Eric: Welcome to the GeriPal podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, we’ve got a great group with us today. Who do we have with us?
Alex: We have an all-star lineup today, Eric. Today we’re delighted to welcome Kathy Foley, who is a member emeritus of the Memorial Sloan Kettering Cancer Center and past director of the International Palliative Care Initiative project of the Open Society Foundation. And Eric Krakauer says that’s too modest. Eric, how did you refer to Kathy before we got started?
Eric K.: Well, either the founder or godmother of palliative care in the United States and for that matter, the world.
Alex: Welcome to GeriPal, Kathy.
Kathy: Thanks.
Alex: We’re delighted to welcome Stephen Connor, who is a licensed clinical psychologist who has been working in palliative care for 46 years in various executive and leadership positions. Most notably he’s executive director of the Worldwide Hospice Palliative Care Alliance. And he has spent the last seven years with the International Palliative Care Initiative. Welcome to the GeriPal podcast, Stephen.
Stephen: Thank you, Eric.
Alex: And then we are going to welcome Eric Krakauer who is a former mentor of mine and is a protege of Kathy Foleys and a colleague of Stephen Connor and he’s associate professor of medicine and global health at the Harvard medical school and a senior attending at Massachusetts general hospital and is a former medical officer for palliative care at the World Health Organization in Switzerland and was formerly funded by the Project on Death in America and the International Palliative Care Initiative. Welcome to GeriPal, Eric.
Eric K.: Great to be here.
Eric: It’s great to have you all here. We’re going to be talking about international palliative care, big subject, lots to talk about, but before we get into that, who has a song request for Alex?
Stephen: I do. It’s “What the world needs now.”
Eric: I will not even ask why you chose that song, because it seems like it’s the title. Is that right?
Eric K.: Is that a Jimmy Hendrix too?
Alex: Burt Bacharach, right. And covered by so many people, Dionne Warwick. I will not be sounding like Dionne Warwick just for the record, but here’s a little bit, we’ll see. (Singing).
Stephen: All right. Well done.
Eric: That’s awesome. Thank you Alex. I’m really hoping, we got a lot to cover today. I think, starting off, just like why… We have a international audience, most of our audience is from the US. Often, the last two years, we’re just trying to stay afloat in our own institution, survive these COVID surges. Kathy, I want to turn to you, why should we care? Why is this important when we think about international palliative care?
Kathy: Thanks Eric. And thanks for having this session. I think in a way it’s complicated by saying why should we care? Because I think all of us would care that palliative care was available to all. And so to then when we begin to think of low and middle income countries where they have such little access to healthcare provisions and in where palliative care could make such an enormous difference. And so my own career began in like in the 1980s, when working with the World Health Organization who had a major effort to improve the care of patients with cancer. And yet 90% of the people who were with cancer were living in developing countries and they had no access to cancer treatment nevermind to access to any other approaches.
Kathy: And so at that point in time with the WHO and the cancer unit, a group of people led by a man by the name of the [inaudible], who was head of the cancer unit, argued strongly that palliative care should be a part of a public health agenda and should be part of an essential program in cancer. And clearly these were patients who had such advanced disease that access to pain relief would be so important. And so why any of us should care is so directly related to the fact that these are sort of easy wins and changes that we could make that would make enormous difference for millions of people.
Kathy: And again, many of, I think our audience, I’m sure in their own ways have been involved in working either internationally or working with international colleagues or being helpful to them in some way or another. So there’s a, I think, there’s an extraordinary interest now in improving and taking the knowledge that we have. And the next best part of this is that when we started this work we didn’t have an evidence base, but now we have an evidence base to make this both, to put it on a public health agenda and to put it on a human rights agenda.
Eric: Well, I’m wondering, I’m going to turn to Stephen, as for our listeners, including myself, as I think about all the things that I should be doing, it’s sometimes helpful to hear kind of what motivated people to do this type of work. When you think about your early career in this, what motivated you to really start working in an international perspective, improving palliative care?
Stephen: Yeah, well, we have it pretty good actually in spite of COVID in high income countries and particularly the US when comes to palliative care, relative speaking. We’re all got a long way to go to meet the need overall. But I was working at the National Hospice and Palliative Care Organization in late 90s through, for 11 years, up until 2009, but I was invited by Daniela Mosoiu from Romania to come to be a partner to them on USAID grant to develop standards for palliative care for the country of Romania. And in the course of a year, when we worked together in a partnership to do that, I spent a good amount of time in Romania just with them and I just realized how much, it reminded me actually of the very early days in the 70s of hospice movement and the energy that people had and the passion that people had about palliative care.
