Caregivers: Podcast with Jessica Zitter

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’re welcoming back Jessica Zitter who is a palliative and critical care physician at Highland Hospital. And is the author of Extreme Measures as well as a film that we are going to talk about today, a caregiver love story. Welcome back to the GeriPal Podcast, Jessica.

Jessica: I’m so thrilled to be here with you guys.

Eric: We’re going to be talking all about caregivers, but before we do, do you have a song request for Alex?

Jessica: You know I do. And I would have to say it’s Here Comes the Sun.

Eric: And can I ask why?

Jessica: Well, I hope it’s apparent to every single one of us listening to this podcast, but this has not been an easy year. This has been a very…well, it’s certainly been a hard year for so many reasons. And I’m looking forward to some excitement, some change and some positive impact from all that we’ve learned.

Eric: Yeah.

Alex: Yeah.

Eric: I feel like I had plenty of excitement this year, so I’ll be with everything else, I’m hoping for a really boring 2021.

Alex: I know, you know 2020 is just going to give us one more kick before it goes right?

Eric: Yeah.

Alex: One more, right, just right at the end there. Okay. So I cut my finger – paper cut. So I have a band-aid on it. So that’s my excuse all right if you don’t hear the full guitar part for this. I can’t play guitar well with his finger bandage, but here you go. Here’s the best I can do.

Alex: (singing) Little darling, it’s been a long cold lonely winter. Little darling, it feels like years since it’s been here. Here comes the sun. Here comes the sun and I say it’s all right.

Eric: Yeah, it worked with the band-aid.

Alex: Jessica, let’s go into the topic. When I think of Jessica Zitter I think of a palliative care, critical care author, director…is this a long standing interesting caregivers and if not, how did you get interested in this?

Jessica: Well, the story is, I think really instructive. I certainly was not intending to make a film about caregivers and I’m going to be totally frank with you and honest. As somebody who’s dedicated most of my career to thinking about improving the way we die in America, I had really been very patient-centered like we do, like we think about ourselves in palliative care, really thinking about the patient. I really had not been thinking about the caregivers and I set out to make this film. It wasn’t even really going to be a film, it was going to be a sort of some educational video was around the time that my book was coming out. And I thought let’s have some great educational material to show how great hospice is and how great dying at home can be. And I had this sort of image that calling and hospice is a slam dunk.

Jessica: It’s kicking the ball through the goal. It’s sort of our sort of Mecca of good dying. And this was my friend, this woman who’s in the film, my friend Bambi, who herself was also a health care provider, a physician assistant. And she was on what I call the end of life conveyor belt. She was going for every treatment, everything. She was deteriorating, you could watch her. And one day she called me and she said, “I can’t do this anymore.” And to speed it up, I came into her house, she hadn’t had a poop in two weeks. She was so sick. We got hospice in there that day, within about 24 to 48 hours her life turned around. The way we think, that sort of vision of hospice, everything got better. Her family, they all were planning to fly in very quickly from overseas, there was going to be a big family reunion.

Jessica: She was feeling so much better. She got a new lease on life. So the whole point of this footage that I started to collect was to show how fabulous death can be if you do the right things, i.e call hospice. And what I didn’t realize was that it would take two years after Bambi died when we were starting to put together some of this footage, it was only then that I actually realized that I had been looking at the completely wrong character for this. It wasn’t Bambi, it was her husband, Rick. And when you watch this film, you just cannot believe that you ever could have thought that it was about Bambi. It’s really about him. I thought he was just going to be the guy that opens the door to the hospice people when they came in, but he became the primary character in this film and made me realize I needed to learn a lot more about this topic.

Alex: Wow. So it was actually in post production like years afterwards, you actually came up with kind of or even recognize this idea of the importance of caregiving at the end of life.

