August 7, 2024 • 48 mins
Dr. Janet Abrahm, a distinguished professor of medicine at Harvard Medical School and an expert in palliative care at the Dana Farber Cancer Institute, sits down with Tina and Leah to discuss palliative or supportive care. Palliative does NOT mean "end-of-life" care! This misconception is just one myth dispelled during their conversation. Dr. Abrahm clarifies other misconceptions around palliative care, emphasizing its role from cancer diagnosis through treatment. Did you know that palliative care may help you stay on track when receiving curative treatment? Dr. Abrahm also discusses integrating non-pharmacologic pain management techniques, the psychological aspects of cancer treatment, and the importance of effective communication between oncologists and patients. Join Tina and Leah for this enlightening discussion about palliative care. (Hint: supportive care may be a more accurate descriptor.)
Links we mentioned and more about Dr. Abrahm:
Dr. Abrahm's website
Announcement of her prestigious award from the American Society of Clinical Oncology (2024)
Her book, Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, 4th ed (2022)
Other resources that were mentioned:
Handbook for Mortals: Guidance for People Facing Serious Illness
Living with Cancer: A Step-by-Step Guide for Coping Medically and Emotionally
The American Society of Clinical Hypnosis
Our website: https://www.thecancerpod.com
Become a member of The Cancer Pod Community! Gain access to live events, exclusive content, and so much more. Join us today and be part of the journey!
Email us: thecancerpod@gmail.com
Follow @TheCancerPod on:
THANK YOU for listening!
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Janet Abrahm (00:00):
I remember I used to have to do bone marrow tests,
(00:01):
you know, I was a hematologist,so I used to have to do that.
And I would use hypnosis and thefellows would say they were
smelling cider donuts andhearing the crackling of the
leaves and the light comingthrough it every time they did a
from then on, because We wouldtake a walk in the woods in the
fall, you know,
Tina (00:21):
I'm Dr Tina Kaczor
Leah (00:22):
and I'm Dr Leah Sherman
Tina (00:23):
And we're two naturopathic doctors who practice integrative
cancer care
Leah (00:27):
But we're not your doctors
Tina (00:29):
This is for education entertainment and informational
purposes only
Leah (00:33):
do not apply any of this information without first
speaking to your doctor
Tina (00:38):
The views and opinions expressed on this podcast by the
hosts and their guests aresolely their own
Leah (00:44):
Welcome to the cancer pod Hi, this is Leah from the Cancer
Pod.
We are so grateful to have youall, our listeners, as the
backbone of the podcast.
The Cancer Pod is listenersupported, which means your
engagement is crucial to helpthis podcast thrive.
If you love what we do, pleaseshare our episodes with your
(01:06):
family, friends, and followers.
Spread the word so we can reachand help more people.
Want to go the extra mile?
Buy us a coffee.
Head over to our website tolearn more or check out the link
on our Instagram.
Explore the affiliates on ourCancer Pod website.
These are trusted resources werecommend.
When you make a purchase throughthe link on our site, we may
(01:27):
earn a commission at noadditional cost to you.
It's a win win.
Now, let's get to today'sepisode.
Tina and I had the opportunityto speak with Dr.
Janet Abram, an internationallyrenowned expert in palliative
and supportive care.
Dr.
Abram is an institute physicianat the Dana Farber Cancer
Institute and a distinguishedprofessor of medicine at Harvard
(01:48):
Medical School.
She combines her background as aformer practicing oncologist
with her passion for supportivecare.
She's the author ofComprehensive Guide to
Supportive and Palliative Carefor Patients with Cancer, the
definitive resource forphysicians about cancer support,
palliative care, and painmanagement.
Most recently, Dr.
Abram was awarded theprestigious Walther Cancer
(02:09):
Foundation Award from theAmerican Society of Clinical
Oncology, recognizing hersignificant contributions to
palliative and supportiveoncology care.
You We were so thrilled to haveher on the podcast to share
insights and expertise.
welcome Dr.
Abram.
Janet Abrahm (02:25):
Thank you.
Tina (02:27):
Yes, thank you so much for taking some time out of your
schedule to come talk to us andour audience about palliative
care.
Janet Abrahm (02:33):
Very happy to be here.
Nowadays, um, some of theoncology practices are calling
it supportive care, which isfine with me too.
I did oncology for about 20years.
And so I have a real sense of,of the supportive, if you will,
and palliative needs.
And if people Conflatepalliative with end of life and
(02:55):
hospice.
We don't want that.
So if supportive is more helpfulto understand that we offer
services from diagnosis of aserious illness like cancer on,
that terminology is fine with metoo.
Leah (03:06):
I think that's the most important thing is that patients
when they hear palliative, theythink end of life.
And so, yeah, I mean, if, ifthere are other ways that you
could, define for us whatpalliative care Slash supportive
care entails,
Janet Abrahm (03:25):
Sure.
Sure.
I think the best way to explainit is that.
We are there to partner with,and I'll say the oncologist,
because that's, that's the groupI know the best.
We're there to partner with theoncologist to make, the patient
and family's quality of life thebest that it can be.
Uh, some people cause an extralayer of support, but when I
(03:45):
introduce myself to a patient orfamily, I say, Your team has
asked me to see you because youhave problems, I'm told, with
some of your symptoms or youhave some questions you wanted
to talk about.
How can I help?
So I don't go into a bigdescription of what palliative
care is.
I just try to be what it is.
Tina (04:05):
Yeah, it's interesting that we start with this because
I can tell you, I'm overseeingsome coursework in integrative
oncology right now, and it's afellowship for people who are
already professionals, and wehave a palliative care segment,
and I would say at least 40%, 4out of 10 of the, of the,
Fellows.
Conflated hospice care andpalliative care.
(04:25):
And I know that that's true forthe public as well, but I was a
little surprised that it wasalso true for professionals.
So, I think this is important,because the word palliative does
sound a little bit, it isconflated with hospice more
often than not, and people arereticent.
So, the fact that you came upright out of the gates telling
us there's another term calledsupportive care, I like that.
I like that.
Janet Abrahm (04:46):
Dr.
Pereira did some studies down inMD Anderson and found that if he
called his team supportive inpalliative care, then he got
earlier referrals.
And so our, our new book.
It's called ComprehensiveSupportive and Palliative Care
for Patients with Cancer, aguide, you
Tina (05:03):
Yeah.
Janet Abrahm (05:04):
It's hard, there's, supportive can also
just mean antibiotics andtransfusions and what we're
doing is so much broader thanthat.
Tina (05:14):
is it fair to say that is addressing symptoms of people
who are not looking at acurative treatment?
Would that be accurate?
Janet Abrahm (05:22):
So again, I would say that palliative care can be
life saving and can enable acure.
So palliative care is there forthe symptoms of people who are
undergoing cancer treatment.
Or not, but undergoing curativeor palliative, if you will,
cancer treatments.
And we're also there for thecommunication challenges because
(05:43):
often a patient or family memberdoesn't want to question the
oncologist.
They don't want to show lack offaith.
They want to be grateful.
And yet as The course continues.
Sometimes there are turnoffs andyou're not sure what the risk
benefit or let's say the burdenbenefit of a given treatment
would be for you if your diseaseis more far advanced.
(06:05):
So we're often there as thepeople you can talk to about
this and we can help you sortout your goals.
Uh, what your hopes are, whatyour worries are, and then match
those because we'll ask theoncologist, what are your hopes
for this treatment?
What are your worries for thistreatment?
So we can match the hopes andworries of the two parties, in a
(06:26):
very supportive and, andrespectful way to say, gee, I, I
hear what you're saying that youhope this treatment will do.
The oncologist isn't really surethat it will do that, but it
could do this.
Would that be okay?
So in a way, we're translators,maybe, interpreters of The
medical ease, uh, you, you oftenhave only 15 minutes or so with
(06:47):
your oncologist and you want totalk about the treatment.
You don't always want to talkabout your symptom or your
worries, because maybe you wantto get an experimental
treatment.
And if you show that you're notwith it and for it, you'll kind
of fall down on a list a littlebit of the people who get the
experimental treatment.
That's.
The projection of the patients,that's not how oncologists
(07:07):
think, but my, even my ownpatients used to think that way,
and sometimes the, um, thedoctors who were caring for my
patient in the hospital wouldhave to tell me that the patient
was done, and I would say, butthey never told me that.
And they said, Oh, they wouldn'twant to disappoint you.
You have tried so hard andthey're so grateful to you.
(07:28):
They would never want to let youdown.
Now, I can't believe I'm theonly oncologist that's happening
to, you know, so I would sayit's not just for people who are
not going to be cured of theircancer.
We have enabled people to becured of their cancer by dealing
with their symptoms from thetreatment.
And the cancer, so they couldget through curative treatments,
(07:48):
those who have that available tothem.
I hope that's helpful.
Tina (07:52):
Yeah, what you're describing is almost like a
navigator, or what we dream anavigator would be, which is to
help bridge that, expanse ofboth options and communication
and be an impartial party ofsorts to say, okay, let's see
where you're at and make surethat the patient as an
individual is served.
Janet Abrahm (08:14):
That's what we're really good at.
Yeah, we're, we're trying toreally explore with patients and
families what they're hopingfor, and then, as I often say,
and what else, and what else,and what else.
Because everybody has layers ofwhat they're hoping for in
cancer treatment, right?
And so we try to unpack that sothat we can help the patient
(08:34):
have a realistic, as much asthey can tolerate, a realistic
understanding of what's going tobe entailed.
And, I think we really do try topartner with the oncology team
because we have more time tounwrap all these things, to be
culturally sensitive, to exploreAs I said, things that the
(08:55):
family and patient might notwant to bother, if you will, the
oncologist with in the time theyhave together.
Leah (09:01):
I think we've all had the experience where there are
patients.
And perhaps it is due tocultural differences where they
will, they will say to theoncologist what they think the
oncologist wants.
To hear, and I know from my ownexperience with my mother who
went through palliative care,um, she was able to speak with
(09:22):
the palliative care doctor on adifferent level,
Janet Abrahm (09:25):
Oh, good.
I'm so
Leah (09:27):
because she had such, she had such a, um, I don't know.
I mean, she loved heroncologist, but sitting in
appointments with her, shewasn't quite, you know, As
forthcoming as I knew, I'm theone answering her questions, you
know, like, that's not true.
And so I feel like she had, shehad a much, uh, different
relationship with her palliativecare doctor.
And yeah, that whole experiencewas, it was so important.
(09:52):
They helped to clarify differentaspects of her treatment and
goals, like you were saying, itreally, um, Yeah.
I have, I have a lot of respectfor palliative care.
Janet Abrahm (10:02):
Thank you.
Tina (10:03):
Well, and saying that palliative care is appropriate,
even for people who are lookingto be cured is actually news to
me.
I honestly always think ofpalliative care as living with a
condition comfortably and with,you know, no pain and no
symptoms, right?
Like symptom control while youhave an underlying condition,
whatever that is, whether it'scancer or a heart condition or
(10:23):
whatever, but palliation ofsymptoms while you live out your
life rather than Being on acurative course, where possibly
you won't be having thatcondition anymore in the future.
I mean, that's actually a twistfor me because I have always
thought of palliative care assymptom management.
Janet Abrahm (10:41):
that because a lot of the palliative care came up
from the end of life aspect.
When we first started our field,which was only less than 20
years ago, 2006, we became asubspecialty of internal
medicine.
At that point, very fewoncologists were actually part
of that initial core of peoplewho started palliative care.