Stephen: You could say then I got bitten by the international palliative care bug. And in the course of the years working at NHPCO we had a big project in Africa for a number of years that we led and worked to help build up Africa and others. And I just saw more and more how valuable and how important it was. And we really have a kind of 80 20 problem, almost 80% of the need for palliative care is in low and middle income countries and almost 80% of the palliative care that is being done is in high income countries. And we really need to kind of switch that around to, I mean, that’s really what we’re trying to do with Kathy, try to do in the International Palliative Care Initiative is to reach those people where the need is most and where the care is least.
Eric: Yeah. And before we talk about needs and what they are worldwide, Eric, how would you then answer that question? Kind of, how did you get interested and what motivated you to get interested to do this type of work?
Eric K.: It was all a big accident, actually. Unintended. I didn’t choose it, it chose me. I was thinking about this as Stephen was talking, I went to grad school and philosophy before I went to med school. And I was particularly interested in two late 20th century philosophers, Adorno and Heidegger. And what I took from them, a lot of what I took from them was that what matters is not the political right, or the political left and even right and wrong, that’s always somebody’s opinion. But the way I judge things, the measure of things in general is what causes more suffering than relieves it and what relieves more suffering than causes it. What will prevent or relief suffering and what’ll generate it. It’s all about trying to prevent and relieve suffering.
Eric K.: That’s what medicine is. That’s what called me to medicine. And when I got in to medicine and saw that, well, I could have done anything. I liked everything. I liked psychiatry, I like surgery, I like pediatrics, I liked everything, but a lot of it was focused on one organ system or one category of disease, like cancer or infectious disease, or one technical skill like cancer or radiology or pathology. And it wasn’t dealing with the whole person in their cultural context. That’s what got me into palliative care. And then I came to realize, partly I guess, because I grew up during the Vietnam war, watching it on TV and the conflict in Nigeria, the war with Biafra and all the wars around the world, the genocides in Cambodia and then in Rwanda, there’s an enormous amount of suffering out there.
Eric K.: My understanding of medicine and of what I’m supposed to do is not just cure, try to cure diseases, but that’s all part of trying to prevent and relief suffering. And most of the suffering as Stephen said is out in the world, low and middle income countries. That’s where I went. And when Kathy and Susan Block directed this extremely important program called the Project on Death in America, which was one of the great of catalysts of palliative care in the United States. And as I was working on my project, which was on palliative care policies at Massachusetts General Hospital, I was getting more and more involved in or called more and more strongly, I should say, by the voices of suffering, usually unheard emanating from the developing world. And Kathy very generously, even though it was called the Project on Death in America said, “Go for it, Eric.” So I’ve been going for it now for 20 some years, I guess.
Eric: And when we think about this 80 20, and flipping this 80 20, what do we know about the palliative care needs worldwide? Sounds like there’s a lot of suffering. Do we know more about that?
Stephen: Well, we were fortunate to get, I mean, for the formation of the Lancet Commission, that Eric was actually very, very much involved in, in terms of doing estimates of the need for palliative care. We used those in the Global Atlas of Palliative Care now. We had come up with our original estimates, which were based, because the WHO is rather conservative about not wanting to be criticized for overestimation. They don’t mind being criticized for underestimation, I guess. But anyway, we ended up at about 40 million people need palliative care. But we knew that was a conservative estimate and probably an underestimate.
Stephen: So the Lancet Commission came up with a number based on serious health related suffering that Eric’s talking about, and the number of people suffering with serious illness well before the sort of period that we think of as six months or less that is not what palliative care’s about. We want to get involved early from the nearly from the point of diagnosis. And that number was 62 million. It’s kind of floating back and forth. It’s in that neighborhood, the need, and that’s the patient that doesn’t include the families. If you add on several family members, because they are patients also, you get up to, well over 200 million people a year needing palliative care, each year, and it’s going to grow. Katherine Sleeman wrote a paper about this recently that projected out to 2060 and an 83% increase in the need. It’s like taxes and.
Eric K.: Eric, I feel like it’s important to jump in here, partly because I like to talk, but I think it’s really important to say very clearly that the three of us and I think I can speak for my two colleagues here, palliative care is not a response to serious illness in the developing world that could be prevented or treated. It should go along with the strong efforts, the necessary efforts to make palliative care universally accessible, including to the rural poor.