Jessica: Absolutely. Yeah. Yeah. And I’m a little embarrassed about that. I’m actually very embarrassed about it. And especially talking to a group of geriatricians and palliative care doctors, I know that among the audience of this podcast, there are many, many people who are probably shaking their saying, “How did she not know about this problem? How did she call herself a palliative care doctor and not have thought holistically about this patient?” And all I can say is, “Yeah, mea culpa. I didn’t.” I was so focused on the hospital location that I just wasn’t thinking about the bigger picture and what happens to the people when they go home.

Eric: Yeah, you probably have everybody and certainly in this group of people when I think back and think about all the patients that I’ve cared for and have these big goals of care discussions, and we agree to hospice, but the caregiver wasn’t involved. The person that we’re going to be relying on may not be involved. And luckily we have an amazing social worker on our team who often is the one who’s reminding us to do that. But I think the challenge is so many other things that we’re trying to incorporate and synthesize and put together that it’s one of those things in health healthcare system that caregiver is often this person that we’re not focused on.

Jessica: Well, it’s that, and it also raised my awareness to the fact that we sub-specialists, whether you’re palliative care or an ICU doctor, we want to envision because this is such hard work. We want to feel like there is some kind of an answer for us. There’s some kind of solution that we can fix this, whether it’s in the ICU, plugging someone into a ventilator, which is one form of fixing a problem or doing something. And in a way it’s the same thing when you’re a palliative care doctor that you want to feel like you don’t have to, all of the social complexities, it’s almost too much to bear and you want to say, “Okay, we got them on hospice. Yes.”

Jessica: The number of times when I look back on this now where we would set up plans of care and we’re talking and we’re getting everybody in and we’ve got the hospice kind of coming in to meet with the patient in the hospital and their family, I think back on it and I just realize how many of those caregivers were kind of deers in the headlights especially once about five years ago, we started realizing like, “Wow, we’d better start preparing them a little bit more and tell them you’re going to be doing the bulk of this work.”

Jessica: And then when you do that, and then you still were plugging them into hospice, there was this like, “Whoa, you’re telling me all these scary things and you’re still sending me home without a lot of support and a lot of understanding of what I’m going to be doing.”

Alex: Well, let’s talk about the film. Eric and I had the opportunity to view it. And I wanted to ask you some questions about Rick in particular, who was the caregiver for Bambi. And I remember there was a scene early on in the film where you’re talking about what it’s going to be like in the future. And Bambi is saying, “I don’t want you to have to clean up after me.” Meaning I think after toileting.

Jessica: Because I don’t want you to have to wipe my butt.

Alex: Rright, I don’t want you to have to wipe my butt, right? She says, and Rick says, “Yeah, I don’t want to do that.” And then I think I heard you say, “That’s not your job.” And yet, if I’m understanding what happens in the film, it does become his job.

Jessica: Exactly. Whose job is it?

Alex: Mm-hmm (affirmative). Right, who else is there? Right, because hospice is not going to come in and be able to clean up after somebody, wipe somebody’s butt when that is a basic need that needs to happen. Toileting basically needs to happen. So I could see even through the evolution of the film, as Rick is learning what his role is, you are also learning what Rick’s role is and that came as something of a surprise to you over the course of the film itself.

Jessica: Did you notice that scene in the film where I’m sitting with him and he’s feeding Maya, and we’re talking and I’m saying, “Rick, you need to ask for more help from hospice. They’re really set.” And he’ll say, “Yeah, yeah, what they offered me was an hour or half an hour, twice a week.” And did you see my mouth literally hanging open? I was shocked. I was shocked. Again, mea culpa but I was shocked.

Alex: No, no, but I think that’s partly what’s remarkable about this film is that you do go into this and that people have growth trajectory throughout this film, including you and what you learn and I think it’s remarkable that you put yourself out there, not as like physician saved the day, palliative care, because you could have cut it differently, right and made that original film that you were intending to make. But in this, you’re vulnerable, you’re learning, you’re making mistakes and you don’t know everything. And I think that’s true to life for a lot of docs out there even if they’ve been trained in hospice and palliative care. I mean, we just don’t know the extent of the burden that caregivers have daily. Moment to moment daily, often without anybody witnessing.

