HTTP request is. So with the long-running request, you just respond as soon as you have a match. And you're great. With polling, to simulate real time, you have to keep making this request to the server over and over and over again. There's got to be a better way. And there is. So you can still use polling as a backup. But the optimization that I went to was using WebSocket, which is an HTML5 technology that allows clients to receive pushes from the server so they open up a channel. It's lightweight. It's perfect for this. And then on our mobile devices, you also add in push notifications. So if the user has enabled push notifications, you can use that to, as soon as a doctor accepts the call, immediately push that information to the clients. And then even if you have polling as a backup, it doesn't have to be as frequent for it to appear real time to the majority of the patients calling it. The cons, it has a few extra moving parts. You have to worry about setting up this extra service. If you don't want to set up your own, there are now SAS providers who do WebSocket for you. I think the biggest one is Pusher, and they'll help you with that. So stage two in making this thing work well. Tracking doctor status. We have a lot of doctors that can be online at any time. They all have licenses in a variety of different states, like I've said before. The first option would just be to have all of this be in the models, and then every time someone makes a call and make the appropriate queries to figure out who's online, who's not, that's slow. It could be out of date. The pros of this approach of just using the database are that there are no external dependencies. And I think that is really the only pro, because it's slow. The data can get stale really fast. You have to make all of these extra reads and writes to your database. It's inefficient. It's not good. Depending on how your models are set up and the way that ours are set up involves quite a few filters and joins to do this just using the database. So I found that Redis worked as a really good solution to this problem. Because I needed the data to be persistent. Did I spell persistent? Right. No, I will fix that later. And that's going to be on video forever. All right. So Redis is really good for persistent data structures. And the data structures that I used are the obvious ones in this case. We have a data structure that has the doctor's ID and their current status. And that's what we update. So it's used as a cache for this ephemeral data of what status the doctor currently has, because we only care about it while they're on shift. It's not something that we need to store long term. And the other thing that is useful in Redis that I found is queues. So the first link there is just the official Redis client. Well, not official, but the biggest Redis client available in Python. The second one is a queue package that I use. So what you can do in this case is instead of storing everything in the database, have queues in Redis of the doctors that are licensed in each state. When they become available, push them into these queues. And then as patients want to see doctors in these states, pop off the next doctor, check their status. And then if they're available, match them. If they're stale, just discard them at that point. And you can keep using queues this way. One disadvantage of this. So if you start with just a FIFO queue and you have to have a separate queue for every state, you can end up with duplicates, depending on how you do it. Where the doctors that have licenses in more states will get richer and see more patients because they'll end up in more queues more frequently. So one of the optimizations you can do instead is to use a priority queue, which won't have duplicates the way that a FIFO queue would if you just have IDs. And it's kind of depending to the end. And it has a score. So whoever's seen patients the least recently can get the next patient available in that state. The last thing that I came across that I thought was interesting in this process of developing this architecture was atomic call acceptance in February. The last half of February, we decided to do this wonderful thing where we made all calls free for two weeks. That was painful for me. Everything worked. So it was actually really great. But one corner case I discovered at that time was that it was possible to have multiple doctors accept a call simultaneously. I thought I had protected against it using pipelines, but I hadn't done it correctly. So I actually switched to something that was a lot easier to read. And that was just to use a simple lock. And this is just kind of a way that you can do distributed locks and resets in their official documentation. What you do is you set a unique ID. That second part that's the value is it doesn't matter what that is if you're just using it as a lock. If you're doing something else with it, this is the standard key value store. And then the two options are that it expires after a certain amount of time. And then you only set this if it's not already set. So what this does is say I set call attempt 2. So this patient is calling in. Their call is number 2. And both doctors try and accept at the same time. I mark call 2. I set the value as some random value. And only one of them, only the one that gets the lock, gets to accept the call. So you can't end up with two doctors accepting the call at the same time. That's just a neat trick if you're using Redis already and you come across something that would use this. So in the end, we have an improved system where the database does what it's good at. We have celery taking care of asynchronous processes that can end whenever they need to. Specialization improves our efficiency. We can, at some point in the future, offload all of the celery tasks to other servers. It clusters well. It's very scalable. It's nice. And Redis keeps track of our ephemeral data and lightweight persistent cues. And that is the end of my talk. So there's now some time for questions. Thank you for listening to me. This was the first talk I've done at DjangoCon. And I'm really glad to be here.


Mosaic is an open-access trait database that integrates data from three existing databases, Kamada, Kampadre, and Padrino, to provide a comprehensive resource for researchers studying the relationship between demographics and traits. The database contains over 1,400 species and provides information on 300 species including biomass, height, growth determination, regeneration, sexual dimorphism, mating system, hermaphrodism, sequential hermaphrodism, dispersal capacity, type of dispersal, mode of dispersal, dispersal classes, volency, and aquatic habitat dependency. Additionally, it includes species-level phylogeny and population-specific climate data. By integrating these datasets, Mosaic allows researchers to better understand the relationship between demographics and traits, as well as identify emerging challenges associated with standardizing databases and demographic measures. This article was authored by Conor Bernard, Gabriel Silva Santos, Jeke Deer, and others. We are article.tv, links in the description below.