(11:01):
But those of us who wereoncologists understood from
having tried to get our patientsthrough treatments, which were a
lot harder in those days thansome of the treatments are now,
they couldn't get through themwithout really, really good
symptom management, but also anunderstanding of the
psychological toll, you know,the trauma that medical
(11:23):
treatment induces.
in everybody, the patients,families.
So we have an understanding ofthe trauma they're going
through.
We have an understanding of thepsychological and spiritual and
existential resources they needto get through it.
And there are many cancers thatare curable.
(11:43):
But the road there is not easy,so having a partner right up
front can make all thedifference, at least in my
clinical experience.
Of course, by far the mostcancer patients are on a
palliative, trajectory.
Nowadays that can mean years andyears and years of, Palliation,
especially for breast cancerpatients, and now other
(12:04):
patients, and the idea of cancerbeing like a chronic disease,
like heart failure, as you said,or lung disease or something.
For many cancers, I think that'strue.
And so you need a partner tohelp you navigate that too.
But the very beginning of, of acurative cancer treatment, maybe
we should have the metaphor of,of the guide that gets you
(12:26):
through the rapids, you know, inthe beginning of that, of the,
uh, of the boat.
Leah (12:31):
Sure.
Janet Abrahm (12:32):
what we're there for is, is we know where all the
rocks are, you know, and we knowwhere the calm place is going to
be, and we can encourage you tostick it out with us to get
there, you know, I like kind oflike white river rafting is a
metaphor for some of thebeginning of the oncology
treatments, even if they're justemotionally and spiritually and
existentially very rocky.
(12:54):
You know, because people blamethemselves unnecessarily.
They look to what they did tohave this happen to them.
And so all of those questionscome in the beginning, right?
Not just the, not just the end.
So I'm glad that we couldclarify, that practice.
Leah (13:10):
I think that the goal setting aspect is also kind of
unusual and in some ways it'sdelightful.
I mean, our palliative caredoctor helped patients get
married,
Janet Abrahm (13:24):
Uh huh.
Leah (13:24):
patients go on a, on a vacation or something, I mean,
or had them create a collage orsomething of like all their
grandchildren.
I mean, there are all of these.
different aspects that werebeyond just the, the symptom,
you know, the physical symptommanagement part.
And so, um, yeah, that's,that's, that's kind of
(13:45):
incredible that there is someonethere who's listening.
Janet Abrahm (13:48):
and as you know, being naturopath, symptom
management is the Maslow'shierarchy is the bottom of that
is the key.
If you're in severe pain, ifyou're severely depressed, if
you can't breathe, you can't doany of those important things.
So all of us have to be veryskilled symptom management, but
that's for me, though.
(14:09):
That's how I started.
That's the bottom layer.
That's the, that's That has tobe done, but you usually can't
do that without addressing theother things too.
But you do have to be prettygood at using the medications
and other techniques, the onesthat you employ, to get people
at least to a place where theirsymptoms, what I say is they're
not here anymore.
(14:30):
Maybe they're down here.
You know they're there, but youcan function again.
Get people back to what theirlevel of function is to start
with.
And then we can start to do theother things.
it's very important.
All palliative care doctors.
And maybe that's why you thinkof them that way, because we do
do magic sometimes withsymptoms.
(14:50):
Uh, nurses certainly have toldus that we do.
Um, they weren't really happy.
They didn't know quite what wedid when we started in 2001 at
Dana Farber in the Brigham.
And then they saw some of thethings we could do and they're
like, Whoa, okay.
Now we, now we see we can getthe person back.
But once you have that personback, that's just part one.
Tina (15:08):
Yeah, yeah, as you're talking I'm thinking about how
much this lends itself tointegrative medicine and
integrative protocols I meanmedications absolutely pain
management and other symptommanagement and it's a quality of
life.
We're talking about so there's alot of things whether it's
through nutrition or acupunctureor movement Uh, exercise, all
(15:29):
sorts of ways of helping peopleoptimize their health, no matter
where they are along that cancercontinuum.
Janet Abrahm (15:35):
lately exercise and nutrition, exercise
especially has been shown to belife prolonging.
In many cancer patients and, andthe amount of exercise that we
can induce them to do, even withsome advanced, more advanced
disease, of course, acupuncture,of course, massage, um,
hypnosis, I'm trained inhypnosis and, and I think it
(15:57):
just informs my communicationwith patients and families and
doctors.
and nurses, everybody, becauseonce you're, as you know, once
you're trained in hypnosis, theworld is a metaphor, sort of
Tina (16:10):
Is that right?
No, I don't know that.
Janet Abrahm (16:13):
all hypnosis.
Have you been trained inhypnosis?
Is it part of your
Tina (16:17):
No.
Janet Abrahm (16:18):
Oh, I'm sorry, Leah.
No.
So I was trained in hypnosisback in the day when we had
fewer medications.
And, I learned there's anAmerican society of clinical
hypnosis, Only lets cliniciansinto the courses.
You have to have a clinicaldegree like you guys do, or a
nurse or a doctor.
And I learned all about thepower of my voice and metaphors
(16:45):
and, the ability to take someonewhere they'd really rather be
when we didn't have good medsfor nausea and vomiting or pain.
Hypnosis is very powerful fordeliveries that can shorten the
first stage of labor, forexample.
It's a very, very wonderfultechnique for symptom
management, but also for egostrengthening.
(17:06):
I mean, you do what you can do.
So psychiatrists do it withpsychiatry and OB do it with OB.
I do it with my, my cancerpatients.
But I found it to be veryrewarding and it really connects
you very closely with yourpatients when you're doing this.
You might've heard of guidedimagery.
Which is close to hypnosis, but,but not the same thing.
(17:29):
But if somebody is in trance,taking them on that guided
imagery.
is more powerful.
I mean, you bring in all thesenses and And I remember I used
to have to do bone marrow tests,you know, I was a hematologist,
so I used to have to do that.
And I would use hypnosis and thefellows would say they were
smelling cider donuts andhearing the crackling of the
leaves and the light comingthrough it every time they did a
(17:51):
from then on, because We wouldtake a walk in the woods in the
fall, you know, because that'swhere the patients one time I
went, I started to go to thebeach and the patient said, no,
no, I want to go for a walk inthe woods.
I know what you're doing.
So off we went for a walk in thewoods and he was, he was
distracted and the fellow wascalm.
It's a very wonderful techniquethat I would very much encourage
(18:13):
you to add to your practice.
If, if you find thatinteresting.
Leah (18:16):
Oh, absolutely.
Absolutely.
Tina (18:18):
Yeah.
I do know some of my colleaguesdo use it, so I'm gonna have to
ask them where they got theirtraining now.
Janet Abrahm (18:23):
Sure.
Leah (18:25):
Are there other, more integrative or, I guess, non
pharmacologic, pain managementtools that you employ with your
patients?
Janet Abrahm (18:34):
Well, now that we have, we have a more robust
Zakem center, which is ourintegrative therapy group at, at
Dana Farber.
I recommend acupuncture.
I've, I've read the data and theNCCN recommendations and the
things that are, are mostrecommended.
So definitely.
definitely yoga, uh, massage,acupuncture, especially electro
(18:56):
acupuncture, which I've hadmyself for a bad back, which has
been life saving, I don't knowenough about Qi Gong to
recommend it or not, but they doit at the Zakem Center.
Exercise.
I mean, I consider education andreassurance a non pharmacologic
pain regimen.
I mean, I had an aunt had breastcancer and had to get a bone
(19:16):
scan to see if it wasmetastasized.
She had arthritis everywhere.
So I told her, Your bone scan isgoing to light up like a
Christmas tree, but don't worryabout that.
They're going to want to get xrays of everything, but it's not
cancer, it's your arthritis.
Yes.
To me, that's educationreassurance prevented an awful
lot of pain.
(19:37):
what other, I mean, nonpharmacologic, all the
counseling techniques, all themeditation techniques, cognitive
behavior therapy for insomnia,all of those in, in my book,
there's a very large chapter onthe non pharmacologic techniques
for pain.
I couldn't treat a patient inpain without, absolutely not.
(19:59):
What, which ones do you findmost useful?
For I'm curious
Leah (20:03):
Depending on the patient, I think, I mean, I think
exercise is huge.
Exercise is the thing where, Imean, I think about my patients
who are on aromatase inhibitorsand I talk to them about, you
know, well, what makes, whatmakes it better?
And they're like, well, movementmakes it better.
So then I encourage exercise andthey're like, well, I can't
exercise, I'm in too much pain.
Janet Abrahm (20:23):
Oh,
Leah (20:23):
it's, it's that dance, but, um, I have referred
patients to an exercise programat one of the cancer centers
where I was working and thepatients who stuck with it were
just they were amazed because itwas it was a it was guided
exercise It was designed forthem,
Janet Abrahm (20:41):
Yeah.
Yeah.
And physical therapy,occupational therapy, art
therapy, music therapy.
I may have left something out,but everything that engages the
mind and the spirit, which areall part of the body, everything
is part of everything.
I mean, Eric Cassell was mymentor and friend.
He's passed now, but he used tosay suffering is suffering is
suffering.
(21:02):
You don't.
parse it out.
The body doesn't parse it out.
And I feel like whatever the, Itried to find out what the
person was doing before they gotsick, you know, and what was
helpful to them.
I'm wondering whether thevirtual reality, extended
reality experiences will behelpful.
I've seen as it can be wonderfulfor pain, virtual reality for
(21:24):
changing dressings and burnpatients.
For example, you don't need anymedication with virtual reality
in the studies that have beendone.
and, and you can, with hypnosis,you can do eye surgery on kids,
you can have them watch the TVor the video, I guess,
Tina (21:37):
Oh.
Janet Abrahm (21:38):
and they are in trance and you can adjust their
strabismus I'm told.
I'm not an expert.
Because you want them to beawake and you want them to look
forward.
Um, but the virtual reality, I'mvery intrigued by how that's
working neurochemically to stopthe parts of the brain that That
(22:00):
register pain.
It must be doing that.
It's only the brain thatregisters pain.
Everything has to get to thebrain for you to feel pain.
So something about the VR,right.
Is, is stopping.
Thank goodness.
Those signals from theperiphery.
And I would love to know whatthat is.
I would love to know.
Leah (22:19):
I have had patients At least one in particular who said
they were very into doing thevirtual reality exercise
programs that there are and theywanted VR in the, in the
infusion room
Janet Abrahm (22:33):
Yeah.
Leah (22:34):
take
Janet Abrahm (22:35):
Should be.
Leah (22:35):
Like exactly.
Janet Abrahm (22:37):
The holodeck, you know, the holodeck.
That would be great.
I mean, I would love that.
And they're not that expensiveanymore.
So I think, you know, maybe the,the friends of every cancer
center could donate VR sets tothe infusion rooms.
I think it'd be a, or for thosepoor patients, you know, who
can't get out of bed, who gettoo sick from any illness, How
(23:00):
wonderful to be, even thoughyou're homebound, to be skiing
or whatever, whatever you liketo do.
You know, I can't believe I've,I've been within five years.
I can't believe we're not goingto have that as just part of
your glasses.
You know, it's going to, Be lesscomplicated like those Google
glasses were.
Tina (23:18):
Yes.
I have.
I've actually seen ads for justthat where you can, you can just
envision that puts up a virtualboard and you just put on these
glasses and you can, well,they're, they're advertising it
to do work, but I could see itused better to do something more
pleasurable than looking at yourcomputer screen.
But yes, it kind of creates whatlooks like a projection wherever
you're looking.
