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Alyne Ellis (Host): Sometimes when we're feeling sick, we need more than tests and pills. Palliative care can make a huge difference in how we feel emotionally and spiritually as we deal with a lingering illness. Today, we're talking with Dr. Joshua Biddle, the Medical Director of the Supportive Care Center, including the Palliative Care Clinic at MarinHealth and Kora Schmid, the Supervisor of the Palliative Care team there.   This is the Healing Podcast brought to you by MarinHealth. I'm your host, Alyne Ellis. So, it's so nice to have both of you with me today. And why don't we start with a definition of what is palliative care?

Joshua Biddle, MD (Guest): That is a wonderful question. Kora and I had a conversation even before this podcast as to who has the right to define palliative care. And I think that, at the heart of what we do really, is a team-based approach in which we have a physician, a chaplain, a nurse, a social worker and clinic coordinators that all work together. And so part of what we try to do in our practice is not have a hierarchy of who gets to define what it is that we do, but I will dip my toes in those waters and start. And then Kora can kind of fill that in, but really, palliative care is a specialized field of medicine that cares for people living with serious illness. And, it's a pretty broadly defined, and sort of intentionally so, because we want all patients to feel welcome and we really want to be able to see people across the disease spectrum

Kora Schmid, BCC (Guest): So, I may add to what Dr. Biddle just said that basically palliative care is taking care of patients that have a chronic illness. It doesn't necessarily mean that they are dying, but they are dealing with a chronic illness and then we follow them through the entire spectrum of their journey. And as Dr. Biddle alluded to, we are approaching it from the whole person perspective. So, that means that we not only look at physical symptoms, but we are also taking care of the psychosocial aspects and as well as of the spiritual and the emotional components, because that all makes us who we are in each and every sector gets touched by that illness. And, in palliative care, that's what we are emphasizing, that we are looking at the person as a whole and how can we support that person as a whole, and also including into that, the family and their support system.

Host: You know, it sounds to me that this, by definition then, is a very intimate form of care that you get to know the patients in a really holistic way. And I believe that palliative care has been really called the soul of medicine. I would assume it's very rewarding.

Kora: Yes, it is. It is intimate and it's very personal. I think, and especially now that we are doing this all via Tele-Health mostly, it is just an amazing field of medicine and patients, the gratitude when they are realizing that we are slightly different than what all the other practitioners are doing, that they can come, that they can share from the bottom of their heart their aches and pains and what contributes possibly to their suffering and what may prevent them in the healing journey. And at the same time, we are also then enhancing the healing journey for them. So, it's up close and personal. And it also requires from all of us, from all of us provider that we are very open and honest to be in a very vulnerable space with our patients because they are vulnerable and we are not here to judge or to guide them in the direction that they don't want to go, but to be with them, to join them and to offer them support.

Host: Can you kind of give me a hybrid sort of example, of the kind of yes you used that you would address in a holistic way with a patient?

Dr. Biddle: I can do that. Absolutely. And just to answer that question and to add on a little bit what Kora said, I think that all of us in palliative care are interested really in the person, beyond the disease, and what we care about are people. And we care about the human condition and know that regardless of what specific disease the person is going through, that having a serious illness is hard and that people can suffer in lots of different ways, whether it be physical, emotional, spiritual, relational, within a family, within a community, certainly spiritually or existentially that in the course of serious illness, a lot of these issues come up, whether it be cancer, heart disease, liver disease, dementia, ALS, certain neurologic diseases, kidney disease, regardless of what the actual disease is, questions of personhood and meaning and grappling what it means to be human in the face of illness and suffering are always at the forefront.

And so regardless of who we see or what condition they have we just start off by getting to know who they are and what's important to them and what their values are and who their support system is and really follow their lead from there. Certainly myself as the doctor on the team and, the nurse practitioner on the team, whose name is Sarah Chow, we specialize in symptom management, whether that be pain or other symptoms associated with illness or the treatment for illness. Oftentimes we'll start there because that's why people come to us or are referred to us often, but that's really just the jumping off point to really start to get to know them and understand again, what's important to them, what they worry about, what they're looking forward to. And, from that platform of trust and relationship building, we can then refer them to whatever resource or person may be helpful, whether that's the social worker or Kora, as the chaplain, or really whoever that is.

Host: And let's talk about that with your role Kora for just a minute, because you specialize, not only as a supervisor, but also in terms of religion in whatever way that it manifests itself, spiritually with a patient. What do you do in regards to that?

Kora: I always start off when I meet a patient and their families as them for the first time, I ask them, what is it that you think that I'm doing? Because, there are so many conceptions around of what a chaplain does or what a spiritual care person does. And my role is to accompany. My role is not to bring doctrines forth, but to connect with the other heart to heart or soul to soul, and really hear them on that level.

And if there is a request, if it's a religious question that is very space specific, then we will endeavor down that pathway. But the most important piece for me is to connect with the other in the heart space and that's where there is no difference. We are connecting there. We are joining there and we can elaborate from there. And when you deal with illness, so much is going on in the headspace, everything is run through the mind and the heart is kind of limping behind. And I often mention to the patients that said, let's explore the heart. Let's hear what the heart has to say. And it's very sacred.

