Palliative Care Nursing: Podcast with Betty Ferrell about ELNEC

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are honored and delighted to welcome Betty Ferrell, who has been in nursing for 47 years. She’s the director of Nursing Research and Education, and professor at the City of Hope in Duarte, California. She’s the founder and principal investigator of ELNEC, which is the subject of today’s podcast. ELNEC is celebrating its 25th anniversary in 2025. She also chaired the National Academy of Medicine report on improving quality of care and nursing homes in 2023. Betty, welcome to the GeriPal podcast.

Betty: Thank you. Very happy to be here.

Eric: I can’t believe it took us this long to get Betty Ferrell on podcast.

Betty: Overdue.

Eric: I’m a little overwhelmed, we got Betty Ferrell on the podcast. Before we jump into the topic at hand, Betty, do you have a song request for Alex?

Betty: Well, I thought about this because I wanted something that would really convey the care that’s provided to older people, and what came to mind was Count on Me by Bruno Mars.

Alex: Great choice.

Eric: Wonderful.

Alex: Here’s a little bit.

(singing)

“If you ever find yourself stuck in the middle of the sea, I’ll sail the world to find you. And if you ever find yourself lost in the dark and you can’t see, I’ll be the light to guide you. I found out what we are made of when we are called to help our friends in need. You can count on me like one, two, three, I’ll be there. And I know it when I need it I can count on you like four, three, two, you’ll be there because that’s what friends are supposed to do, oh yeah.”

Betty: Thank you. Wonderful.

Eric: Betty, that song resonated with me because probably for the entire duration of my academic life, your work has been so integral to my own career. Our team here at the San Francisco VA where I practice, we’ve done ELNEC trainings for a very long time, led by initially Patrice Villars, who was our nurse practitioner on our team. And I’ve done ELNEC training myself and have taught in ELNEC training around the ethics. I really want to get into how you developed it and created it back in 2000. I think something like 1.5 million nurses and other providers have been educated through ELNEC. But maybe we can take an even bigger step back, is how did your path lead to palliative care even before ELNEC?

Betty: Sure, thank you. Well, I started my nursing career in 1977, so 47 years ago. And as a new graduate, I worked in a hospital setting and it was actually the very first oncology unit in this hospital. So some of you are not old enough to remember that there was no such thing as an oncology program, that if you had prostate cancer you were down on the urology unit and if you had ovarian cancer, you were sadly over on the postpartum unit. And so in the 1970s and about the time I graduated, there was this idea that we should really put all these patients on one unit so that we could learn how to give chemotherapy and have nurses who really were there to take care of people with cancer. And of course, the development of oncology. So I worked in the hospital setting for three years in oncology. And then shortly after that, this was at a period of time where the hospital was the world of healthcare.

If you were sick, you came to the hospital, you stayed as long as you needed to. And so about that time, literally I came to work one day and my manager said, “Oh, by the way, there’s this new thing called DRG’s. And what that means is we got to kick people out of the hospital.” And I remember as a nurse my first thought was like, wow, we’re not doing such a great job managing their pain and symptoms here in the hospital. How are we going to send people home? And so remember, there were no hospice programs. There were a dozen in the entire United States. There were none in my state where I was living. And so there was no net out there. And so I decided to leave the hospital because I really, curiosity, I wanted to know how are these patients and families managing at home.

Through these years I decided to go back to school and that I needed more education if I really wanted to be an agent of change. And so in 1984, my doctoral dissertation was on the topic of home versus hospital deaths and bereavement outcomes, because it was a unknown thing. It was a rare thing, very new idea that a patient would die at home. And so that was sort of my journey from oncology into home care into before there was hospice, but caring for people at home. And then of course, that was the late ’70s, 1980s. And then of course, hospice did begin to spread around the country. And then that took us into the ’90s when now this new word, so I tell people all the time-

Eric: This new word palliative care came up.

Betty: Yeah, there was no palliative care. And so I tell people all the time, the word palliative care didn’t exist, was not in our vocabulary. There was no such thing. And so it was… What a great ride I’ve had, what a great privilege to see the birth of hospice and then to see the development of palliative care as a whole specialty just during my lifetime, which is fantastic.

Eric: Yeah, it always amazes me how young palliative care is as a field when you talk to people who were around in the nineties building these palliative care programs for the very first time, and building the need to train people on serious illness, end of life care. And I think that kind of takes us to the year 2000 where that was the year that ELNEC was created. Is that right?