Um, I was at a conference andthere was a company looking at
(23:42):
using virtual reality goggles inthe infusion room.
And it was specific topancreatic cancer patients in
their study.
it was a passion project.
The founder and CEO's parent hadpancreatic cancer and as a
person who was technology savvyand said, we need to get these
people out of here.
Like the infusion room, wasn't agreat experience for the parent.
(24:03):
And so.
They were coupling it withbreathing techniques
Janet Abrahm (24:07):
that's a good idea.
Abdominal breathing, especiallyhave them do abdominal breathing
would be
Tina (24:13):
yeah, and it was really neat.
Cause if you're looking at abeach and the waves are coming
and going, and there's a mooncoming up and you had to, you
had through your breathing, youcould kind of control the
scenery and you, you had a goal,you know, um, I can't remember
what's to keep the moon up orwhat it was, but it was
something where like, oh, okay.
And then afterwards they showedyou how you're.
Janet Abrahm (24:31):
it would be, it would, it would time with the
waves.
I was thinking I would do it.
So it would time with the wavesthat that would be my suggestion
if I were doing it is to be ableto sync your breathing with the
in.
That's what I do in hypnosis,the in and out of the waves, but
abdominal breathing is sohelpful and people have such
bad, um, hard wiring of the sideeffects of, of being in those
(24:54):
infusion rooms.
I mean, it isn't so bad anymore,but I would be at the grocery
store and people would throw upif they saw me.
Tina (25:00):
Oh,
Janet Abrahm (25:01):
Or, or at an airport and people just, the
smells of the infusion roomwould be enough, but nowadays
the treatments are so muchbetter.
The drug treatments are much,much better but they're still
not fun.
And the week after treatmentisn't fun.
So
Tina (25:16):
I think there's a little bit more cognizance of the
setting for the infusion room tobe a little nicer now.
I feel like it was very, I mean,I, I did my residency in 2000,
2002, and it was very different.
it was at CTCA, which they did amuch better job than most,
Janet Abrahm (25:30):
Yeah, they were supposed to be the fanciest.
the TV show, at least the ads,they looked elegant.
CGCA, I thought, Whoa, this islike the Cadillac of oncology
practices.
Leah (25:42):
Yeah, that's it was
Janet Abrahm (25:46):
What happened to It is, it still, is it still in
practice?
Leah (25:48):
it's city of
Tina (25:49):
it's owned by City
Janet Abrahm (25:50):
No.
Oh, Oh, wonderful.
That's a wonderful place.
Betty Farrell's there.
She's a genius.
Yeah.
Tina (25:59):
So yes, they, you are correct.
It was actually wonderfulbecause a lot of the services
you're talking about Inpalliative care, it was all
under one roof, which I think isbecoming more and more common
now, Dana Farber, like youmentioned, you know, you're
either allying with integrativepractitioners or you have them
under your roof, but there's alittle bit more patient
centeredness around cancer carethan there was 24 years ago.
Janet Abrahm (26:20):
yeah.
Tina (26:21):
So that's that's the right direction.
I'm happy about that.
Janet Abrahm (26:23):
Yeah, me too.
Um, I just was hoping I couldmention the website just as a
resource.
Leah (26:28):
Oh, Absolutely.
Janet Abrahm (26:30):
So after we, we wrote the book, this is the
fourth edition.
The first one was in 2000, whichwas called A Physician's Guide
to Pain and Symptom Managementin Cancer Patients.
And it just showed how everyedition shows me how much I've
grown, which is wonderful.
So this edition is, is called.
A Comprehensive Guide toSupportive and Palliative Care
(26:51):
for Patients with Cancer.
And it has chapters by socialworkers about family dynamics
and by chaplain, of course, andby psychiatrist, and there's
lots of stories and lots ofsymptom management.
But once we finished that, wethought, well, a lot of people
don't read books.
I mean, they're good to have onyour desk, but.
Or online, but we learned that60% of community oncologists did
(27:16):
not have a palliative carepartner.
Now, hospitals, over 300 beds,95% of them have palliative care
teams.
But most people aren't inhospitals, thank goodness,
right?
I mean, most people are caredfor outside a hospital.
So I thought, I used to speak tocommunity oncologists when we
did our updates at Dana Farberabout symptoms, but also about
(27:36):
moral distress andcommunication, you know, how to
break bad news and how to breakreally bad news and how to not
feel terrible about it.
And so we created this website,which is just my name,
JanetAbrahm.
com.
You just have to get the H inthere and you can find it.
And what it has is, resources insymptom management and
(27:58):
communication and end of lifecare, and then special topics
like people who want miracles,LGBTQ issues, trans issues.
We have interviews with peoplewho are experts in all those
fields.
And then we also have papers andlinks to websites and things.
And the goal is for, and we'llhave a newsletter and the goal
(28:20):
is for practicing oncologists tojust stop by and see is, you
know, is there something thatthey need to know how to manage
better or do they want to emailme?
You know, do they want toconnect with me or things like
that?
So the idea was to be a resourceand we've just started we're
just launching it now, really.
and so, uh, we'll be veryinterested to see what, um, what
(28:44):
people need, what questions theyask, what we haven't included
that they need.
Leah (28:49):
it is geared towards clinicians.
Janet Abrahm (28:51):
yes, there's nothing on it that is wrong for
patients and families, but theAmerican Cancer Society has
wonderful resources for patientsand families, and they, in fact,
just partnered with the AmericanSociety of Clinical Oncology,
the doctors, so that for theirmessaging, American Cancer
Society is is so good atmessaging, you know, for
(29:12):
patients and families or livingbeyond breast cancer.
There's so many, it feels likecommunity resources for patients
and families, but fewer for theoncologists who need a little
bit more expert training becausemost of them weren't trained in
this in their fellowships.
They, they don't really know howto do, like if somebody has
(29:33):
really bad neuropathic pain,nerve pain from a cancer that's
invading the nerves, they don'toften know how to use the drug
called methadone, which isreally good for that kind of
pain.
And they would want a partner,even at Dana Farber, we often
will see those patients to getthem under better control so
they can go on and get theirtreatment.
Tina (29:52):
hmm.
Janet Abrahm (29:53):
we thought it might be really useful to have.
Have all that information in oneplace for them as a resource,
especially the videos, thecommunication videos, like you
were talking about, about, whena patient isn't doing so well,
how to talk with them.
Usually they don't get trainedin that.
Maybe one day now of oncologytraining.
we get to teach them for a day.
That doesn't seem like quiteenough.
(30:14):
So we made some videos of thesame kind of thing so people
could watch them and seeexamples of how to have that
conversation without feelinglike you failed the patient.
Leah (30:23):
sure.
Tina (30:24):
You know, it's, it's interesting because, you know,
we're all clinicians.
We've all worked with cancerpatients and in our offices, I
think this is true of all threeof us, we get to see the patient
kind of exhale and relax.
Like you said at the beginningof this interview, like, you
know, there's a differencebetween a medical oncologist and
they're putting all their chips,they feel like all their chips
are with that person.
Right.
And so they don't want to do thewrong thing and there's, they're
(30:45):
a little bit like, I just wantto do whatever they want and I
don't want to disappoint them.
And I feel like when they werewith their naturopath or perhaps
their palliative care team, theycan relax and just be a little
bit more real about everything.
Um, so that's a privilege.
It's a, it's a privilege.
But in that setting, sometimespatients will gripe about the
(31:06):
communication from their medicaloncologist about the harshness
or about how things weredelivered or, and It's a
challenge to both acknowledgeand validate that they have a
good point and try to explainthe other side, right?
I've had these conversationswith medical oncologists my
whole career.
It's like, okay, so
Janet Abrahm (31:25):
hmm,
Tina (31:25):
you said this to the patient so I can understand
their perspective better, right?
Like, why, why are you goingstraight to hospice when the
patient has two more treatmentsdown the road?
You know, and they don't want tothink about hospice yet.
But You know, there's this,like, burden on the medical
oncologist to prepare thepatient.
Like, I, they, that's alwaysbeen explained to me.
(31:45):
They feel an obligation to bevery honest and prepare the
patient for whatever is to come.
but I would argue a palliativecare team is better at that.
So this is, this, this isanother reason that palliative
care should be everywhere, is Ifeel like it shouldn't be the
medical oncologist's job to dothose things.
It should be a it should bededicated to someone else down
the hall.
So,
Janet Abrahm (32:05):
Oh, I can't, I can't totally agree with that,
but I can give you some language
Tina (32:10):
No?
Janet Abrahm (32:10):
you'll accept.
Which is that, I feel likepatients really rely on that
oncologist because they've takenthem through so much.
So, the language that we hopethe oncologist will use is the
hope and worry language.
So, I really hope this treatmentis going to work and I'm going
to do everything, our team, yournurse practitioner, our social
(32:31):
worker, our team is doingeverything we can to get you
through this treatment.
I worry that there aren't aninfinity of treatments left.
Now, maybe something will comealong.
But I do worry.
And some of those treatments arekind of hard to take.
So it's okay with me if we talka little bit about, kind of the
what ifs.
Now, what we always ask theoncologist to say is, is this a
(32:52):
good time for you to do that?
And the patient says, no, I justwant to get through this
treatment.
Then you say, fine.
But at least you heard youroncologist say, I hope and I
worry.
Tina (33:03):
Mm.
Janet Abrahm (33:03):
just your palliative care doctor says
that, it doesn't have quite thesame authority.I don't t think.
Tina (33:10):
hmm.
Mm hmm.
Janet Abrahm (33:11):
And then it'd be great if the oncologist gave me
a heads up and said, I had thewhole worry conversation today.
Can you let me know how itlanded?
How she feels?
Um, was it too much?
Was it not enough?
Cause you, you don't want theoncologist, you know, the
oncologist feel failures.
That's why they use that wordfail the chemotherapy.
(33:33):
Nobody fails chemotherapy.
The chemotherapy failed thepatient,
Tina (33:35):
Exactly.
Janet Abrahm (33:36):
but doctors use the fail word.
And I think it's a countertransference.
They feel that they failed.
The patient and it's not a it'sin here.
It's not up here.
If you ask them, they will say,Oh, no, I didn't.
I did everything.
But then in that last meeting,they recite all the things they
did.
So I know they're hurting.
I know this feels terrible forthem.
(33:58):
So I'm a partner for theoncologist for that reason.
And I think that, you know,their grief can lead them if
they don't have a partner towhat I call truth dump.
You know, you don't want to dothat.
Because you haven't processedit.
You don't, you've got some badnews back.
It's so overwhelming.
Usually it's junior people whodo this.
(34:19):
Trainees.
They got the news back and theycan't hold it so they dump it on
the patient and family.
That's not a good technique.
And maybe your patients have hadthat happen to them.
Sort of a truth dump where itwas just unfiltered.
It wasn't nuanced.
So, so our training, we'relucky.
We were able to train theoncologists in what vital talk.
(34:41):
Have you heard of thatcommunication training program?
Leah (34:45):
No.
Janet Abrahm (34:46):
called, it's called vital talk.
Uh, my boss, James Tulsky, Dr.
Tony back and, um, Bob Arnoldstarted it about 20 years ago
now.
And there's wonderful trainingfor regular doctors and also
oncologists in all of thesetechniques.
and there's an app that canremind you what the questions
are.
For the breaking bad newsconversation, where after you
(35:08):
break the bad news, I mean,there's rules for how to set it
up, but then there's thesewonderful nurse acronym, which
is how you respond to theemotion.