Alex: And in this case, they had you and they had the filmmakers witnessing and the audience will witness as well. But normally, it’s done unwitnessed.

Jessica: And did you see in the LA Times, and I would give a shout out to this, Nathan Gray, who, if people don’t know is an amazing palliative care physician at Duke, he did a gorgeous, and we should put this in the resources, if you’re putting out resources, a gorgeous spread in the LA Times on caregiver burden. And he does a lot of home visits and I was reading it. It just came out like a week and a half ago. And I’m like, “Oh my gosh, this is my keynote,” because I’m writing a keynote to go with the film. He’s talking about his surprise and it was always when he started going home and he said, “I have to filter into my day, an extra 15 or 20 minutes just to be on the porch with the caregiver while they cry.” This is not anything I knew about.

Eric: Wow.

Jessica: And I think we all need to be aware of that.

Eric: We’ll have a link to Nathan. I love his, I guess, graphic artist style-

Eric: I know you love his style. He’s a graphic artist, right? Yeah. He’s great stuff. Very tweetable.

Eric: I was going to say cartoonist, but that’s the wrong word.

Jessica: Yeah, he told the story so beautifully, but what you said, Eric, I think it was you who said about editing the film. You have no idea how much re-editing had to go into this. Not only because it was a different story, although the story told itself enough in the rough cut. When I still thought that this was a story about how hospice is so fabulous, which it is, I mean, I’m not saying hospice isn’t fabulous, but hospice saved the day, it was sort of the message here. And there was another piece because they were very much part of my Jewish community. And so we had this strong community coming in and it’s sort of like show how having a community can be helpful, which obviously a lot of people don’t, but it was sort of just another like what are some of the things that can make for a good death?

Jessica: So there were couple of things that needed to be seriously reedited. One was, “Oh my gosh, the entire thesis of this film is totally different from what I thought.” And number two, and this was really challenging, I don’t want this film to feel like it’s throwing hospice under the bus because that’s the last thing I want to do. This is not about throwing hospice under the bus. And the early cuts of the film, friends and family would watch it and we’d sort of have some screening parties and a lot of people were coming and going, “Oh my gosh, maybe I do want to die in the hospital.” And I’m like, “Wait, wait, wait, wait. Wait a minute. Have you seen Extremis? No, you don’t want to die in the hospital.”

Eric: It’s going to be a lot worse. Well, I think that’s a really interesting thing is that I think sometimes we oversell interventions like hospice. We set expectations potentially because some people in palliative care have never actually worked in hospice before, or we really want to make sure that they choose a particular route so we may oversell it. And it sets this expectation that’s just setting hospice up for failure. Oh yeah, yeah, totally hospice with 24-hour caregivers, sure they can do that. Yeah, in their $120 a day that they’re making, yeah, they can totally spend $30,000 a month on caregiver support. [sarcastic]

Jessica: One of the things as I started to really research this a lot more and sort of try to prepare, there’s many audiences. This is not just a healthcare systems problem. Okay, we can do our part, okay, between healthcare systems, whether it’s inpatient and outpatient and hospices and sort of how we interact in that sort of moving a patient around and making sure we don’t drop the caregivers out of the picture and we do not support their caregivers. So there’s a lot we can do in healthcare. And in fact, when you think about the healthcare system is a place that really attracts caregivers because they’re there because they’re sick people that they’re taking care of, but there’s many other systems that interact with and can impact the lives of caregivers.

Jessica: For example, employers, politicians, and local state and federal laws around caregiver support. Communities, whether they be faith communities or other types of communities, and then just individuals themselves who are living, part of the general audiences of people who are going to be interacting with caregivers all the time. More than one out of five Americans is a caregiver, 53 million people in this most recent 2020 support from the national lines on caregiving. That’s a lot of people. And so there’s many stakeholder groups that need to understand about this problem because many of these stakeholder groups can have calls to action that will help to improve and prevent caregivers from slipping through the cracks. But we in the healthcare world, I think have a very big responsibility to start because we are dealing with such a high concentration of them. And I’m trying to remember what my original point was.