Betty: Right. So actually starting about 1995, ’96, I started trying to figure out a way to create training for nurses in this new thing called palliative care. And nobody wanted to support it. I pounded on doors and wrote grants and never could get a dime. And finally-

Eric: Why do you think that was? People just didn’t understand it?

Betty: People didn’t understand it. I heard every possible reason when I would say, we need to educate nurses. I was told, “Oh, no, nurses already know this.” Or I was told, “Nurses don’t need to know this.” So no one would give me a dime. And so finally in 1997, the Robert Wood Johnson Foundation was starting to support some efforts in this new area of palliative care. And so I tried and tried and they would also not give me a dime. And so I just kept going back to them and honestly finally they got sick of me. And in 1997, they decided to give me a small grant to just get rid of me. And the grant was called Strengthening Nursing Education in End of Life Care, because remember we weren’t even saying palliative care yet. It was still all end of life. But I had a three-year grant which was supposed to be a needs assessment.

And so in that grant we decided to review the top 50 textbooks in schools of nursing to see what was being taught or what knowledge existed if nurses wanted to provide better care. And that study documented that less than 2% of the content in the leading schools of nursing textbooks had any relationship, and that was a liberal 2%, I can tell you. If you took out the pain chapters and the ethics chapters, it was closer to 0.1%. And starting that project, then RWJ decided, well, we should have medicine do the same thing. And so that’s when I got to know Mike Rabow and Steve Pantilat who were fellows, and they did the review of the medical textbooks. So from ’97 to 2000 we did these needs’ assessment things like looking at textbooks, we interviewed faculty in schools, we interviewed practicing nurses. And then at the end of that project, here’s the data.

Nurses are not prepared to provide this care. There isn’t a knowledge base. There are still a lot of attitudes and practices that are very outmoded, and so we really need to change nursing and nursing education. And so in the year 2000, RWJ gave us a grant. And our grant was to create one ELNEC curriculum, and we were going to do five courses throughout the country and then our work would be done, the end. And we were naive enough to believe it, so this is great. We’re going to do this. And so we launched our first, our budget was so small, we kind of had one the opportunity to announce. And actually from that one announcement all five of the courses for the three years were full. That was the demand. People were really so desperate for this. But it’s kind of like the rest is history, because at the very first course we ever did by the first coffee break, because we crammed it all in that one curriculum.

We had pediatrics to geriatrics in ELNEC Core, but by the first coffee break people were coming up to me saying, “I take care of children and thank you for including pediatrics, but pediatric people do not want to sit in this room and listen to all this talk about adults.” And people in geriatrics came up to me and said, “It’s really different in the nursing home or when multiple illnesses.” So that was our first, oh man, just when we thought we had solved the problem we realized that it was much more complicated. And so then that led to the next decade of trying to move ahead and create ELNEC geriatrics and pediatrics and critical care and all of this specialty curriculum.

Eric: Now, my memory of the ELNEC curriculum, which probably was through ELNEC for Veterans. There is ELNEC for Veterans, right?

Betty: Yep. So early on, the VA came to us and we knew that the VA had made a commitment to palliative care. And so the VA came to us and said, “We need a curriculum for the VA because we all know the special needs of veterans.” And so we took the Core curriculum and we created that curriculum, and we had this incredible opportunity over about a three-year grant where we actually trained almost every VA acute care setting in the country. And everything we’ve ever done in ELNEC is train the trainers. So we were teaching people to go back and teach other people. And so that was again, early 2000s. And so after that grant ended and after we stopped holding the courses ourselves, we continued to have a wonderful relationship with the VA where about every two to three years, the VA comes to us and we take our current curriculum. And then we use nurses with faculty, with expertise in the VA, and we update the curriculum and then we hand it back to actually through the VA and NHPCOs relationship.

And so the curriculum at no cost, we get no funding. The only cost is paying for faculty to update the curriculum, but then we hand it back and it’s available free for all the VAs in the country. So that’s been a great relationship.

Eric: How much has the Core curriculum changed over the last almost 25 years? Because I remember it was like a one-day curriculum, but eight modules, eight hours. You talk about things like symptoms, ethics, cultural issues, spiritual issues, communication, bereavement, what happens in the last couple of hours? Has that always been somewhat standard or has changed a lot?