You name it or, you know, yousay you understand or you
respect it or, uh, the patientor, you're going to support them
through it or exploring more.
That's the nurse acronym.
(35:30):
For me, it's always when I breakbad news and I get an emotion
back, it's always some form ofgrief.
You know, the five things.
So it'll be anger, denial,bargaining.
Those are the things that peoplerespond with when you give them
bad news because they're ingrief at some level.
But anyway, the vital talktraining can be done in a day by
(35:51):
oncologists or by anyclinicians.
It's a wonderful communicationtraining, I think, uh, Dr.
Chelsky came to us in 2015.
I was curious, so I got trainedin it I did the more advanced
training because I thought thatwas my responsibility.
And I found it very helpful tohave these phrases to use, like,
um, for that patient of yours,maybe he could have said, we're
(36:13):
in a different place now.
That's a really gentle way ofletting somebody know that,
yeah, we can treat you, andwe're in a different place now,
maybe we should think abouttalking about code status, for
example, right?
You know, so, of course, we'regoing to treat you, we're going
to do everything we can, butthis cancer is so far advanced,
it would be awful if, when youpassed, We had to do that.
(36:36):
So there's lots of very wellhoned phrases that are a good
resource for the clinicians, whowatch your podcast.
Tina (36:45):
Yeah, well, and I would say what vital talks is what you
call that, right?
That's the app
Janet Abrahm (36:50):
a, it's a program called vital talk.
Yeah.
Tina (36:55):
encourage, I know some patients are like good riddance
and they don't go back and helpclinicians become better
clinicians because they're tooupset sometimes.
But I would encourage patientswho have the energy or their
caregivers to say, you know,maybe suggest this to a doctor
who wasn't very good at theircommunication because it's only
through feedback that people getbetter.
So very
Janet Abrahm (37:14):
I think that's great.
You can say there's this new,new program that I'm sure wasn't
around when you were first, youknow, being trained.
And I so appreciate everythingyou're doing for me.
And,
Tina (37:25):
Yeah.
that's great.
Janet Abrahm (37:26):
and that's the other thing instead of, but
instead of, but we've beentalked to use and, and I like
that much better.
Just like, instead of saying,I'm sorry, I say, I wish it were
different because then I'mconnected to you.
I say I wish
Leah (37:41):
Mm
Janet Abrahm (37:42):
because I do.
Yeah,
Tina (37:45):
Yeah, that may be a bit more accurate more than I'm
sorry.
Janet Abrahm (37:49):
Yeah, it really is.
But we weren't.
You need to be taught to uh,just like, you know, we don't do
procedures differently everytime.
Our communication is a reallyimportant medical, as you know,
uh, medical intervention.
The way we communicate can makeall the difference.
And so if somebody's figured outways, That are really helpful,
(38:13):
like, I think these things arereally helpful, I use them over
and over and over and they helpme connect or maybe a better way
of saying is they make manifestthat I am connected.
They don't get in the way orinterfere with how much I care
about a patient.
They manifest how much I careabout a patient in a very
(38:33):
professional way.
That's what I like about them.
Tina (38:36):
I think that's lovely and I think you you have also spoken
about burnout among cliniciansand being able to connect
without being Completely burntout on the emotional Aspect of
being a physician for the forpatients going through difficult
times no matter what thecondition.
(38:57):
Um, That's a whole skill set tooSo what you're what I like what
you're saying because Iunderstand that you can be with
the patient and connect withpatient Because I think
sometimes the harshness thatcomes across is just people self
protecting
Janet Abrahm (39:09):
I would agree and I think the biggest problem
which happened to me and ofcourse happened to every
oncologist is not having a placefor your grief.
Not having anybody to talk toabout your grief.
Feeling guilty that anybody elsebut you would have saved this
patient.
That's how doctors are trained.
That it's us that are supposedto save everybody.
(39:30):
So the unspoken curriculum asyou're training is nobody talks
about the people who diedovernight.
I did.
I was, I said, your rounds arevery different.
You know, I want us to unpackany feelings you had about that
person.
I want to respect her.
I want us to.
Really talk about how we caredfor her and, and how her passing
(39:52):
was very peaceful thanks to us.
I think most oncologists havewritten about this, do not have
a place for their grief and itbuilds up and after a while you
don't have any margin left formore grief, but you don't know
it.
It's just in here.
You just don't want to go intothose rooms and the patients can
see it.
They can tell, and they thinkthey did something wrong, which
(40:14):
is really hard, you know, tocause you to look like that.
Yeah.
You think you're doing such agood job of hiding your, you
know, your, your sadness.
But I think if there were moreability for oncologists to
process their grief, in astructured way, we do that with
a remembrance every week becausewe have so many people who pass
in palliative care.
(40:34):
But oncologists, I really feelcould do it once a month with
their staff.
They could read something, apoem, or they could, have music,
or something.
And then you read the names ofthe people who passed, and you
talk about them.
It's a wonderful way of, youknow, remember the anxiety
closet, of emptying that anxietycloset.
It's, you have to do that.
And if there's no place for it,then I worry that what happened
(40:57):
to your patient happens, becausethat person has no place to put
that grief and those feelings.
And so burnout manifests asanger, right?
That's one of the, ordepression, depression manifests
as anger.
Um, inappropriate anger,inappropriate pulling back,
making rounds when the family'snot there on purpose.
Leah (41:14):
Right.
Janet Abrahm (41:15):
There's all kinds of things that, that manifest, I
think, as, as grief, and if wecould do something about that,
we could decrease burnout, andthere's a lot on our website
about grief.
Moral distress.
Tina (41:27):
are they teaching this more in nursing and medical
schools because I feel like ithas to be done out of right out
the gates In order to be managedover life.
Janet Abrahm (41:34):
Nursing school has always taught about moral
distress.
It's a little different becausenursing moral distress is when
you know something should bedone and you're not the doctor
and you can't order it.
And you have to carry out
Leah (41:46):
Oh.
Cool.
Janet Abrahm (41:47):
these horrible plans.
So my, my introduction to moraldistress was from my nursing
colleagues who consulted me intheir moral distress.
To say so and so won't write ahigher dose of morphine or, you
know, the people where they seethe suffering and the oncologist
sees that they just make itthrough the rapids, they're
(42:08):
going to be cured of theirleukemia.
So we have to support them andget the nurses there for 12
hours.
the suffering.
so I think they don't, I don'tknow how much if they, I don't
know about the curriculaanymore.
I worry that too much of thiskind of thing is in the first
couple of years.
And then the real thing theylearn is when they start working
(42:31):
with, residents and so forth onthe wards.
Mm hmm And what they learn thereis what counts.
So we're trying to induce,introduce communication
training.
We have to the first, second andthird year residents at the
Brigham are, we have a corecurriculum, core communication
curriculum in which we do roleplays and really show them how
(42:52):
to use this vital talk type oflanguage.
We, we teach them how to havethe family meeting in the first
year.
And then we teach them how tohave that things are not going
so well in the second year.
You know, and we, we kind ofbuild on those, on those skills,
but it is only one day for eachof them, but it's pretty
powerful because I've seen themuse it.
They must need it, but I have noidea in the country, uh, what
(43:16):
the norm is.
It would make people feel a lotbetter if they felt skilled in
these areas.
I know it, they would feel somuch more empowered if they knew
that they could say somethingthat would be helpful.
Tina (43:28):
Well, yeah.
It serves everybody.
The and the patient.
Hopefully your work goes on toinfluence you.
The many, many more thousands ofpractitioners out there who, who
will read your book or watch,get the app.
So it's very commendable thatyou're getting that work out
there making a big difference.
Janet Abrahm (43:45):
Well, it's, you know, it's a very rewarding
profession and anything I can doto give back, to the patients
and their families and to thosewho are taking this on, that's
what I'm happy to do and so Ireally do appreciate the
opportunity to talk with you.
I think you've asked me somereally interesting questions and
the, the work you're doing isvery interesting as well.
I'm so glad that you're bothhere.
(44:06):
Well, it's constant and, uh,have compassion for the
oncologist.
That's all I ask.
It's really hard.
It's really hard for them.
And the more compassion you havefor them, the more they can have
for their patients and families.
I mean, just asking, how is yourday going?
I'm in the stairwell and theoncologist will say, I've had
three DNR conversations so fartoday, so it's, it's,
Tina (44:27):
Yeah.
Janet Abrahm (44:27):
the compassion is real.
Tina (44:29):
Yeah.
It's heavy, heavy stuff.
Janet Abrahm (44:31):
Yeah.
It's heavy stuff and they'redoing wonderful stuff and they
love their patients dearly.
Yeah.
Tina (44:36):
Yes.
Well, was there anything else,Leah, that you wanted to ask?
Leah (44:41):
I was just going to ask, is there, is there one piece of
advice in terms of now that ourlisteners are, are aware of what
supportive and palliative careis like, is there any specific
time that they should requestthis I mean, is there any
specific time when, um, When youfeel like it's good for a
(45:03):
patient to ask to see apalliative care doctor.
Janet Abrahm (45:06):
Well, I think that we don't have enough palliative
care doctors to see everybody.
And I do feel that if you'vebeen diagnosed with an advanced
form of cancer, that is notlikely to be curable, that from
the very beginning, at leastmeet with a palliative care
team.
There was just a recent reportat the national meetings of the
(45:27):
cancer organization that meetingin the beginning, especially for
patients who have lung cancer,and then meeting in If the
treatment changes or meeting, ifyou're hospitalized, that
that's.
That can provide all thebenefits, um, of meeting like in
a regular way.
(45:48):
Now those patients were trackingtheir symptoms, so if their
symptoms went really crazy, theyasked to see a palliative care
person, of course.
But even if your symptoms aren'tcrazy at the very beginning,
just meet somebody and say, youknow, for this, for my road
ahead, I need a partner and I'dlike to meet with a palliative
care team.
(46:08):
And then that palliative careteam will reach out to you
afterwards, as often as they canand depending on what your needs
are.
And that way when, the timecomes that maybe the treatments
are more burdensome thanbenefit, you have someone to, to
help you through thosedecisions.
You and your family.
Leah (46:26):
Great.
Tina (46:27):
All right.
Well, thank you again forjoining us.
I mean, this has been reallyeducational and a lovely
conversation.
Janet Abrahm (46:33):
Oh, thank you.I I think so too.
Tina (46:35):
And again, I just commend you for all the work you're
doing.
And, and
Janet Abrahm (46:38):
Thank you.
Tina (46:39):
I feel like you're taking some time out of your schedule
to help us out.
Bring this palliative care talkto our listeners is very
generous of you.
So truly appreciate your timeand all the work you do.
Janet Abrahm (46:50):
Well, again, it's all my pleasure.
And if you know, they want to goto the website again,
understanding it's designed for,for the doctor part of it, but I
might be able to put them ontoo.
Other resources, um, Dr.
Vicki Jackson wrote a wonderfulbook for patients and their
families that I could recommend.
It's from Johns HopkinsUniversity Press for people who
(47:11):
like to read.
It's really very patient andfamily focused.
And, uh, she's the head of thepalliative care program at Mass
General.
uh, has been in the field forover 20 years.
So I would recommend her book toeverybody.
Also, Mortal Lessons by JoanneLynn.
Those two are, are great.
Tina (47:28):
Okay.
We'll put links to those booksin our, in our show notes.
Janet Abrahm (47:32):
That would be great.
Thank you for doing that.
That would be terrific.
Tina (47:35):
your book as well, of course.
Leah (47:37):
And your website.
We'll put, we'll
Janet Abrahm (47:38):
oh,
Leah (47:39):
everything.