Eric K.: Need to go along with equally strong efforts to make prevention of preventable diseases and treatment of treatable illness accessible. So yes, women with cervical cancer suffer horribly in the developing world, everywhere, but especially in the developing world, but there needs to be HPV vaccination so they don’t get cervical cancer and there needs to be early diagnosis. I know our audience is mainly focused on geriatrics. So are we going to get to geriatrics one of these days or shall we talk more about general palliative care? Because I got a lot to say about that too.
Eric: What are your thoughts on geriatrics, Eric, worldwide?
Eric K.: Well, again, how many hours do we here? [laughter]
Alex: Succinctly. I do remember that you like to talk. [laughter]
Stephen: We don’t want people to die prematurely obviously. [laughter]
Eric K.: Every word is carefully chosen, like every note in Mozart. Okay. [laughter]
Kathy: I want to interrupt for a minute because I think there’s a bigger picture here. So the bigger picture is that we’ve sort of fought the for fight to make palliative care a public health issue. We have it on the agenda of public health people of the World Health Organization of the World Bank of a variety of other important bilateral funders, et cetera. We have a human rights component to it. But I think what the audience I think should be aware of is the fact that there still is such profound inequity. And so for us to move this inequity forward and to work on the kind of policies that Eric has talked about the working at Mass general and then eventually in Vietnam and Rwanda and other countries was that we to be able to implement palliative care, you’ve got to know the numbers and you’ve got to be able to say them, to give them to the government.
Kathy: So Steven’s work on the Global Atlas has been critical because now they can’t tell us there’s nobody out there that needs these palliative care because we don’t know what it is. They’ve defined it, they’ve categorized it, they’ve put the numbers on it. And then Eric brilliantly has worked on this serious health related suffering index, which is a way for countries to be able to assess that. And if they can assess it, then they need to know how many people have serious health related suffering.
Kathy: And we brought together great economists. I mean, brilliant economists who bought into this and said, “You’re right. This is another measure.” So I think that why we should care about palliative care now is we have a handle that we never had before. We have the effectiveness data that’s come out of developed countries, but now we have a handle in these lower and middle income countries of a number that we can use and a way to be able to assess it. So I think Eric, you should just talk a little bit about how you assess serious health related suffering because I think that’s been a major step forward.
Kathy: And it covers older persons, it covers geriatrics, it covers the range. And so it’s not specific to any age group, but it’s disease related in a sense.
Eric K.: The Lancet Commission was chaired by physician Noel who’s an economist. And the person I worked with most who I think I learned more from than from anyone since I worked with you, Kathy, was Dean Jameson who’s also a world famous health economist who gave me the ideas of how to start thinking about out how to quantify the need for palliative care. And it was a remarkable conversation for over a year, which I just, I was so thrilling and it was humbling because I realized that as a physician, even with a lot of experience in palliative care, without this knowledge of health economics and policy, severe limits of what one could do.
Eric K.: So with his guidance, I developed a way to estimate the need for palliative care, which was by identifying the 20 conditions listed in the ICD-10, that most commonly generate a need for palliative care, 95% of the need. And then what types of suffering, whether physical, psychological, social, or spiritual are associated with each of these conditions. Malignant neoplasms, everything from malignant neoplasms to dementia to end stage major organ failure and the duration of those symptoms. And that also then enabled a calculation and creation of an essential package of palliative care to respond to each type of suffering with each condition and even to calculate how much it would cost in each country by costing each item in the essential package. So that’s what the Lancet Commission did.
Eric K.: And it’s thrilling to see Stephen as the editor of the Global Atlas to absorb that method into the work of the WHO. We know now or we have a pretty good idea of what the needs are. The needs are enormous in the developing world, and they’re unmet needs. A lot of the need, not all of it, but a lot of the need is met in rich countries, but not in poor countries. And, segue coming up here, there’s huge demographic shifts that are happening not only because the shift from infectious diseases to more noncommunicable diseases, but also the demographic shifts that take young people out of homes, more movement of people so that older people are not cared for as much, especially in the developing world, in quickly developing countries, by their kids, by their grandkids. They’re more on their own. So this is a huge problem. Who’s going to take care of older people who in the past were cared for by their kids and grandkids.
Eric: And can we get maybe some examples of what are some of these needs? I’m guessing it’s for both primary and specialty palliative care, but I’m also guessing it’s access to medications for palliative care. How would you describe-
Stephen: You need to talk about that, Kathy.