Betty: We update every curriculum every year just to keep the evidence current. And then we do sort of a pretty significant update every three years of every curriculum. And the curriculum has changed tremendously because the world has changed tremendously, obviously. And so it’s very hard because it’s hard to get people away from work and it’s hard to keep them away for very long. And so now most all of our courses that are in-person courses are two full days of training. And again, it’s every course that we do, our Train-the-Trainer where people then are taught the content but also how to teach others the content. And then everyone goes home with the full access to all the resources, teaching techniques, et cetera. We also, in around 2007, 2008, started having ELNEC online. And so now all of our curricula, we also have a relationship with Relias Learning. And so our ELNEC curricula are hosted on Relias. And so we have many thousands of people every year who do ELNEC online in addition to our in-person Train-the-Trainer courses.

Eric: The Train-the-Trainers, is all of that in-person and is that at City of Hope or how does that work?

Betty: The Train-the-Trainers, so actually this is now April 2024, and in January of this year we hosted our 300th ELNEC Train-the-Trainer course.

Eric: That’s amazing. Do you know how many trainers have you trained?

Betty: So we have trained right at 48,000 trainers in all 50 states and 114 countries. And the 48,000 trainers we have trained have now trained over 1.5 million clinicians and these across disciplines. So our ELNEC website is www.aacinnursing.org/ELNEC, and so that’s the American Association of Colleges of Nursing hosts our website. And there’s a fact sheet where we keep up all the numbers, so we update every couple of months. But that’s where you’ll find all the statistics about all that we’ve done over the last 25 years. But we did surpass last year the 1.5 million mark.

Eric: Can you sign up for courses on that website?

Betty: Yes. So all of our courses are posted there. We just had a course two weeks ago in Salt Lake City. It’s what we call a summit. So when we go somewhere and I’ll hold several courses at the same time, it’s called a summit, bringing all the courses together. This fall, we will have two courses held in New York City. We have a lot of other international work going on this year, and then all of our online work and schools of nursing work. And then again, next month we’ll be planning all of 2025. And so then you’ll see all the opportunities for courses in 2025. We have a mechanism where people who are trainers and they go home and they’re going to host a full ELNEC course, the whole tamale two days, all the modules, they notify us so that we can give them permission to call it an ELNEC course. We don’t count it in our count of courses because we’re not holding it, but we do tally that data every year.

And so generally there are about 225 to 250 complete ELNEC courses held each year by somebody else, not us. And so that’s part of our dissemination.

Eric: So I got a question. You mentioned this is for healthcare providers, but in the name it’s nursing education. How do you think about that? How much of it is very specific towards nurses versus something that’s important for all providers?

Betty: Sure. We’ve wrestled with this a lot ourselves from the very beginning. We felt at the very beginning that because there was nothing specific for nursing, nursing is the largest profession. There are a lot of very nursing specific responsibilities and roles that there really needed to be ELNEC, there needed to be something for nursing. But from the beginning, we’ve always said anybody can come to an ELNEC course. So at any course, we may have obviously the largest part of our audience is nurses. But we often have physicians, social workers, chaplains, PAs. We have all kinds of people. Interestingly, all our international work if we’re going to go to Kenya India, the Philippines, China, wherever we go, it’s probably about half of our international audiences are other disciplines because if we’re going to go somewhere they’re going to come, whoever is available is going to come. And so we have a very high interdisciplinary.

We do have one course which is actually funded by the National Cancer Institute. It’s our interprofessional communication course, the ICC course and it’s funded by NCI R25 grant. And it is focused on nurses, chaplains, and social workers. So mostly nursing, but all are welcome and many people participate. And once people go back into their work setting, the nurses who are trained we always tell them, yes, it’s fine to include your interdisciplinary team members to help you teach this. And it’s fine to welcome anybody to come to the course.

Eric: Yeah.

Alex: And just taking a step back, ELNEC has probably done more than any other intervention, educational or otherwise to boost primary palliative care skills of practicing clinicians than any other program ever, most likely. And that’s just remarkable. I just wanted to say that or let you know, acknowledge that and to say thank you for this incredible contribution to our field. And for boosting the floor level of nursing education around end of life care and palliative care. I did want to follow up on Eric’s question about nurses, and just take a step back because for the three of us we feel like it’s just obvious the important contribution of nursing to palliative care and end of life care. And there may be some of our listeners who are saying, why focus on nurses? What is it about nursing in particular where these skills are so essential? And I just want to give space to educate those folks.