Tina (47:39):
Links will abound.
Janet Abrahm (47:41):
oh, wow.
That's wonderful.
I really appreciate it.
And if you know, you, if youthink of things that I could.
Uh, be helpful with the future.
always happy to come back.
Leah (47:48):
Thanks for listening to The Cancer Pod.
Remember to subscribe, review,and rate us wherever you get
your podcasts.
Follow us on social media forupdates.
And as always, this is notmedical advice.
These are our opinions.
Talk to your doctor beforechanging anything related to
your treatment plan.
The Cancer Pod is hosted by me,Dr.
Leah Sherman, and by Dr.
(48:10):
Tina Kaser.
Music is by Kevin MacLeod.
See you next time.
I remember I used to have to do bone marrow tests,
(00:01):
you know, I was a hematologist,so I used to have to do that.
And I would use hypnosis and thefellows would say they were
smelling cider donuts andhearing the crackling of the
leaves and the light comingthrough it every time they did a
from then on, because We wouldtake a walk in the woods in the
fall, you know,
Tina (00:21):
I'm Dr Tina Kaczor
Leah (00:22):
and I'm Dr Leah Sherman
Tina (00:23):
And we're two naturopathic doctors who practice integrative
cancer care
Leah (00:27):
But we're not your doctors
Tina (00:29):
This is for education entertainment and informational
purposes only
Leah (00:33):
do not apply any of this information without first
speaking to your doctor
Tina (00:38):
The views and opinions expressed on this podcast by the
hosts and their guests aresolely their own
Leah (00:44):
Welcome to the cancer pod Hi, this is Leah from the Cancer
Pod.
We are so grateful to have youall, our listeners, as the
backbone of the podcast.
The Cancer Pod is listenersupported, which means your
engagement is crucial to helpthis podcast thrive.
If you love what we do, pleaseshare our episodes with your
(01:06):
family, friends, and followers.
Spread the word so we can reachand help more people.
Want to go the extra mile?
Buy us a coffee.
Head over to our website tolearn more or check out the link
on our Instagram.
Explore the affiliates on ourCancer Pod website.
These are trusted resources werecommend.
When you make a purchase throughthe link on our site, we may
(01:27):
earn a commission at noadditional cost to you.
It's a win win.
Now, let's get to today'sepisode.
Tina and I had the opportunityto speak with Dr.
Janet Abram, an internationallyrenowned expert in palliative
and supportive care.
Dr.
Abram is an institute physicianat the Dana Farber Cancer
Institute and a distinguishedprofessor of medicine at Harvard
(01:48):
Medical School.
She combines her background as aformer practicing oncologist
with her passion for supportivecare.
She's the author ofComprehensive Guide to
Supportive and Palliative Carefor Patients with Cancer, the
definitive resource forphysicians about cancer support,
palliative care, and painmanagement.
Most recently, Dr.
Abram was awarded theprestigious Walther Cancer
(02:09):
Foundation Award from theAmerican Society of Clinical
Oncology, recognizing hersignificant contributions to
palliative and supportiveoncology care.
You We were so thrilled to haveher on the podcast to share
insights and expertise.
welcome Dr.
Abram.
Janet Abrahm (02:25):
Thank you.
Tina (02:27):
Yes, thank you so much for taking some time out of your
schedule to come talk to us andour audience about palliative
care.
Janet Abrahm (02:33):
Very happy to be here.
Nowadays, um, some of theoncology practices are calling
it supportive care, which isfine with me too.
I did oncology for about 20years.
And so I have a real sense of,of the supportive, if you will,
and palliative needs.
And if people Conflatepalliative with end of life and
(02:55):
hospice.
We don't want that.
So if supportive is more helpfulto understand that we offer
services from diagnosis of aserious illness like cancer on,
that terminology is fine with metoo.
Leah (03:06):
I think that's the most important thing is that patients
when they hear palliative, theythink end of life.
And so, yeah, I mean, if, ifthere are other ways that you
could, define for us whatpalliative care Slash supportive
care entails,
Janet Abrahm (03:25):
Sure.
Sure.
I think the best way to explainit is that.
We are there to partner with,and I'll say the oncologist,
because that's, that's the groupI know the best.
We're there to partner with theoncologist to make, the patient
and family's quality of life thebest that it can be.
Uh, some people cause an extralayer of support, but when I
(03:45):
introduce myself to a patient orfamily, I say, Your team has
asked me to see you because youhave problems, I'm told, with
some of your symptoms or youhave some questions you wanted
to talk about.
How can I help?
So I don't go into a bigdescription of what palliative
care is.
I just try to be what it is.
Tina (04:05):
Yeah, it's interesting that we start with this because
I can tell you, I'm overseeingsome coursework in integrative
oncology right now, and it's afellowship for people who are
already professionals, and wehave a palliative care segment,
and I would say at least 40%, 4out of 10 of the, of the,
Fellows.
Conflated hospice care andpalliative care.
(04:25):
And I know that that's true forthe public as well, but I was a
little surprised that it wasalso true for professionals.
So, I think this is important,because the word palliative does
sound a little bit, it isconflated with hospice more
often than not, and people arereticent.
So, the fact that you came upright out of the gates telling
us there's another term calledsupportive care, I like that.
I like that.
Janet Abrahm (04:46):
Dr.
Pereira did some studies down inMD Anderson and found that if he
called his team supportive inpalliative care, then he got
earlier referrals.
And so our, our new book.
It's called ComprehensiveSupportive and Palliative Care
for Patients with Cancer, aguide, you
Tina (05:03):
Yeah.
Janet Abrahm (05:04):
It's hard, there's, supportive can also
just mean antibiotics andtransfusions and what we're
doing is so much broader thanthat.
Tina (05:14):
is it fair to say that is addressing symptoms of people
who are not looking at acurative treatment?
Would that be accurate?
Janet Abrahm (05:22):
So again, I would say that palliative care can be
life saving and can enable acure.
So palliative care is there forthe symptoms of people who are
undergoing cancer treatment.
Or not, but undergoing curativeor palliative, if you will,
cancer treatments.
And we're also there for thecommunication challenges because
(05:43):
often a patient or family memberdoesn't want to question the
oncologist.
They don't want to show lack offaith.
They want to be grateful.
And yet as The course continues.
Sometimes there are turnoffs andyou're not sure what the risk
benefit or let's say the burdenbenefit of a given treatment
would be for you if your diseaseis more far advanced.
(06:05):
So we're often there as thepeople you can talk to about
this and we can help you sortout your goals.
Uh, what your hopes are, whatyour worries are, and then match
those because we'll ask theoncologist, what are your hopes
for this treatment?
What are your worries for thistreatment?
So we can match the hopes andworries of the two parties, in a
(06:26):
very supportive and, andrespectful way to say, gee, I, I
hear what you're saying that youhope this treatment will do.
The oncologist isn't really surethat it will do that, but it
could do this.
Would that be okay?
So in a way, we're translators,maybe, interpreters of The
medical ease, uh, you, you oftenhave only 15 minutes or so with
(06:47):
your oncologist and you want totalk about the treatment.
You don't always want to talkabout your symptom or your
worries, because maybe you wantto get an experimental
treatment.
And if you show that you're notwith it and for it, you'll kind
of fall down on a list a littlebit of the people who get the
experimental treatment.
That's.
The projection of the patients,that's not how oncologists
(07:07):
think, but my, even my ownpatients used to think that way,
and sometimes the, um, thedoctors who were caring for my
patient in the hospital wouldhave to tell me that the patient
was done, and I would say, butthey never told me that.
And they said, Oh, they wouldn'twant to disappoint you.
You have tried so hard andthey're so grateful to you.
(07:28):
They would never want to let youdown.
Now, I can't believe I'm theonly oncologist that's happening
to, you know, so I would sayit's not just for people who are
not going to be cured of theircancer.
We have enabled people to becured of their cancer by dealing
with their symptoms from thetreatment.
And the cancer, so they couldget through curative treatments,
(07:48):
those who have that available tothem.
I hope that's helpful.
Tina (07:52):
Yeah, what you're describing is almost like a
navigator, or what we dream anavigator would be, which is to
help bridge that, expanse ofboth options and communication
and be an impartial party ofsorts to say, okay, let's see
where you're at and make surethat the patient as an
individual is served.
Janet Abrahm (08:14):
That's what we're really good at.
Yeah, we're, we're trying toreally explore with patients and
families what they're hopingfor, and then, as I often say,
and what else, and what else,and what else.
Because everybody has layers ofwhat they're hoping for in
cancer treatment, right?
And so we try to unpack that sothat we can help the patient
(08:34):
have a realistic, as much asthey can tolerate, a realistic
understanding of what's going tobe entailed.
And, I think we really do try topartner with the oncology team
because we have more time tounwrap all these things, to be
culturally sensitive, to exploreAs I said, things that the
(08:55):
family and patient might notwant to bother, if you will, the
oncologist with in the time theyhave together.
Leah (09:01):
I think we've all had the experience where there are
patients.
And perhaps it is due tocultural differences where they
will, they will say to theoncologist what they think the
oncologist wants.
To hear, and I know from my ownexperience with my mother who
went through palliative care,um, she was able to speak with
(09:22):
the palliative care doctor on adifferent level,
Janet Abrahm (09:25):
Oh, good.
I'm so
Leah (09:27):
because she had such, she had such a, um, I don't know.
I mean, she loved heroncologist, but sitting in
appointments with her, shewasn't quite, you know, As
forthcoming as I knew, I'm theone answering her questions, you
know, like, that's not true.
And so I feel like she had, shehad a much, uh, different
relationship with her palliativecare doctor.
And yeah, that whole experiencewas, it was so important.
(09:52):
They helped to clarify differentaspects of her treatment and
goals, like you were saying, itreally, um, Yeah.
I have, I have a lot of respectfor palliative care.
Janet Abrahm (10:02):
Thank you.
Tina (10:03):
Well, and saying that palliative care is appropriate,
even for people who are lookingto be cured is actually news to
me.
I honestly always think ofpalliative care as living with a
condition comfortably and with,you know, no pain and no
symptoms, right?
Like symptom control while youhave an underlying condition,
whatever that is, whether it'scancer or a heart condition or
(10:23):
whatever, but palliation ofsymptoms while you live out your
life rather than Being on acurative course, where possibly
you won't be having thatcondition anymore in the future.
I mean, that's actually a twistfor me because I have always
thought of palliative care assymptom management.
Janet Abrahm (10:41):
that because a lot of the palliative care came up
from the end of life aspect.
When we first started our field,which was only less than 20
years ago, 2006, we became asubspecialty of internal
medicine.
At that point, very fewoncologists were actually part
of that initial core of peoplewho started palliative care.
(11:01):
But those of us who wereoncologists understood from
having tried to get our patientsthrough treatments, which were a
lot harder in those days thansome of the treatments are now,
they couldn't get through themwithout really, really good
symptom management, but also anunderstanding of the
psychological toll, you know,the trauma that medical
(11:23):
treatment induces.
in everybody, the patients,families.
So we have an understanding ofthe trauma they're going
through.
We have an understanding of thepsychological and spiritual and
existential resources they needto get through it.
And there are many cancers thatare curable.
(11:43):
But the road there is not easy,so having a partner right up
front can make all thedifference, at least in my
clinical experience.
Of course, by far the mostcancer patients are on a
palliative, trajectory.
Nowadays that can mean years andyears and years of, Palliation,
especially for breast cancerpatients, and now other
(12:04):
patients, and the idea of cancerbeing like a chronic disease,
like heart failure, as you said,or lung disease or something.