Kathy: One of the greatest public health inequities that was identified in the Lancet Commission report was the lack of availability of essential medicines for pain relief. And I mean, the economists were shocked. I mean, they were quite amazed at the idea that this was such an extraordinary public health inequity, where there was lack of availability of essential medicines as analgesics. So that stood out. But the second area was this lack of availability of essential medicines for symptom control. That was a second area that was really profound. So you can’t begin to get governments to think they should pay for these essential medicines even though they’ve agreed to a policy on essential medicines. But for them to pay for them, they have to cost them out. They have to know what they are. So by Eric putting together this health related suffering, and by identifying the symptoms, and by more importantly, various organizations putting together an essential medicine list for palliative care, we know what the governments need to have, and we know what they need to pay for.
Stephen: Eric, we need millions of people trained in palliative care that are not trained now. Everybody that graduates from a professional school should have training in, basic training in palliative care. And we think that about two thirds of people could be cared for by their primary care physicians without referral necessarily to specialist palliative care providers, if they had training in palliative care that you don’t need to be a specialist necessarily. And symptoms, some patients are much more, have much more severe suffering than others and symptoms, they can be managed in a decent healthcare system. Part of the problem we have in terms of models is we’ve got this high income model and Cicely told us just find a way to do it in your setting the way that makes the most sense. So we find-
Alex: When Steven says Cicely, by the way, Cicely Saunders. Yes.
Stephen: Not too many Cicelys in palliative care.
Alex: Just want to make sure our listeners are clear.
Stephen: Yeah. So there was a program, a project, there’s a program in Southern India in Kerala started by Suresh Kumar called The Neighborhood Network for Palliative Care. And that is a model that has used volunteers and backed up by health professionals to deliver palliative care at the front, in the neighborhood that the people live in actually. It’s a really interesting model. We’ve modified it and made it indigenous in lots of other countries, but it’s really driven by the community and by power professionals.
Stephen: A lot of these professionals like teachers or social workers, whatever, and they were trained in palliative care and they were out there checking on people, but, when someone started to have more severe symptomatology or problems with pain, what have you, they were able to bring right in the nurses and physicians needed to be able to prescribe and assess for that patient, what was really going on with them [inaudible 00:25:03]. But that’s a model that’s used all over the world now on various ways. And it’s something we should look at here because I mean, we have our problems with what I would term Guild issues within the United States when it comes to healthcare and that includes palliative care. We don’t want a task shift. Home and Health Aids could be doing a lot more than they’re doing now and volunteers could be doing, and it wouldn’t hurt. I mean, for legal issues but.
Eric: That’s interesting too, because it often feels like the older model, the US is going to send experts over to another country and teach them how to do this thing. Recognizing the US healthcare system is screwed up in so many ways.
Eric K.: Eric, you’ve just touched on something there that’s really important. And it’s not just because the US healthcare system is screwed up. It’s much deeper than that. Europe and the United States, the Western countries have always, for centuries, have always thought that they know how to do things better than all the others cultures of the world. And we need to go and enlighten the unenlightened. And that’s, for me, that’s what’s most fundamental about bigotry in general that we think we know how to do things better. So at the beginning of this call, we were talking about why should our audience care? Well, I think one answer that we’ve already provided is because there’s a sea of unnecessary suffering out there that shouldn’t be, that we have the means should to find a way to make sure that people are not suffering for lack of very cheap, very safe, very effective medicines and treatments that they don’t have access to.
Kathy: We have the medicines and we have the knowhow, we have the training to do this. This unnecessary suffering is unacceptable. That’s why they should care.
Eric K.: That’s one answer. That’s maybe the first answer. The second is that in our European American zeal to enlighten the unenlightened, we’ve failed to recognize, we failed to learn from others. I’ve just, in recent years, been starting to get into this, but I think it’s really important. Let me give you one example from Rwanda. Kathy mentioned that I’ve been working in Rwanda for years with Partners in Health, thanks to Paul Farmer and his amazing group to integrate palliative care into the healthcare system there. And one of my colleagues, Dr. Christian Ntizimira is very interested in traditions of caregiving for older persons, older adults, and at the end of life.
Eric K.: And what he’s found working with an anthropologist in Rwanda and here in Boston, when he was doing his masters at Harvard, is that there was a tradition in that region of death as accomplishment. That is the last weeks, days of life were not a sad time, it was a time for the family to come together, celebrate the life of the person who was being honored and it seems that this was also a time for the dying person to prepare for the next step, which was to join the ancestors, which was something and the ancestors revered. So it’s actually a kind of a happy time and the introduction of the Europeans with their ideas of heaven and hell introduced a concept that hadn’t existed before that death can be scary, because I might go to hell.