Betty: Right. If you put yourself in the shoes of the patient or family, I think that’s the best way to answer that question. So if you are the person with COPD or heart failure or cancer or any serious illness, who’s really at your bedside? Who’s in the critical care unit at three in the morning? Who is the nurse that’s caring for you with your newly diagnosed pancreatic cancer? Who’s coming into your home to see you in home care? Who’s the primary provider in hospice? Who is the absolute, 99% of the time the most likely person to be with you at the time of death? Nurses. So I think at ELNEC, we’ve always tried to balance that nurses are the predominant healthcare providers and by far the most likely people to be there with patients and families. While at the same time in everything we do in ELNEC we try to emphasize and we work as teams.

The best patient care will always be the care where you’re collaborating with your physician colleagues, with social work, with chaplains, with psychologists. And so there is this very unique role and place for nursing. And there also is a very real need for all of us to promote the idea of interdisciplinary care.

Alex: And just by way of follow up, Eric was talking at the beginning how about we’ve taught in ELNEC, I’ve taught in ELNEC as well. And also taught on and off in the nursing school and the communication course and the palliative care and end of life course at the nursing school here at UCSF. And I’ve on several occasions tried to teach communication around end of life care. And I would start off by showing that a magnificent scene from Wit, the play that was made to movie starring Emma Thompson where the nurse is talking with the… Sorry, I don’t remember the name of the character, but the Emma Thompson character who’s dying. And they’re sharing a popsicle and they start talking about code status and the nurse just says something, and this is off the top of my head, like, “What have you said to the doctors when they ask you about this?” And then the Emma Thompson character says, “Yeah, do it. Try to save me.”

And the nurse says, “I don’t think that’s right, and here’s why.” And has this amazing conversation. And so I’ve asked nurses to role play that up front, and many of them have been deeply uncomfortable with it. They’re like, “This is not my role, this is outside of my boundaries.” And I just wonder from your perspective what you see, because yes, nurses should play a role in interdisciplinary teams. And there’s an advocacy for empowering nurses to have these conversations, and I wonder where you lie on that.

Betty: Sure. So when we first started ELNEC, we did a literature search to write the first communication module. And the interesting thing happened, and that was when we searched communication, of course, remember this is the year 2000, but when we searched communication and palliative care, communication of life care, we found that 95% of all the literature, all the literature was on one single topic. And the one single topic was Breaking Bad News. And so we immediately said, “Wow, that’s an important conversation.” But there are so many more important conversations to have with people beyond, so we actually wrote a paper called Beyond Breaking Bad News. And so in our communication curriculum, for example, and our ICC course funded by NCI now, all of our curriculum, all of our ELNEC curriculum, our communication curriculum are organized by the NCP domains, because for example we emphasize you will never provide good pain or symptom management without good communication skills.

So how you ask the patient about their pain, how you communicate about not just the physical pain but what about the pain in your soul because of what’s happening to your body. To really assess dyspnea is not just checking the pulse ox. It is what does this feel like to you to feel like you can’t breathe? So in all of our communication work, we try to really emphasize that communication is way past breaking bad news. And that it is the role of nursing and all clinicians to apply good communication principles to pain management, symptom management. How could you possibly do loss, grief and bereavement without good communication skills? We talk about communication in the final hours. So communicating with patients, communicating with families. We do a lot of interactive teaching, a lot of role plays, a lot of videos like Wit and many other videos and a lot of… Remember communication we always say, if you want to teach pain management, that’s a cognitive. That’s the list of drugs and what dose, et cetera. When you want to teach communication, that’s a behavior you’re trying to change and so it’s experiential.

So you can only teach communication by having people experience, practice, really have confidence in their skills. And we love the communication part of every one of our curriculum and then of course the whole communication course.

Alex: I would love to follow up about this. I know we want to get to talk about geriatrics and ELNEC geriatrics. And I wonder if you could distinguish the communication within ELNEC from other courses that have grown up over your career. Like a VitalTalk, for example, like Serious Illness Communication guide or framework, or was checklist now has changed to be I think, guide. How do you view ELNEC within the context of these other communication training, Train-the-Trainer approaches that have taken your model and boosted it for their own educational purposes?