Alex: Well, let’s go with we in the healthcare world angle, because most of our listeners are clinicians. Doctors, nurses, nurse practitioners, social workers, chaplains, seeing patients clinically, what can they do? And what do you hope for from this film, from any movement that you advance associated with this film from healthcare workers, from people who are working clinically vis-a-vis caregivers and caregiving.

Jessica: Yeah, I think that the essential question is in healthcare systems, we tend to focus on the patient. We have to lift up our view and understand that there is this holistic system just like we’ve done in palliative care, right? We’ve lifted up our view from just the Oregon or the disease to the person. Now I think we’ve got to lift ourselves up and understand there’s really this whole system. I think hospice and palliative care nominally does that. In general, we believe in supporting family, we have this concept of supporting the bereaved, but we don’t necessarily talk about supporting them before the death. So I think we’ve got to start doing that. I think hospices inpatient teams that are discharging people out of the hospital, outpatient clinics that are dealing with seriously ill and chronically ill people have to be more formulaic about identifying caregivers.

Jessica: We’ve got to suss out, find these people. Don’t forget a lot of these people don’t even know they’re caregivers because they think they’re a daughter or they’re the wife, or they don’t understand they’re part of a group that actually is probably going to need some support. And so we’ve got to start by identifying these people. And how do we do that? There’s many ways and we know how to take a history. If a person’s a patient, you can start by saying, “Are you taking care of anybody at home?” Our patients themselves may be caregivers, but then if they’re not, the patients are going to have a whole series of people who are caregivers and we’ve got to figure out who they are. And it doesn’t just mean who’s in the house with them, there may be people who are an hour away who are also dealing with these caregivers.

Jessica: And by the way, this report on caregivers that just came out, shows that, and I think a caregiver who lives an hour or more away from the patient spends about $13,000 of their own money taking care of the patient and a caregiver who lives in the house spends I think about 6,000. So there’s a big burden on people who are not in the house with that patient or that care recipient. So we have to be thinking not just about who’s in the house with you, but who is involved in the care of this person, even from a distance. So identifying, assessing their level of burden, there’s many different kinds of things that increase the level of burden on a caregiver and therefore worse in their outcomes. So things like is the person got dementia? Is the care recipient have dementia because that is a significant increase in the burden.

Alex: Huge.

Jessica: Yeah, huge. And there’s a whole lot.

Eric: We just had a podcast with Zaldy Tan about caregiver dementia bootcamps, things that we could do. And we’ve had past podcasts on caregiver support. I got to say a lot of that’s coming from the geriatric side that we’ve been having those podcasts around geriatric or caregiver support outside of the hospice realm. I also wonder from the identify, I don’t think it’s enough just to identify, but is there a place anywhere in that medical record where that information is shared? If I know somebody is a caregiver, how am I sharing it to people like, “Hey, by the way, we’re going to be sending this person home with Lovenox and you’re going to be the one giving it to them and maybe we should identify and that that’s a source of training.”

Jessica: I love that. Yeah. I created a program that goes with this film for medical residents that we’re actually trying to work with the American college of physicians to disseminate. And I came up with this very crappy…sorry, am I not allowed to say that?

Eric: No, you can say “crappy”.

Jessica: Okay, crappy [laughter]. Crappy acronym, but nonetheless, it’s an acronym. IASF, it means nothing, but identify, assess, support, and follow up because so many of these caregivers completely lose. They just are too overwhelmed to follow up. They completely forsake their own. Follow-up their own preventive healthcare. They stopped seeing the doctors, many of them, because they’re just so busy taking care of this person. So if we can get involved in sort of proactively find these people and support them and follow up with them, I think that’s important but I love the document D. So where does that go? Identify document, assess, support, and follow up. And if anyone wants to help me with creating this workbook that I want for medical residents and other places, I’m calling all people come and help me create this. I think this is an important thing.