Eric K.: That’s a massive oversimplification, but that’s just one example. Every culture, since time immemorial has had a way of dealing with aging and frailty and death. And there’s a lot that can be learned from that. And I’m just going to give one more example of working with colleagues in China now. And I think as Stephen or both Stephen and Kathy mentioned, palliative care is not one specific activity. Palliative care, what it should be, what it should consist of, depends on the needs of the population served. And people don’t suffer the same way in rural Malawi as they do in Boston or as they do in Ho Chi Minh City. Palliative care needs to differ. How do you translate palliative care into Mandarin, into Chinese?
Eric K.: There’s been a fascinating discussion about what is optimum palliative care, what is optimum care for the seriously ill and the dying in China? In a big discussion with a lot of people, the characters, and I think Alex your wife speaks Chinese. [Eric K. speaking Chinese phrase]. I think it means something like healthcare, healthcare for comfort and harmony. [speaking Chinese phrase] is harmony. And it’s nothing about cloaks or a palace, it’s healthcare for comfort and harmony. Harmony with self, harmony with others, harmony with the environment. That’s what’s meaningful in Mandarin. It’s different. And this is important, not just for Asian Americans or Chinese Americans or Chinese Canadians who may bring this culture with them, this can inform how we take care of people in Boston.
Stephen: We need harmony in the US health care system.
Eric K.: A little harmony wouldn’t hurt. Would it Stephen?
Stephen: Badly, in need of harmony.
Eric: And Stephen, coming from your perspective too, like when you think about palliative care services that are developing worldwide in all of these different countries, I’m guessing some are focused on hospice and around palliative care, how do you think about that question, what it looks like?
Stephen: The word hospice actually is more high income country kind of language. We tend to use palliative care around the world as a bigger sort of framework. The origin of the term palliative care, of course, from Balfour Mount in Canada, which was just a cloak. It was only because he couldn’t sell the word hospice in French Canada because it meant in French Canadian poorhouse or.
Alex: I didn’t know that part of the story.
Kathy: But I think as Stephen is saying, there is a strong movement to address the needless suffering of large populations of individuals in their last year of life rather than in the last days of life. And so there was a very strong movement to move from hospice to the broader concept of palliative care that Balfour Mount had promoted and to use that term and it was more acceptable in translation and to other countries to use that term. As much as people want to use other terms like supportive care and we can go through 100 other names, the importance of palliative care is that we built policies around it. And so the Worldwide Hospice and Palliative Care Association, the WHO in 2014, came out with a resolution in which the member state signed on and said that they would be supportive of promoting palliative care for their individuals in their country. So they signed a resolution saying they’re committing to this.
Kathy: In attempts in working with the human rights groups, the word in language palliative care has been used. And again, it’s to focus on this idea of people with life limiting serious illnesses and not to focus on specifically on end of life care, but more broadly, this last years of life and the needs of that population. And so importantly, in the rights of the elder persons, I think is the name of the human rights document, there was nothing ever said about palliative of care. And so we again went to the UN and were able to include palliative care in that document to be sure that the rights of older persons, that they would have access to palliative care. So there’s a lot of meaning in palliative care as a policy word. I think it’s important for people to think of it and use it that way. This is not in any way to speak disparagingly about hospice work or hospices, they’re incredibly critical and they were the beginnings of this, but the policy agenda is a bigger agenda and palliative care is the language we need to use there.
Stephen: The resolution says, strengthening palliative care in the continuum of care.
Kathy: Right. Which is really important.
Alex: Before Eric asks you the wave the magic wand question, which we ask our guests at the end of each podcast, I just want to reiterate what I’ve heard so far and summarize. And I’ve heard that there’s tremendous need for palliative care because there are people living with serious illness around the globe who have unmet needs for palliative care. And that crosses a whole range of domains from symptom management, to psychosocial, to caregiver. And that with the aging of the population globally and shifts, demographic shifts, in the way people live their lives and the way they care for older adults, there’ll be a tremendous growth in the need for geriatric specific palliative care worldwide.