For many cancers, I think that'strue.
And so you need a partner tohelp you navigate that too.
But the very beginning of, of acurative cancer treatment, maybe
we should have the metaphor of,of the guide that gets you
(12:26):
through the rapids, you know, inthe beginning of that, of the,
uh, of the boat.
Leah (12:31):
Sure.
Janet Abrahm (12:32):
what we're there for is, is we know where all the
rocks are, you know, and we knowwhere the calm place is going to
be, and we can encourage you tostick it out with us to get
there, you know, I like kind oflike white river rafting is a
metaphor for some of thebeginning of the oncology
treatments, even if they're justemotionally and spiritually and
existentially very rocky.
(12:54):
You know, because people blamethemselves unnecessarily.
They look to what they did tohave this happen to them.
And so all of those questionscome in the beginning, right?
Not just the, not just the end.
So I'm glad that we couldclarify, that practice.
Leah (13:10):
I think that the goal setting aspect is also kind of
unusual and in some ways it'sdelightful.
I mean, our palliative caredoctor helped patients get
married,
Janet Abrahm (13:24):
Uh huh.
Leah (13:24):
patients go on a, on a vacation or something, I mean,
or had them create a collage orsomething of like all their
grandchildren.
I mean, there are all of these.
different aspects that werebeyond just the, the symptom,
you know, the physical symptommanagement part.
And so, um, yeah, that's,that's, that's kind of
(13:45):
incredible that there is someonethere who's listening.
Janet Abrahm (13:48):
and as you know, being naturopath, symptom
management is the Maslow'shierarchy is the bottom of that
is the key.
If you're in severe pain, ifyou're severely depressed, if
you can't breathe, you can't doany of those important things.
So all of us have to be veryskilled symptom management, but
that's for me, though.
(14:09):
That's how I started.
That's the bottom layer.
That's the, that's That has tobe done, but you usually can't
do that without addressing theother things too.
But you do have to be prettygood at using the medications
and other techniques, the onesthat you employ, to get people
at least to a place where theirsymptoms, what I say is they're
not here anymore.
(14:30):
Maybe they're down here.
You know they're there, but youcan function again.
Get people back to what theirlevel of function is to start
with.
And then we can start to do theother things.
it's very important.
All palliative care doctors.
And maybe that's why you thinkof them that way, because we do
do magic sometimes withsymptoms.
(14:50):
Uh, nurses certainly have toldus that we do.
Um, they weren't really happy.
They didn't know quite what wedid when we started in 2001 at
Dana Farber in the Brigham.
And then they saw some of thethings we could do and they're
like, Whoa, okay.
Now we, now we see we can getthe person back.
But once you have that personback, that's just part one.
Tina (15:08):
Yeah, yeah, as you're talking I'm thinking about how
much this lends itself tointegrative medicine and
integrative protocols I meanmedications absolutely pain
management and other symptommanagement and it's a quality of
life.
We're talking about so there's alot of things whether it's
through nutrition or acupunctureor movement Uh, exercise, all
(15:29):
sorts of ways of helping peopleoptimize their health, no matter
where they are along that cancercontinuum.
Janet Abrahm (15:35):
lately exercise and nutrition, exercise
especially has been shown to belife prolonging.
In many cancer patients and, andthe amount of exercise that we
can induce them to do, even withsome advanced, more advanced
disease, of course, acupuncture,of course, massage, um,
hypnosis, I'm trained inhypnosis and, and I think it
(15:57):
just informs my communicationwith patients and families and
doctors.
and nurses, everybody, becauseonce you're, as you know, once
you're trained in hypnosis, theworld is a metaphor, sort of
Tina (16:10):
Is that right?
No, I don't know that.
Janet Abrahm (16:13):
all hypnosis.
Have you been trained inhypnosis?
Is it part of your
Tina (16:17):
No.
Janet Abrahm (16:18):
Oh, I'm sorry, Leah.
No.
So I was trained in hypnosisback in the day when we had
fewer medications.
And, I learned there's anAmerican society of clinical
hypnosis, Only lets cliniciansinto the courses.
You have to have a clinicaldegree like you guys do, or a
nurse or a doctor.
And I learned all about thepower of my voice and metaphors
(16:45):
and, the ability to take someonewhere they'd really rather be
when we didn't have good medsfor nausea and vomiting or pain.
Hypnosis is very powerful fordeliveries that can shorten the
first stage of labor, forexample.
It's a very, very wonderfultechnique for symptom
management, but also for egostrengthening.
(17:06):
I mean, you do what you can do.
So psychiatrists do it withpsychiatry and OB do it with OB.
I do it with my, my cancerpatients.
But I found it to be veryrewarding and it really connects
you very closely with yourpatients when you're doing this.
You might've heard of guidedimagery.
Which is close to hypnosis, but,but not the same thing.
(17:29):
But if somebody is in trance,taking them on that guided
imagery.
is more powerful.
I mean, you bring in all thesenses and And I remember I used
to have to do bone marrow tests,you know, I was a hematologist,
so I used to have to do that.
And I would use hypnosis and thefellows would say they were
smelling cider donuts andhearing the crackling of the
leaves and the light comingthrough it every time they did a
(17:51):
from then on, because We wouldtake a walk in the woods in the
fall, you know, because that'swhere the patients one time I
went, I started to go to thebeach and the patient said, no,
no, I want to go for a walk inthe woods.
I know what you're doing.
So off we went for a walk in thewoods and he was, he was
distracted and the fellow wascalm.
It's a very wonderful techniquethat I would very much encourage
(18:13):
you to add to your practice.
If, if you find thatinteresting.
Leah (18:16):
Oh, absolutely.
Absolutely.
Tina (18:18):
Yeah.
I do know some of my colleaguesdo use it, so I'm gonna have to
ask them where they got theirtraining now.
Janet Abrahm (18:23):
Sure.
Leah (18:25):
Are there other, more integrative or, I guess, non
pharmacologic, pain managementtools that you employ with your
patients?
Janet Abrahm (18:34):
Well, now that we have, we have a more robust
Zakem center, which is ourintegrative therapy group at, at
Dana Farber.
I recommend acupuncture.
I've, I've read the data and theNCCN recommendations and the
things that are, are mostrecommended.
So definitely.
definitely yoga, uh, massage,acupuncture, especially electro
(18:56):
acupuncture, which I've hadmyself for a bad back, which has
been life saving, I don't knowenough about Qi Gong to
recommend it or not, but they doit at the Zakem Center.
Exercise.
I mean, I consider education andreassurance a non pharmacologic
pain regimen.
I mean, I had an aunt had breastcancer and had to get a bone
(19:16):
scan to see if it wasmetastasized.
She had arthritis everywhere.
So I told her, Your bone scan isgoing to light up like a
Christmas tree, but don't worryabout that.
They're going to want to get xrays of everything, but it's not
cancer, it's your arthritis.
Yes.
To me, that's educationreassurance prevented an awful
lot of pain.
(19:37):
what other, I mean, nonpharmacologic, all the
counseling techniques, all themeditation techniques, cognitive
behavior therapy for insomnia,all of those in, in my book,
there's a very large chapter onthe non pharmacologic techniques
for pain.
I couldn't treat a patient inpain without, absolutely not.
(19:59):
What, which ones do you findmost useful?
For I'm curious
Leah (20:03):
Depending on the patient, I think, I mean, I think
exercise is huge.
Exercise is the thing where, Imean, I think about my patients
who are on aromatase inhibitorsand I talk to them about, you
know, well, what makes, whatmakes it better?
And they're like, well, movementmakes it better.
So then I encourage exercise andthey're like, well, I can't
exercise, I'm in too much pain.
Janet Abrahm (20:23):
Oh,
Leah (20:23):
it's, it's that dance, but, um, I have referred
patients to an exercise programat one of the cancer centers
where I was working and thepatients who stuck with it were
just they were amazed because itwas it was a it was guided
exercise It was designed forthem,
Janet Abrahm (20:41):
Yeah.
Yeah.
And physical therapy,occupational therapy, art
therapy, music therapy.
I may have left something out,but everything that engages the
mind and the spirit, which areall part of the body, everything
is part of everything.
I mean, Eric Cassell was mymentor and friend.
He's passed now, but he used tosay suffering is suffering is
suffering.
(21:02):
You don't.
parse it out.
The body doesn't parse it out.
And I feel like whatever the, Itried to find out what the
person was doing before they gotsick, you know, and what was
helpful to them.
I'm wondering whether thevirtual reality, extended
reality experiences will behelpful.
I've seen as it can be wonderfulfor pain, virtual reality for
(21:24):
changing dressings and burnpatients.
For example, you don't need anymedication with virtual reality
in the studies that have beendone.
and, and you can, with hypnosis,you can do eye surgery on kids,
you can have them watch the TVor the video, I guess,
Tina (21:37):
Oh.
Janet Abrahm (21:38):
and they are in trance and you can adjust their
strabismus I'm told.
I'm not an expert.
Because you want them to beawake and you want them to look
forward.
Um, but the virtual reality, I'mvery intrigued by how that's
working neurochemically to stopthe parts of the brain that That
(22:00):
register pain.
It must be doing that.
It's only the brain thatregisters pain.
Everything has to get to thebrain for you to feel pain.
So something about the VR,right.
Is, is stopping.
Thank goodness.
Those signals from theperiphery.
And I would love to know whatthat is.
I would love to know.
Leah (22:19):
I have had patients At least one in particular who said
they were very into doing thevirtual reality exercise
programs that there are and theywanted VR in the, in the
infusion room
Janet Abrahm (22:33):
Yeah.
Leah (22:34):
take
Janet Abrahm (22:35):
Should be.
Leah (22:35):
Like exactly.
Janet Abrahm (22:37):
The holodeck, you know, the holodeck.
That would be great.
I mean, I would love that.
And they're not that expensiveanymore.
So I think, you know, maybe the,the friends of every cancer
center could donate VR sets tothe infusion rooms.
I think it'd be a, or for thosepoor patients, you know, who
can't get out of bed, who gettoo sick from any illness, How
(23:00):
wonderful to be, even thoughyou're homebound, to be skiing
or whatever, whatever you liketo do.
You know, I can't believe I've,I've been within five years.
I can't believe we're not goingto have that as just part of
your glasses.
You know, it's going to, Be lesscomplicated like those Google
glasses were.
Tina (23:18):
Yes.
I have.
I've actually seen ads for justthat where you can, you can just
envision that puts up a virtualboard and you just put on these
glasses and you can, well,they're, they're advertising it
to do work, but I could see itused better to do something more
pleasurable than looking at yourcomputer screen.
But yes, it kind of creates whatlooks like a projection wherever
you're looking.
Um, I was at a conference andthere was a company looking at
(23:42):
using virtual reality goggles inthe infusion room.
And it was specific topancreatic cancer patients in
their study.
it was a passion project.
The founder and CEO's parent hadpancreatic cancer and as a
person who was technology savvyand said, we need to get these
people out of here.
Like the infusion room, wasn't agreat experience for the parent.
(24:03):
And so.
They were coupling it withbreathing techniques
Janet Abrahm (24:07):
that's a good idea.
Abdominal breathing, especiallyhave them do abdominal breathing
would be
Tina (24:13):
yeah, and it was really neat.
Cause if you're looking at abeach and the waves are coming
and going, and there's a mooncoming up and you had to, you
had through your breathing, youcould kind of control the
scenery and you, you had a goal,you know, um, I can't remember
what's to keep the moon up orwhat it was, but it was
something where like, oh, okay.