Alex: And they should reach out to you at caregiver@jessicazitter.com?

Jessica: Yeah, that would be great. So caregiver@jessicacenter.com is anybody, any group, any sort of training body, educational body, any residency program, medical school, nursing program, social work, any program that might be interested in seeing the film and having some sort of an educational component, we’ve actually gotten CME for the film. So if you go to the American Medical Women’s Association website, you can watch the film and do a didactic short film for CME credit as well.

Eric: Can I take a step back? So what are you hoping will happen with this film? It sounds like you’re hoping that people can use it for an educational purpose.

Jessica: So yeah. So I hope that we can show the film to as many healthcare groups as possible and start to film. This is not in and of itself just wholesome. I don’t know what the local situation at Kaiser is, but I would like for Kaiser to see this film and say, “Hey, wait a minute, maybe we need to enhance some of our strategies for making sure that caregivers aren’t falling through the cracks.” And figuring out their own systems internally, and then some hospital sees it. I think that if we can get this film scene, we’re creating a workbook right now for hospices. So how can hospices best support family caregivers? So if we start to raise awareness with the film and trigger people’s emotions and motivate them to want to change and create systems so that these people are not dropping through the cracks, I think that will make a big difference.

Eric: So the other question is, the larger general public. So when you did Extremis, your last short documentary, it was on Netflix, it was nominated for an Oscar, are you also-

Alex: That’s right. You were at the award ceremony.

Jessica: Yes.

Alex: That’s what we talked about on our last podcast, right? What are you going to wear to the award ceremony as well as the movie and all sorts of deep stuff.

Eric: We learned it wasn’t what are you going to wear, it was who are you wearing?

Alex: Oh, that’s right. That’s right. Who are you wearing? [laughter]

Jessica: Kind of the exciting news about this film is it won best documentary short at the San Francisco Jewish Film Festival.

Alex: Great. Congratulations.

Jessica: Thank you. It makes it Oscar eligible. So they’re hoping that somehow it will get noticed. We’re hoping that they’ll notice it. It’s a long shot, but we’re going for it.

Eric: How do you get your film on Netflix?

Jessica: Well, that’s a good question. I think they have to notice you. Netflix is doing much more of their own stuff lately. We’re going to be doing outreach to all of these platforms eventually, but we’re not ready because this year we really don’t want to make it publicly available until we’ve had as much impact with target key stakeholders so that it’s not just freely available and people can go see it when they want to and not have it accompanied by some kind of didactic.

Eric: And for our listeners who are those target stakeholders? It sounds like all of our listeners, right?

Jessica: Certainly, all healthcare, because as I said, I think it’s a tremendously important area that can have impact. All hospices, all social workers, all people who work in and out of hospitals, in clinics and in inpatient, we should all be more aware of this and have strategies for how we’re going to start thinking about caregivers in our midst. I would like to get this in front of employers. Right now, well, what do we have? Rick did this for nine weeks. Do you know the average moment caregiver does this for four and a half years? How has 12 weeks of family medical leave in any way going to support somebody to keep working? It’s not enough. We’ve got to have more flexible approaches. Employers need to create more flexible approaches to supporting caregivers in their midst. They need to understand who they are. By the way, employers are losing $65 billion every year in employees having to quit or miss work because of caregiving duties, they will benefit significantly.

Jessica: The caregivers themselves who could continue to work do much better than caregivers who have to quit their jobs. So there’s a win-win situation here that if employers are aware of this issue, everyone’s going to do better. Legislators, I mean, there’s been some untoothy sort of stuff that’s kind of been put forward to support caregivers. It hasn’t really done much. Joe Biden is coming in with a plan. It’s a huge plan that Ai-jen Poo from the National Domestic Caregivers Alliance and all of the people who do work in this area feel that this plan that Joe Biden and Kamala Harris have to come in to support family caregivers actually is holistic and has a chance of really making a difference for family caregivers more than anything that’s come our way so far.