Alex: Particularly I would say in dementia, this is the longest we have gone in a podcast without mentioning the word Aducanumab, I’ll just note that for our listeners who have listened to our previous podcast. And I also say that it’s important that we not impose our norms and moral standards and mechanisms of palliative care delivery that we have developed in the United States or in Canada or Europe or in Australia upon other countries, because they have their, we should, instead, this is like implementation science, think about how we can get to the underlying issue of providing high quality care for people with serious illness. And that includes relief of suffering, but we have to situate it within the cultural context, within the history, within the ways and systems that they have in place already and strengths that bring to bear across the globe.
Kathy: Good summary.
Stephen: Sure.
Alex: Eric, with that framework, because there’s so much there. And Eric’s going to make you choose one thing. Like if you could make a magic wand with one thing, what would your highest go ahead, Eric? You ask the question.
Eric: No, I think you just asked the question. If you had a magic wand right now, anything related to international palliative care, what would you do? Eric, start off with you.
Eric K.: I’ll give you two answers.
Alex: He’s cheating already. [laughter]
Eric K.: Well, I mean, that’s what we do. [laughter]. It would be to to change the way we think about others. No longer think about them based on their use value, but think of them as others who have a value in themselves. And therefore older people, older adults do not diminish in their value when they can’t work and should be put in nursing homes. They are to be respected and cared for as honored members of the family and the community. That’s my change in thinking. Something very concrete? How about this, adult diapers. That’s a demeaning term, diapers. Adult sanitary shorts that are eco-friendly, biodegradable and cheap so that they can be universally available and family caregivers do not have the stress of dealing with incontinence all the time.
Eric: With big NA, very concrete example. Kathy, your magic wand.
Kathy: Yeah. Mine would be that we educate health professionals and we pay them to do this work. So my magic wand is we need this data that Stephen and Eric have put together to convince governments to pay for it. And in that way, then we’ll have healthcare professionals that can do it. But we need to educate them. So there’s two pieces to that.
Eric: And Stephen, the magic wand still has a little bit of left in it.
Stephen: I’d like to be able to lessen death anxiety in the world because that’s been what prevents people from embracing.
Eric: Any ways on how to do that. I know that’s a whole other podcast. You’re magic wand, there has to be concrete now. Is there anything?
Stephen: Well, I think we do need to remember that we need psychological services within palliative care and sometimes we’re a little medically oriented. I’d like to see that holisticness balanced a bit more with. I’m sorry it’s not a diaper.
Eric: No, that’s perfect. All right. Alex is going to be upset at me because it’s going to eat into his song, but Kathy, I got one last question for you. For those who you’ve motivated that we should care, we should do something about this and they’re like me, they work in their medical center, they’re trying to do what they’re doing, but they also see the need that’s out there far outside their institutional walls. Where does one start? If you want to.
Kathy: I mean, I do think they should start at home. I mean you live in San Francisco, it seems to me you have a lot of resource limited issues on the streets of San Francisco that where you could start. I don’t know that you need to go to a low resource country to do that. But being very specific, I think the American Academy of Hospice and Palliated Medicine does have an international group and I’m well glad to provide people with that group that’s trying to do this work. And then I think you can hear from Stephen, there’s the Worldwide Hospice and Palliative Care Association that does a lot of work and groups that are asking for help. The Indian Palliative Care Association loves any teacher that will come at any time and they will communicate with you about that and then lastly, the International Association for Hospice and Palliative Care similarly has a whole international effort.
Stephen: And the International Children’s Palliative Care.
Kathy: And the International Children’s Palliative Care. So there are these international organizations that are on websites and are looking for people to donate their time.
Stephen: Right. And we’ll have links to all of those on our GeriPal show notes so people are interested, that’s one way. I want to thank all of you for joining us and before we end we got a little bit more, what the world needs now is a little palliative care.
Alex: (Singing).
Eric: Well, Kathy, Stephen, Eric, thank you for joining us on this GeriPal podcast. It really was a pleasure. And thank you for all the amazing work that you’re doing.
Kathy: Thanks for having us.
Eric K.: Thank you. And I just want to lastly say thanks to Kathy Foley, without whom I wouldn’t be, none of us would be where we are and palliative care would be nowhere near what it is. Kathy, thank you.
Kathy: You’re welcome, Eric. But, thank you for all the good work that you’ve done. There’s so many people that have made such a good difference. So many people.
Eric: And a very big shout out to Archstone Foundation for your continued support and to all of our listeners and to all of those people who are doing amazing work worldwide. Geriatrics and palliative care really is amazing. It’s hard enough to do this in a well resourced environment that I am constantly impressed it can happen elsewhere too. So big thank you.