Betty: Sure. We’re really fortunate, and my colleagues remind me we’re really fortunate in our field of palliative care because we have collaborated with so many wonderful disciplines. And so from the very beginning, as soon as I knew about VitalTalk, of course Tony Bach was so helpful and generous in sharing things from VitalTalk. So in ELNEC we use VitalTalk materials and we show the Great Family Meeting video that everyone’s so familiar with from VitalTalk and we pull from all the other sources of communication training. I think again, so much of what we have seen that exists, which is outstanding, but it’s often about the initial bad news or the recurrence news or the family meeting of we are now at the end. And so we use all of those things, but what we are really interested in is communication that happens throughout the continuum.

So if you’re the geriatric nurse practitioner and you now are seeing a patient over years as they decline from their dementia or post-stroke or post heart failure or whatever it may be, there are many conversations to be had. There are important skill in listening as patients and families grieve these chronic illnesses in geriatric care. And so we are interested in how can we enhance the skills of nurses in geriatrics, but in every area that we work in critical care, in every area so that nurses have good communication around pain and symptom management, spiritual care. We have a spiritual care module. We have a very heavy focus on culture and diversity and everything that we do. And so we practice having a conversation with the LGBTQ patient and partner or spouse. We practice having communication with people with no religious affiliation or very diverse religious affiliations when it comes to spiritual pain or suffering. And so communication is as enormous as our whole field. Every aspect of our field of palliative care has an element that needs good communication training.

Alex: Last question from me, then I promise I’ll send it back to Eric. I love this vision of it’s much more than the breaking bad news. And it’s really a spectrum. And it’s like everyday conversations can be enriched to be higher quality around ordinary things like asking about pain. And the name is end of life, it’s in the title. And as you say-

Eric: We’re really breaking down that title from nursing to end of life.

Alex: That was the term right before there was palliative care. And there is, I say, a healthy debate, a discussion within palliative care around whether we should use the term end of life care or whether we should make it verboten, strike it from our lexicon. And only focus on palliative care and only talk about caring for people with serious illness. I’m interested-

Eric: Or even change the name of palliative care to serious illness cares and kiddies care.

Betty: Yeah, we’ve had this conversation many times where we’ve said, should we change our name? Because not long into our history we’re like, really, we’re a lot more than end of life care. But I think at that point we were in so deep and we thought you have several 1000 people trained around the world, and that ELNEC kind of became a household term. So we have opted to keep the name ELNEC, but everything that we do says ELNEC preparing nurses in palliative care. And if I was starting ELNEC tomorrow, would I use the term end of life? No. Would I have the name ELNEC? No, but it sort of is our name. But absolutely, I think we all know that palliative care extends as we know from the time of diagnosis. I would also say we still have a heck of a lot of work to do on the end of life part.

And geriatrics is one big example of where people don’t die well still. And so I think we want to embrace palliative care across all phases of serious illness. But we also want to say there’s a lot to do to improve end of life care.

Eric: How much does the geriatrics curriculum look like the traditional ELNEC curriculum?

Betty: So we now have our ELNEC Core, which is very general. We have pediatrics, we have geriatrics, we have critical care, we have advanced practice nursing where a lot of geriatric nurse practitioners would come to APRN versus the general geriatric course. And we also have our communication curriculum. And then we have this whole new world which started about 10 years ago which is ELNEC for all undergraduate nursing schools and ELNEC for all graduate schools. So all of those curriculums have the same framework, which is the NCP guidelines. And we’re very intentional about that because if the NCP guidelines are supposed to be the clinical practice, what is evidence-based standard of best care, then that’s what we should be teaching clinicians. And so all the curriculum look a lot alike. They have the same modules and they look a lot alike, but we also try to make sure that each of the curricula are taught by experts in that area.

Their curriculum is updated by experts in that area. So for example, in geriatrics, we have two outstanding geriatric nurse leaders, Shila Pandey, who’s a nurse practitioner at Memorial Sloan Kettering. And Dorothy Wholihan, who is a nurse practitioner and faculty at NYU. And so in every curriculum we bring in experts in the field. They teach because in all of our courses we want teaching done by clinicians, people who really were in the clinic yesterday and can really tell you about the patient they saw with this problem they’re teaching about. So we have experts in the field, scholars, but also clinicians who are teaching the content.

Eric: Wow. And when did ELNEC for geriatrics start?