It's very, very sacred, and it is very meaningful when patients allow themselves to go there and also feel that they can, and there is no judgment. There's, there is an openness and a willingness to join and being in relationship with another human being.

Host: Yeah, I think so many times when people are facing something, they either want to protect their families or they feel like they are so alone and they can't explain what's happening. I think it can be a very scary time. Dr. Biddle, I'm curious about, pain control with these patients and also, dealing with really helping them to focus on the quality of life. And I'm wondering if you can talk a little bit about how, as a physician, you finesse that?

Dr. Biddle: Absolutely. Yeah. I think that pain control is certainly a very important part of what we do. It's hard to address some of the other forms of suffering that people may be experiencing without first addressing their physical pain. And so, there are certainly a lot of ways we can do that. A lot of different medications that we can use to treat pain. We like to employ what is often called a multimodal approach to pain. Meaning there are different medications that target different receptors that, can be helpful, everything from Tylenol to ibuprofen to other non-opioid medications.

For many patients that we talk to, opioids are something that comes up. Whether that be morphine or oxycodone or some other form of opioid. Obviously, there's a lot of energy around those medicines and the current cultural climate. And we can answer people's questions about them. Talk about the risks and benefits, and just really hold people's hand and make sure they feel comfortable about how we're going to treat their pain in whichever way makes the most sense for them.

Cannabis is also a medication that people often have many questions about and cannabis can be helpful for both pain and other symptoms. And that's another medication that I'm happy to have, conversations about with anyone that has them. But I think that all of that is to say that physical pain is often addressing it in some form or another as often, the bedrock of helping people achieve as much quality of life as possible. And for many of our patients, that's the starting point, but it's certainly by no means the ending point of what we like to do with people.

Host: Now with COVID at the moment, the clinic I assume, is not open. And you're addressing these issues with the patients remotely. Is that correct?

Dr. Biddle: Yes, that's right. Currently we are seeing patients by Tele-Health over zoom and occasionally a patient can come into the clinic if for whatever reason they can't operate zoom on their computer.

Host: And when you can do this, at some point you can even have group meetings perhaps with patients, so they can talk to each other about how their journeys are going, or is that relative with palliative care?

Dr. Biddle: I mean, that would certainly be a dream, at some point. We don't currently have support groups set up through our own clinic in which patients can interface with one another. I'm sure that those things do exist outside of our clinic that we can help refer people to and help look into. We absolutely can set up conversations between patients and family members that are all over the country. I mean, that's one nice thing about Zoom is that we've had many meetings with a patient in Marin and a daughter in New York and parent in another place. And so, it really does facilitate family meetings that we haven't been able to have otherwise.

Kora: There is one factor that we rarely address in this society, and that is grief and grief starts basically at the time of diagnosis. But we rarely address that with the patient. And so the fact that the patient and their support system are going through this journey of treatment and there is grief accumulating, and also grief can add tremendously to the suffering, to the responsibility of I just don't feel good and I have to keep going and I don't know what is going on, and when we start addressing the grief, at times, that also helps to actually relieve physical pain.

Host: So, one more thing in relation to the overview of this and that is that palliative care does not mean that the patient is necessarily going to end up in hospice and pass away. It really means, that the person could get better, to help them through their journey, whichever direction things are going.

Dr. Biddle: Absolutely. Another way to say that is palliative care is really, based on the needs of the patient and not on the patient's prognosis. This is a practice of medicine that's really appropriate for any stage of illness, any age. And it can be provided along with all the other treatment the patient may be getting whether that's chemotherapy or seeing your cardiologist or your pulmonologist, you can get palliative care alongside of traditional curative treatment. And so, for us, it really is kind of a no-brainer, you know, it's a whole other suite of services and extra layer of support that patients and families get in addition to all the other medical care they get. And so, we are not interested in taking away any other forms of care and treatment that a patient and family is getting. We just really want to supplement everything they're getting and provide them a space to experience themselves in the context of difficult stuff.

Host: Well, it sounds like kind, compassionate, complete care. And I thank both of you very much for talking to us about this.

Dr. Biddle: Oh, absolutely. Our pleasure.

Kora: Thank you for your insightful questions. As you have realized, this is a field that we could talk for a long time, because it is so complex. And it is very simple. So, it carries both components of complexity and simplicity and palliative care I think that I would like to add that for the listener to know actually grew out of the hospice movement because in hospice, we really take care of the end of life by addressing all the needs that the patient may have in the last stage of life and then a Canadian physician actually was wondering why that happens only at the end of life. It also should happen before that. And so palliative care grew out of the hospice movement so that we attend to patients in the whole body, mind, spirit approach and give them meaning, allow them to live a qualitative really meaningful life. And have them, positive and hopeful and not devastated and wondering is that just it? So palliative care, gives hope where hope can be found and it gives meaning to life.

Host: Well, thank you both very much. It's very nice to talk to both of you.

Kora: Thank you, Alyne.

Dr. Biddle: Absolutely. Thank you so much.

Host: Kora Schmid and Dr. Joshua Biddle, are Palliative Care Specialists at MarinHealth. You can learn more about all our This email address is being protected from spambots. You need JavaScript enabled to view it.. This is the Healing Podcast brought to you by MarinHealth. I'm Alyne Ellis. Stay well.