Jessica: So legislators need to be made aware of this. Let’s show it in our halls of Congress. This is an issue that should be bipartisan. All races are going to experience this. Almost everybody, except the exceedingly rich is going to be touched by this issue. So it’s something that we really all, Democrat and Republican should be coming together to talk about changing the way we govern around this issue.

Alex: Yeah. Yeah, a huge need for health policy reform. And you’ve touched on this. We talked about this a little bit with Zaldy Tan as well. And in your film, right, Rick saying, “Yeah, I talked to hospice and they offered just small, additional help.” And then there was a point where he was doing the laundry and well, he can’t afford paying for somebody to come by and be the personal caregiver there. There is a huge need and ultimately what happens is many people who would prefer to be at home towards the end of their lives aren’t able to be at home because the caregiver is overwhelmed, burnt out. And the person gets admitted to the hospital. Maybe they get admitted for respite and then back home. But a lot of times I think what happens is they get admitted to the hospital and they ended up dying in the hospital which is not their preferred place of death.

Jessica: Or they get admitted to the hospital and they get right back on the end of life conveyor belt, why? They get pulled into the ICU, put on a ventilator because their family, their caregiver has lost trust because we sent them home unprepared and they had a terrible experience and they were frightened and they were overwhelmed and exhausted, and they bring them back to the emergency room. And they say, “You deal with this, you do everything because you didn’t do anything. You sent us home and we suffered and now I want you to do everything you can.” And so we get people come and they go right back into the ICU.

Alex: Yeah. And I think it’s important for people who are viewing this film from within geriatrics and palliative care, which is our community to not take the view of, “Okay, so Jessica Zitter had this moment where she realized caregivers are really important. We’ve been paying attention to caregivers forever. We know they’re important. She just realized this.” And approach it instead with humility about what we don’t appreciate and what we think we know, but we don’t know about the extent of burden for caregivers in the extent of our obligation to help them as professions who are focused, not just on patients, but on their caregivers as well. And I think that the related point is one of the ideal target audiences are critical care physicians. Those people who work just in the inpatient setting, whether they’re anesthesia or they come from pulmonary critical care, I guess pulmonary critical care, you get a little bit of outpatient, but you’re generally not in people’s homes. You’re not seeing that daily burden of caregiving in the same way that people who are home care physicians are seeing, for example.

Jessica: Yeah, absolutely. Absolutely. We just got to wake people up and that’s one of the things I really believe in the power of film to stir people, to not necessarily in and of itself have to be so didactic, but just to show you a story, look at this, and then make people say, “Oh, you know what, I think I want to learn more.” I mean, for me, this was narrative medicine instruction, just making the film. I then went and learned more. And I’m hoping that this film will have that impact on other people as well to want to go learn more about it.

Alex: And we should say some points about the film. It’s about 25 minutes long?

Jessica: 24 minutes.

Alex: 24 minutes long. So if you want to show this to your audience, you don’t have to clear out a two-hour spot for what you think of as a movie, right? This could be a 24-minute showing with plenty of time for discussion afterwards because that’s the key piece. The film is great, but it should launch a conversation.

Jessica: Right. Extremis is also 24 minutes. And what I learned is if you keep it under half an hour, you got a few minutes for an introduction. You’ve got 25 minutes for the film and then you got a half an hour to have a conversation and it fits into a lunch slot. And then really, if you want to bring it to people, you got to bring it in a way they can digest it.

Eric: Right. And if people are interested in watching the movie and using this for teaching, how do they get it again? Could you just do a quick reminder?

Jessica: So just reach out to us at caregiver@jessicazitter.com and we will talk with you about your particular needs. And we have lots of ways of presenting it. Whether it’s just seeing the film itself, doing the film along with Q&A, or lecture or some things. And we’re creating programming for some slightly different audiences and are open to creating more if someone wants to help create some for nurses or for administrators.