Betty: I think it was around 2008 is my guess.

Alex: Yeah, we started GeriPal 2009 as a blog. As around the time, thinking back for those of you whose clinical clear could extend back then, there was some tension I would say between geriatrics and palliative care, gerontology and palliative care at that time. And there was a sense within medicine that some of the fellows who would previously have gone into geriatrics were now going into palliative care, for example. I wonder from your perspective whether… And that’s part of the reason that we started GeriPal quite frankly, was because we felt like, hey, this tension is ridiculous. We have so much more to accomplish if we work together and learn from each other than we do if we are at odds.

Betty: Absolutely. In the world of nursing, I would say the world of geriatric nursing which certainly preceded palliative care, has a world of knowledge to share with us about what geriatric nurses have learned and researched and taught and live every day in every clinical setting about management of comorbidities and multiple symptoms and complex family issues and across the spectrum of diseases. And so there is in fact a strong body of knowledge and clinical experience in geriatric nursing beyond palliative care, but geriatric nursing. We also very much believed though that when we looked at a lot of geriatric nursing work, a lot of it the goal of care was still increased function and prolonging life. And so there really was not much in even the geriatric nursing books or courses or journals about end-of-life care. And so I think that is the richness of combining the experts in geriatric care and geriatric pharmacology and functional status and nutritional support.

And that’s a whole world of knowledge in geriatric nursing. But what we bring to that is, and how do we then help these patients and families in shifting goals of care? And how do we manage all those medications when now we’re about to add six or seven more medications because of the symptoms? And what does the end-of-life look like and where do older people die? And how can we support caregivers and nursing assistants in nursing homes? And all of that work has been the merger, but I think it’s critical that these are separate but absolutely very shared domains of patient care.

Eric: Yeah. I guess another question is of the 1.5 million people, the nurses, other health providers who’ve taken these courses, and especially the ones who’ve done the Train-the-Trainers, it does require a lot of leadership skills to bring it home to your institution to argue for the two days for the curriculum. And they’re often also program builders within palliative care. Is there, I guess a leadership component on how to do that as part of that? And is there any tension too that you feel amongst different disciplines, nurses, doctors, how to think about that as you’ve kind of done this over the last 20 years?

Betty: Sure. One of the reasons we created the APRN, our Advanced Practice Curriculum was many years ago when we realized that nurses who were the NPs or the clinical specialists or advanced degrees, those that were supervisors or leaders within their systems, that they were at a very different place. Obviously they were at a different place clinically in terms of their clinical role, but they also were in a different place because they had such an opportunity to provide leadership. And so our APRN curriculum provides these nurses with advanced pain management, advanced symptom management, but we spend a lot of time in the APRN training on leadership. How do you make the case? How do you change the culture? So those courses look really different. In a lot of our international work, we’ve created a whole leadership institute or leadership training because we needed to groom leaders in these countries if they were going to make system change.

So leadership is essential. We also know that getting off work and coming to a two-day ELNEC course is not going to sustain your efforts, because then you’re just going to go back to work and you got to go back to work. Your patient load didn’t change and so we try to do a lot of reinforcement. Our website has abundant resources that are continually available. We have social media, we have webinars monthly across many of our courses. We have a newsletter that goes out quarterly to all of our trainers that gives them constant new resources, highlights what other people are doing. We are available by phone and email to just talk with people once they run into a brick wall. We do lots of matchmaking with people. All of our faculty across all of our courses continue to serve as mentors. And so definitely the course is the course but it’s the infrastructure that supports people as they grow.

One of the fun things when you’ve done this for 25 years is now we have a lot of repeat customers. We have people who they came to a Core course, but now they actually spend most of their time in geriatrics so they come back for geriatrics. Or they came to a Core course and now they’ve become an APRN and so they need to come and get that. So we love to have our repeat customers or we have people who say, “Gee, I went to an ELNEC course 20 years ago. I thought I needed a refresher.” And so that’s always fun to have people come back and get renewed.

Eric: Yeah.

Alex: 25 years is just a remarkable legacy. And the number of people that you have influenced and educated around the world is just remarkable. And as we think about the next 25 years, I wonder if there are things you worry about. What are the challenges and what are the opportunities for ELNEC over the next 25 years?