And then afterwards they showedyou how you're.
Janet Abrahm (24:31):
it would be, it would, it would time with the
waves.
I was thinking I would do it.
So it would time with the wavesthat that would be my suggestion
if I were doing it is to be ableto sync your breathing with the
in.
That's what I do in hypnosis,the in and out of the waves, but
abdominal breathing is sohelpful and people have such
bad, um, hard wiring of the sideeffects of, of being in those
(24:54):
infusion rooms.
I mean, it isn't so bad anymore,but I would be at the grocery
store and people would throw upif they saw me.
Tina (25:00):
Oh,
Janet Abrahm (25:01):
Or, or at an airport and people just, the
smells of the infusion roomwould be enough, but nowadays
the treatments are so muchbetter.
The drug treatments are much,much better but they're still
not fun.
And the week after treatmentisn't fun.
So
Tina (25:16):
I think there's a little bit more cognizance of the
setting for the infusion room tobe a little nicer now.
I feel like it was very, I mean,I, I did my residency in 2000,
2002, and it was very different.
it was at CTCA, which they did amuch better job than most,
Janet Abrahm (25:30):
Yeah, they were supposed to be the fanciest.
the TV show, at least the ads,they looked elegant.
CGCA, I thought, Whoa, this islike the Cadillac of oncology
practices.
Leah (25:42):
Yeah, that's it was
Janet Abrahm (25:46):
What happened to It is, it still, is it still in
practice?
Leah (25:48):
it's city of
Tina (25:49):
it's owned by City
Janet Abrahm (25:50):
No.
Oh, Oh, wonderful.
That's a wonderful place.
Betty Farrell's there.
She's a genius.
Yeah.
Tina (25:59):
So yes, they, you are correct.
It was actually wonderfulbecause a lot of the services
you're talking about Inpalliative care, it was all
under one roof, which I think isbecoming more and more common
now, Dana Farber, like youmentioned, you know, you're
either allying with integrativepractitioners or you have them
under your roof, but there's alittle bit more patient
centeredness around cancer carethan there was 24 years ago.
Janet Abrahm (26:20):
yeah.
Tina (26:21):
So that's that's the right direction.
I'm happy about that.
Janet Abrahm (26:23):
Yeah, me too.
Um, I just was hoping I couldmention the website just as a
resource.
Leah (26:28):
Oh, Absolutely.
Janet Abrahm (26:30):
So after we, we wrote the book, this is the
fourth edition.
The first one was in 2000, whichwas called A Physician's Guide
to Pain and Symptom Managementin Cancer Patients.
And it just showed how everyedition shows me how much I've
grown, which is wonderful.
So this edition is, is called.
A Comprehensive Guide toSupportive and Palliative Care
(26:51):
for Patients with Cancer.
And it has chapters by socialworkers about family dynamics
and by chaplain, of course, andby psychiatrist, and there's
lots of stories and lots ofsymptom management.
But once we finished that, wethought, well, a lot of people
don't read books.
I mean, they're good to have onyour desk, but.
Or online, but we learned that60% of community oncologists did
(27:16):
not have a palliative carepartner.
Now, hospitals, over 300 beds,95% of them have palliative care
teams.
But most people aren't inhospitals, thank goodness,
right?
I mean, most people are caredfor outside a hospital.
So I thought, I used to speak tocommunity oncologists when we
did our updates at Dana Farberabout symptoms, but also about
(27:36):
moral distress andcommunication, you know, how to
break bad news and how to breakreally bad news and how to not
feel terrible about it.
And so we created this website,which is just my name,
JanetAbrahm.
com.
You just have to get the H inthere and you can find it.
And what it has is, resources insymptom management and
(27:58):
communication and end of lifecare, and then special topics
like people who want miracles,LGBTQ issues, trans issues.
We have interviews with peoplewho are experts in all those
fields.
And then we also have papers andlinks to websites and things.
And the goal is for, and we'llhave a newsletter and the goal
(28:20):
is for practicing oncologists tojust stop by and see is, you
know, is there something thatthey need to know how to manage
better or do they want to emailme?
You know, do they want toconnect with me or things like
that?
So the idea was to be a resourceand we've just started we're
just launching it now, really.
and so, uh, we'll be veryinterested to see what, um, what
(28:44):
people need, what questions theyask, what we haven't included
that they need.
Leah (28:49):
it is geared towards clinicians.
Janet Abrahm (28:51):
yes, there's nothing on it that is wrong for
patients and families, but theAmerican Cancer Society has
wonderful resources for patientsand families, and they, in fact,
just partnered with the AmericanSociety of Clinical Oncology,
the doctors, so that for theirmessaging, American Cancer
Society is is so good atmessaging, you know, for
(29:12):
patients and families or livingbeyond breast cancer.
There's so many, it feels likecommunity resources for patients
and families, but fewer for theoncologists who need a little
bit more expert training becausemost of them weren't trained in
this in their fellowships.
They, they don't really know howto do, like if somebody has
(29:33):
really bad neuropathic pain,nerve pain from a cancer that's
invading the nerves, they don'toften know how to use the drug
called methadone, which isreally good for that kind of
pain.
And they would want a partner,even at Dana Farber, we often
will see those patients to getthem under better control so
they can go on and get theirtreatment.
Tina (29:52):
hmm.
Janet Abrahm (29:53):
we thought it might be really useful to have.
Have all that information in oneplace for them as a resource,
especially the videos, thecommunication videos, like you
were talking about, about, whena patient isn't doing so well,
how to talk with them.
Usually they don't get trainedin that.
Maybe one day now of oncologytraining.
we get to teach them for a day.
That doesn't seem like quiteenough.
(30:14):
So we made some videos of thesame kind of thing so people
could watch them and seeexamples of how to have that
conversation without feelinglike you failed the patient.
Leah (30:23):
sure.
Tina (30:24):
You know, it's, it's interesting because, you know,
we're all clinicians.
We've all worked with cancerpatients and in our offices, I
think this is true of all threeof us, we get to see the patient
kind of exhale and relax.
Like you said at the beginningof this interview, like, you
know, there's a differencebetween a medical oncologist and
they're putting all their chips,they feel like all their chips
are with that person.
Right.
And so they don't want to do thewrong thing and there's, they're
(30:45):
a little bit like, I just wantto do whatever they want and I
don't want to disappoint them.
And I feel like when they werewith their naturopath or perhaps
their palliative care team, theycan relax and just be a little
bit more real about everything.
Um, so that's a privilege.
It's a, it's a privilege.
But in that setting, sometimespatients will gripe about the
(31:06):
communication from their medicaloncologist about the harshness
or about how things weredelivered or, and It's a
challenge to both acknowledgeand validate that they have a
good point and try to explainthe other side, right?
I've had these conversationswith medical oncologists my
whole career.
It's like, okay, so
Janet Abrahm (31:25):
hmm,
Tina (31:25):
you said this to the patient so I can understand
their perspective better, right?
Like, why, why are you goingstraight to hospice when the
patient has two more treatmentsdown the road?
You know, and they don't want tothink about hospice yet.
But You know, there's this,like, burden on the medical
oncologist to prepare thepatient.
Like, I, they, that's alwaysbeen explained to me.
(31:45):
They feel an obligation to bevery honest and prepare the
patient for whatever is to come.
but I would argue a palliativecare team is better at that.
So this is, this, this isanother reason that palliative
care should be everywhere, is Ifeel like it shouldn't be the
medical oncologist's job to dothose things.
It should be a it should bededicated to someone else down
the hall.
So,
Janet Abrahm (32:05):
Oh, I can't, I can't totally agree with that,
but I can give you some language
Tina (32:10):
No?
Janet Abrahm (32:10):
you'll accept.
Which is that, I feel likepatients really rely on that
oncologist because they've takenthem through so much.
So, the language that we hopethe oncologist will use is the
hope and worry language.
So, I really hope this treatmentis going to work and I'm going
to do everything, our team, yournurse practitioner, our social
(32:31):
worker, our team is doingeverything we can to get you
through this treatment.
I worry that there aren't aninfinity of treatments left.
Now, maybe something will comealong.
But I do worry.
And some of those treatments arekind of hard to take.
So it's okay with me if we talka little bit about, kind of the
what ifs.
Now, what we always ask theoncologist to say is, is this a
(32:52):
good time for you to do that?
And the patient says, no, I justwant to get through this
treatment.
Then you say, fine.
But at least you heard youroncologist say, I hope and I
worry.
Tina (33:03):
Mm.
Janet Abrahm (33:03):
just your palliative care doctor says
that, it doesn't have quite thesame authority.I don't t think.
Tina (33:10):
hmm.
Mm hmm.
Janet Abrahm (33:11):
And then it'd be great if the oncologist gave me
a heads up and said, I had thewhole worry conversation today.
Can you let me know how itlanded?
How she feels?
Um, was it too much?
Was it not enough?
Cause you, you don't want theoncologist, you know, the
oncologist feel failures.
That's why they use that wordfail the chemotherapy.
(33:33):
Nobody fails chemotherapy.
The chemotherapy failed thepatient,
Tina (33:35):
Exactly.
Janet Abrahm (33:36):
but doctors use the fail word.
And I think it's a countertransference.
They feel that they failed.
The patient and it's not a it'sin here.
It's not up here.
If you ask them, they will say,Oh, no, I didn't.
I did everything.
But then in that last meeting,they recite all the things they
did.
So I know they're hurting.
I know this feels terrible forthem.
(33:58):
So I'm a partner for theoncologist for that reason.
And I think that, you know,their grief can lead them if
they don't have a partner towhat I call truth dump.
You know, you don't want to dothat.
Because you haven't processedit.
You don't, you've got some badnews back.
It's so overwhelming.
Usually it's junior people whodo this.
(34:19):
Trainees.
They got the news back and theycan't hold it so they dump it on
the patient and family.
That's not a good technique.
And maybe your patients have hadthat happen to them.
Sort of a truth dump where itwas just unfiltered.
It wasn't nuanced.
So, so our training, we'relucky.
We were able to train theoncologists in what vital talk.
(34:41):
Have you heard of thatcommunication training program?
Leah (34:45):
No.
Janet Abrahm (34:46):
called, it's called vital talk.
Uh, my boss, James Tulsky, Dr.
Tony back and, um, Bob Arnoldstarted it about 20 years ago
now.
And there's wonderful trainingfor regular doctors and also
oncologists in all of thesetechniques.
and there's an app that canremind you what the questions
are.
For the breaking bad newsconversation, where after you
(35:08):
break the bad news, I mean,there's rules for how to set it
up, but then there's thesewonderful nurse acronym, which
is how you respond to theemotion.
You name it or, you know, yousay you understand or you
respect it or, uh, the patientor, you're going to support them
through it or exploring more.
That's the nurse acronym.
(35:30):
For me, it's always when I breakbad news and I get an emotion
back, it's always some form ofgrief.
You know, the five things.
So it'll be anger, denial,bargaining.
Those are the things that peoplerespond with when you give them
bad news because they're ingrief at some level.
But anyway, the vital talktraining can be done in a day by
(35:51):
oncologists or by anyclinicians.
It's a wonderful communicationtraining, I think, uh, Dr.
Chelsky came to us in 2015.
I was curious, so I got trainedin it I did the more advanced
training because I thought thatwas my responsibility.
And I found it very helpful tohave these phrases to use, like,
um, for that patient of yours,maybe he could have said, we're
(36:13):
in a different place now.