Eric: So if people have good ideas about how to use this and want to try something new, it sounds like you’re not set on or you’re actually happy that people want to try this and use it for different things.

Jessica: Yeah, yeah. That’s fabulous.

Alex: And you’re able to do this via Zoom now presumably, or some sort of remote presentation?

Jessica: Yeah. Yes. We’re doing everything remote obviously. We’ve actually just created, we were working with a new platform called Eventive and we have an impact producer who’s really in charge of trying to maximize impact with the film. And so she’ll be the person who is getting back to people about it. Although if we’re going to create new programming, which I’m really open to doing, I’ll be talking to these people who might want to help.

Alex: Right. I wanted to ask, speaking of that tangentially related, do you know if anyone’s making a film about the impact of COVID on people with serious illness or their caregivers?

Jessica: I don’t know, but it sure should happen.

Jessica: I suspect there’s going to be a lot of film that comes out, but let me tell you from personal experience, it takes a long time to make a film.

Alex: Right, right. And it’s hard to do now because part of the nature of the disease is that you really shouldn’t be going into somebody else’s home unless there’s a strong clinical reason to do so.

Eric: And Jessica…so two years from when you shot it to the end of editing?

Jessica: No. It was two years in the can before I got the first rough cut. And that was not just because, well, that was partly just because I was so busy doing other things at the time that I didn’t have time. And I didn’t even know if there was really a movie in it. So I hired this guy who ended up becoming my co-director, this fabulous filmmaker, Kevin Gordon. And he came in and just started looking at it and putting it together and he said, “Well, here’s a rough cut. What do you think?” And I looked at it and that’s when I was like, “Oh my gosh, I am so embarrassed I missed the whole point of this film.” But it was two years until we started really working on it. And then probably let’s see, and then it was probably another year and a half of editing. And I mean, it’s a lot of work.

Eric: Yeah. I’m just wondering, I mean, I just think back to if somebody recorded all of my palliative care conversations, looking at it in hindsight, like, “Oh my God, Eric, you’ve missed the big theme here. You missed the important part.” Yeah, I’m just going through in my mind the movies of my last family meetings of the last week.

Jessica: Yeah, I think as you said, one of you said before, the name of it all. And I think that’s what we’re really particularly good at in geriatrics and in palliative care is trying really hard to cover up our shame and embarrassment. I don’t mean cover it up, but put it in a package and move on and accept it. I mean, I’m embarrassed to think of what people are going to say. I know there are a lot of people who think about caregiver burden. I mean, I know Brooke Colton is making house calls all the time. Brooke, I hope you’re listening.

Jessica: I know there are a lot, Nathan Gray making house calls. I mean, and so for those people, this is a duh obviously, but I really do think that if I, Jessica Zitter who cares about this very, very much, if I didn’t know about this, I am confident that there are many, many other people, including in the palliative care movement who did not know about this and who would be shocked to watch this. So even if there are people who are going to laugh at me and say, “What the heck were you missing?” I know there’s enough people that even if it’s five people for whom this makes a difference, I know it will have been worth it.

Eric: Well, Jessica, I want to thank you for joining us and for doing this video and for just being vulnerable too, and sharing kind of what you’ve learned. I think those are the types of things that move this conversation forward rather than people saying, “You should know this.” So a big thank you.

Alex: Thank you, Jessica.

Eric: Can we end with a little bit more here comes the sun.

Alex: A little bit more sun. (singing) Little darling, the smiles returning to the faces. Little darling, it seems like years since it’s been here. Here comes the sun. Here comes the sun and I say it’s all right.

Eric: Jessica a very big thank you for joining us. It’s always wonderful to have you. A big thank you to Archstone Foundation for your continued support and to all of our listeners out there really we do appreciate your continued support in sharing this podcast with your colleagues.

Alex: Thanks everyone. Good night.

Eric: Good night.

Jessica: Bye-bye.