Betty: Yes. I think it’s really important for every one of us that are in the field of palliative care to be thinking about succession planning and to really be thinking about the future, because when we all started there were no mentors and there was no field actually. And so we were really inventing as we went along. But it’s interesting because we all started together then that means a whole lot of us are going to exit together. And so that’s something the whole field should be worried about because we will have a whole lot of leaders in our field retiring in the next probably five to 10 years at least. And so in ELNEC we’re very thoughtful about this, and we’ve been doing a lot of things. One of the things is as of this year in every one of our curricula, we now have recruited new young faculty that are now teaching in our courses, being mentored by the more senior faculty so that we make sure that we have seasoned faculty to continue.

ELNEC is not one thing, it’s actually a whole big massive thing. And so I’ve been, the last few years, thinking about each component of ELNEC. There’s our work with schools of nursing. So I’ve taken two leaders in nursing, Megan Lippe, who’s in University of Texas in San Antonio and Andre Davis, who’s the faculty at University of Portland. And so they have now groomed them to take over our work with schools of nursing. And University of Portland is also really supporting that effort. So each element of our undergraduate work, our graduate work, all of our clinical curriculum, our international work, I’ve now identified a leader to make sure that that work continues. And I needed to start that now.

I hope to keep doing this work for some additional years, but for everything that we do in ELNEC I now have someone in place who is well qualified to continue the leadership. Judy Pace has been faculty with us from the very first course teaching pain management. And Judy has now taken on a role with us coordinating across all of our curriculum and also leading some of our international work. You have to groom and you have to plan.

Eric: And when you think about the things that you’re working on and you foresee will happen the next five to 10 years with ELNEC, what are you most excited about aside from succession planning?

Betty: I think I would say three things. One is every one of our clinical curriculum, geriatric critical care piece, et cetera, the needs are growing. You might say you’ve trained a lot of people, but we’re just starting. All of those clinical areas need more and more training, that’s one area. The work I’m extremely excited about is our work with schools of nursing. We created a whole curriculum for undergraduate programs and graduate programs, but more importantly, because our partners AACN we’ve worked with them for all of these 25 years, and now AACN requires that every school there’s a document called the Essentials, which is kind of like the constitution of nursing schools. And now we started remember with nothing in nursing schools and less than 2% in the textbooks. Now AACN has redefined nursing, and one of the four spheres of nursing practice is palliative care.

So the work with schools of nursing, we have 1200 undergraduate programs and 400 graduate programs now using ELNEC in some way teaching palliative care. And so we’re all playing catch up. Every one of us have spent our careers playing catch up because we’re all out there taking care of patients, but we don’t know how to provide palliative care. And so wouldn’t it be better if every medical student and nursing student and social worker started their practice prepared to do this care? So our work with schools of nursing is my second big joy of the future. And the third is our international work, so 114 countries. And that to see the work spread around the world, to see very low resource countries be able to advance palliative care as well as those that are resource countries. So I think the impact that… And I would just say to all my palliative colleagues, like everywhere we go in the world, people they’re looking at America. They’re looking at these palliative care fellowships and what does the palliative care physician do.

And the ability to see what we’ve done in America, but how it can be a model for others. Obviously we learn from all these other countries too, but I think to see the international impact of our field as a whole is very, very rewarding.

Eric: Well, Betty, I want to thank you for being on this podcast because this is just amazing. Just the sheer numbers and what you’re doing and where you see things going, it’s pretty impressive. And even for me personally, ELNEC has been such an important part of my career, my learning, and also being a part of the honor of being a faculty in ELNEC too in my own local institution. So thank you. But before we end, I think we got a little bit more of Alex’s Bruno Mars song. What’s the title again?

Betty: Count On Me.

Eric: Count on Me.

Alex: (singing)

“If you’re tossing in, you’re turning in, you just can’t fall asleep, I’ll sing a song beside you. If you ever forget how much you mean to me, every day I will remind you. Find out what we’re made of when we are called to help our friends in need. You can count on me like one, two, three, I’ll be there. And I know it when I need it I can count on you like four, three, two, you’ll be there because that’s what friends are supposed to do, oh, yeah.”

Betty: Wonderful. Thank you.

Alex: Great choice of song.

Eric: Betty, thank you for coming on this GeriPal podcast with us.

Betty: Sure. Well, continue your great work. I love the podcast.

Eric: Ditto. We love ELNEC. So thank you again for being on, and thank you all of our listeners for your continued support.