That's a really gentle way ofletting somebody know that,
yeah, we can treat you, andwe're in a different place now,
maybe we should think abouttalking about code status, for
example, right?
You know, so, of course, we'regoing to treat you, we're going
to do everything we can, butthis cancer is so far advanced,
it would be awful if, when youpassed, We had to do that.
(36:36):
So there's lots of very wellhoned phrases that are a good
resource for the clinicians, whowatch your podcast.
Tina (36:45):
Yeah, well, and I would say what vital talks is what you
call that, right?
That's the app
Janet Abrahm (36:50):
a, it's a program called vital talk.
Yeah.
Tina (36:55):
encourage, I know some patients are like good riddance
and they don't go back and helpclinicians become better
clinicians because they're tooupset sometimes.
But I would encourage patientswho have the energy or their
caregivers to say, you know,maybe suggest this to a doctor
who wasn't very good at theircommunication because it's only
through feedback that people getbetter.
So very
Janet Abrahm (37:14):
I think that's great.
You can say there's this new,new program that I'm sure wasn't
around when you were first, youknow, being trained.
And I so appreciate everythingyou're doing for me.
And,
Tina (37:25):
Yeah.
that's great.
Janet Abrahm (37:26):
and that's the other thing instead of, but
instead of, but we've beentalked to use and, and I like
that much better.
Just like, instead of saying,I'm sorry, I say, I wish it were
different because then I'mconnected to you.
I say I wish
Leah (37:41):
Mm
Janet Abrahm (37:42):
because I do.
Yeah,
Tina (37:45):
Yeah, that may be a bit more accurate more than I'm
sorry.
Janet Abrahm (37:49):
Yeah, it really is.
But we weren't.
You need to be taught to uh,just like, you know, we don't do
procedures differently everytime.
Our communication is a reallyimportant medical, as you know,
uh, medical intervention.
The way we communicate can makeall the difference.
And so if somebody's figured outways, That are really helpful,
(38:13):
like, I think these things arereally helpful, I use them over
and over and over and they helpme connect or maybe a better way
of saying is they make manifestthat I am connected.
They don't get in the way orinterfere with how much I care
about a patient.
They manifest how much I careabout a patient in a very
(38:33):
professional way.
That's what I like about them.
Tina (38:36):
I think that's lovely and I think you you have also spoken
about burnout among cliniciansand being able to connect
without being Completely burntout on the emotional Aspect of
being a physician for the forpatients going through difficult
times no matter what thecondition.
(38:57):
Um, That's a whole skill set tooSo what you're what I like what
you're saying because Iunderstand that you can be with
the patient and connect withpatient Because I think
sometimes the harshness thatcomes across is just people self
protecting
Janet Abrahm (39:09):
I would agree and I think the biggest problem
which happened to me and ofcourse happened to every
oncologist is not having a placefor your grief.
Not having anybody to talk toabout your grief.
Feeling guilty that anybody elsebut you would have saved this
patient.
That's how doctors are trained.
That it's us that are supposedto save everybody.
(39:30):
So the unspoken curriculum asyou're training is nobody talks
about the people who diedovernight.
I did.
I was, I said, your rounds arevery different.
You know, I want us to unpackany feelings you had about that
person.
I want to respect her.
I want us to.
Really talk about how we caredfor her and, and how her passing
(39:52):
was very peaceful thanks to us.
I think most oncologists havewritten about this, do not have
a place for their grief and itbuilds up and after a while you
don't have any margin left formore grief, but you don't know
it.
It's just in here.
You just don't want to go intothose rooms and the patients can
see it.
They can tell, and they thinkthey did something wrong, which
(40:14):
is really hard, you know, tocause you to look like that.
Yeah.
You think you're doing such agood job of hiding your, you
know, your, your sadness.
But I think if there were moreability for oncologists to
process their grief, in astructured way, we do that with
a remembrance every week becausewe have so many people who pass
in palliative care.
(40:34):
But oncologists, I really feelcould do it once a month with
their staff.
They could read something, apoem, or they could, have music,
or something.
And then you read the names ofthe people who passed, and you
talk about them.
It's a wonderful way of, youknow, remember the anxiety
closet, of emptying that anxietycloset.
It's, you have to do that.
And if there's no place for it,then I worry that what happened
(40:57):
to your patient happens, becausethat person has no place to put
that grief and those feelings.
And so burnout manifests asanger, right?
That's one of the, ordepression, depression manifests
as anger.
Um, inappropriate anger,inappropriate pulling back,
making rounds when the family'snot there on purpose.
Leah (41:14):
Right.
Janet Abrahm (41:15):
There's all kinds of things that, that manifest, I
think, as, as grief, and if wecould do something about that,
we could decrease burnout, andthere's a lot on our website
about grief.
Moral distress.
Tina (41:27):
are they teaching this more in nursing and medical
schools because I feel like ithas to be done out of right out
the gates In order to be managedover life.
Janet Abrahm (41:34):
Nursing school has always taught about moral
distress.
It's a little different becausenursing moral distress is when
you know something should bedone and you're not the doctor
and you can't order it.
And you have to carry out
Leah (41:46):
Oh.
Cool.
Janet Abrahm (41:47):
these horrible plans.
So my, my introduction to moraldistress was from my nursing
colleagues who consulted me intheir moral distress.
To say so and so won't write ahigher dose of morphine or, you
know, the people where they seethe suffering and the oncologist
sees that they just make itthrough the rapids, they're
(42:08):
going to be cured of theirleukemia.
So we have to support them andget the nurses there for 12
hours.
the suffering.
so I think they don't, I don'tknow how much if they, I don't
know about the curriculaanymore.
I worry that too much of thiskind of thing is in the first
couple of years.
And then the real thing theylearn is when they start working
(42:31):
with, residents and so forth onthe wards.
Mm hmm And what they learn thereis what counts.
So we're trying to induce,introduce communication
training.
We have to the first, second andthird year residents at the
Brigham are, we have a corecurriculum, core communication
curriculum in which we do roleplays and really show them how
(42:52):
to use this vital talk type oflanguage.
We, we teach them how to havethe family meeting in the first
year.
And then we teach them how tohave that things are not going
so well in the second year.
You know, and we, we kind ofbuild on those, on those skills,
but it is only one day for eachof them, but it's pretty
powerful because I've seen themuse it.
They must need it, but I have noidea in the country, uh, what
(43:16):
the norm is.
It would make people feel a lotbetter if they felt skilled in
these areas.
I know it, they would feel somuch more empowered if they knew
that they could say somethingthat would be helpful.
Tina (43:28):
Well, yeah.
It serves everybody.
The and the patient.
Hopefully your work goes on toinfluence you.
The many, many more thousands ofpractitioners out there who, who
will read your book or watch,get the app.
So it's very commendable thatyou're getting that work out
there making a big difference.
Janet Abrahm (43:45):
Well, it's, you know, it's a very rewarding
profession and anything I can doto give back, to the patients
and their families and to thosewho are taking this on, that's
what I'm happy to do and so Ireally do appreciate the
opportunity to talk with you.
I think you've asked me somereally interesting questions and
the, the work you're doing isvery interesting as well.
I'm so glad that you're bothhere.
(44:06):
Well, it's constant and, uh,have compassion for the
oncologist.
That's all I ask.
It's really hard.
It's really hard for them.
And the more compassion you havefor them, the more they can have
for their patients and families.
I mean, just asking, how is yourday going?
I'm in the stairwell and theoncologist will say, I've had
three DNR conversations so fartoday, so it's, it's,
Tina (44:27):
Yeah.
Janet Abrahm (44:27):
the compassion is real.
Tina (44:29):
Yeah.
It's heavy, heavy stuff.
Janet Abrahm (44:31):
Yeah.
It's heavy stuff and they'redoing wonderful stuff and they
love their patients dearly.
Yeah.
Tina (44:36):
Yes.
Well, was there anything else,Leah, that you wanted to ask?
Leah (44:41):
I was just going to ask, is there, is there one piece of
advice in terms of now that ourlisteners are, are aware of what
supportive and palliative careis like, is there any specific
time that they should requestthis I mean, is there any
specific time when, um, When youfeel like it's good for a
(45:03):
patient to ask to see apalliative care doctor.
Janet Abrahm (45:06):
Well, I think that we don't have enough palliative
care doctors to see everybody.
And I do feel that if you'vebeen diagnosed with an advanced
form of cancer, that is notlikely to be curable, that from
the very beginning, at leastmeet with a palliative care
team.
There was just a recent reportat the national meetings of the
(45:27):
cancer organization that meetingin the beginning, especially for
patients who have lung cancer,and then meeting in If the
treatment changes or meeting, ifyou're hospitalized, that
that's.
That can provide all thebenefits, um, of meeting like in
a regular way.
(45:48):
Now those patients were trackingtheir symptoms, so if their
symptoms went really crazy, theyasked to see a palliative care
person, of course.
But even if your symptoms aren'tcrazy at the very beginning,
just meet somebody and say, youknow, for this, for my road
ahead, I need a partner and I'dlike to meet with a palliative
care team.
(46:08):
And then that palliative careteam will reach out to you
afterwards, as often as they canand depending on what your needs
are.
And that way when, the timecomes that maybe the treatments
are more burdensome thanbenefit, you have someone to, to
help you through thosedecisions.
You and your family.
Leah (46:26):
Great.
Tina (46:27):
All right.
Well, thank you again forjoining us.
I mean, this has been reallyeducational and a lovely
conversation.
Janet Abrahm (46:33):
Oh, thank you.I I think so too.
Tina (46:35):
And again, I just commend you for all the work you're
doing.
And, and
Janet Abrahm (46:38):
Thank you.
Tina (46:39):
I feel like you're taking some time out of your schedule
to help us out.
Bring this palliative care talkto our listeners is very
generous of you.
So truly appreciate your timeand all the work you do.
Janet Abrahm (46:50):
Well, again, it's all my pleasure.
And if you know, they want to goto the website again,
understanding it's designed for,for the doctor part of it, but I
might be able to put them ontoo.
Other resources, um, Dr.
Vicki Jackson wrote a wonderfulbook for patients and their
families that I could recommend.
It's from Johns HopkinsUniversity Press for people who
(47:11):
like to read.
It's really very patient andfamily focused.
And, uh, she's the head of thepalliative care program at Mass
General.
uh, has been in the field forover 20 years.
So I would recommend her book toeverybody.
Also, Mortal Lessons by JoanneLynn.
Those two are, are great.
Tina (47:28):
Okay.
We'll put links to those booksin our, in our show notes.
Janet Abrahm (47:32):
That would be great.
Thank you for doing that.
That would be terrific.
Tina (47:35):
your book as well, of course.
Leah (47:37):
And your website.
We'll put, we'll
Janet Abrahm (47:38):
oh,
Leah (47:39):
everything.
Tina (47:39):
Links will abound.
Janet Abrahm (47:41):
oh, wow.
That's wonderful.
I really appreciate it.
And if you know, you, if youthink of things that I could.
Uh, be helpful with the future.
always happy to come back.
Leah (47:48):
Thanks for listening to The Cancer Pod.
Remember to subscribe, review,and rate us wherever you get
your podcasts.
Follow us on social media forupdates.
And as always, this is notmedical advice.
These are our opinions.
Talk to your doctor beforechanging anything related to
your treatment plan.
The Cancer Pod is hosted by me,Dr.
Leah Sherman, and by Dr.
(48:10):
Tina Kaser.
Music is by Kevin MacLeod.
See you next time.
Popular Podcasts
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com