00:00 - And thank you for being here, everybody.

00:02 - so I just want to give a little bit of background.

00:05 - so I am in, in with hospice and community care.

00:07 - I actually work on the Choices Palliative program,

00:11 - which is our outpatient, in-home palliative program.

00:14 - And we are based out of Lancaster in York County.

00:18 - we do cover some of the surrounding counties, like Berks and Chester.

00:22 - I've been in the hospice field for about 17 years now.

00:28 - and my co-presenter is Deb Gonzalez.

00:31 - as as mentioned before, she is a bilingual, a bereavement

00:35 - counselor at the Pathway Center for Grief and Loss, which is in Mount Joy.

00:40 - but it is also affiliated with Hospice and Community Care.

00:44 - and Deb has been in this field for about 11 years.

00:47 - So in our time working in this hospice and palliative

00:52 - world, we've noticed that there's a discrepancy between the amount of,

00:57 - Latinos that use hospice services and non Latinos.

01:02 - and that is what prompted us to start asking this question.

01:05 - And one of the things that we noticed is that there's a lot of hesitancy

01:10 - in the Latino community to accept hospice or to talk about hospice.

01:14 - and so that is what we're going to be focusing on today.

01:19 - So first I want to start with explaining

01:21 - exactly what is hospice and what is palliative care.

01:25 - I think that a lot of times these two terms are used interchangeably.

01:29 - But there is one key difference.

01:31 - So palliative care is a medical specialty,

01:34 - just like cardiology, just like pulmonology.

01:38 - it focuses on optimizing quality of life

01:42 - for people that are living with a serious illness.

01:45 - under palliative care patients can still receive curative treatment.

01:49 - So somebody with cancer can be having chemotherapy.

01:54 - Radiation therapy can be going into the hospital.

01:56 - And also receive palliative care at the same time.

02:00 - That is very different from hospice care.

02:02 - Hospice care is a way of giving care, to somebody with a serious

02:07 - or life limiting illness that is focused on comfort and managing symptoms.

02:13 - Hospice is also very holistic approach in that it

02:18 - assists the

02:19 - patient and the family, and they not only manage

02:22 - physical symptoms, but also emotional and spiritual distress.

02:27 - Hospice is offered to people with serious illnesses

02:30 - when they have weeks to months to live, rather than days.

02:36 - And first,

02:37 - I just want to highlight that both hospice and palliative programs are covered

02:41 - by Medicare, Medicaid and private insurances.

02:46 - So now let's look at some of the ways that these programs can help.

02:50 - They both offer an interdisciplinary team approach, meaning that they work with.

02:55 - They have a group of people that work with the patient and family,

02:58 - including doctors, nurses, social workers and chaplains.

03:04 - One of the key things that hospice and palliative care

03:07 - programs help with is goals of care discussions.

03:12 - they help patients and families understand

03:14 - their illness, understand how their illness can change.

03:18 - But also most importantly, is that they help the health

03:21 - care team understand how that patient

03:24 - and family want to be treated and what kind of care they want to get.

03:29 - they can also help them put things in writing

03:32 - through advanced directives, through a pulse, or living well.

03:37 - And as I mentioned before, one of the key benefits is symptom management.

03:41 - Some of the main symptoms are the most common symptoms.

03:44 - When someone is facing a serious illness are things

03:47 - like pain or shortness of breath, nausea.

03:51 - So these are the things that a hospice or a palliative

03:54 - team would be focusing on.

03:58 - And as I mentioned before,

03:59 - they do have social workers and chaplains as part of the team.

04:03 - And they do, look at the whole picture, the whole family,

04:07 - and offer emotional and spiritual support as well as the physical.

04:12 - There's also some guidance with resource coordination,

04:15 - things like reaching out to resources in the community,

04:19 - like, meals on Wheels or private duty caregiving.

04:23 - These are some of the, benefits of being under one of these programs.

04:28 - And then lastly, they can help acquire DME medical equipment

04:32 - like hospital beds, oxygen wheelchairs.

04:36 - a lot of times they are covered under the hospice program.

04:39 - and if they're not covered, a palliative program can help

04:42 - patients get the right prescriptions to get that, equipment in their home.

04:47 - So we know that these programs are very helpful.

04:51 - the next question is, are they being used?

04:54 - and that can be a little challenging to track,

04:56 - but we did find this data that shows in 2023,

05:01 - the amount of Medicare people that died on hospice

05:04 - services broken down by, by race.

05:08 - And we can see that 50% of those people were white.

05:12 - and if we look for Hispanics or Latinas,

05:15 - you have to go down is 34%.

05:19 - So this supports what we already knew, that Latinos are not using

05:24 - hospice care or palliative care at the same rates that non-Latino O's are,

05:30 - which promise us to ask ourselves, why?

05:35 - Just in our practice, in our experience with patients, we've noticed

05:39 - some barriers, for accessing

05:43 - palliative or hospice care in the Latino community.

05:46 - And we'll talk some more about some of these in details.

05:49 - the first one is probably the most prevalent

05:51 - and the most obvious one, and that is the language barrier.

05:55 - when people feel like they cannot, have conversations

05:59 - and ask questions and make their needs known in the language that,

06:03 - they are used to, they're less likely to seek these, services.

06:08 - a lot of times we run into that with our program

06:12 - when if someone is symptomatic,

06:15 - after hours, or on the weekends, they hesitate to call

06:19 - because they're afraid that the person they're going to talk to on

06:21 - the phone is not going to speak their language.

06:25 - The language barrier can also account for a lot of misinformation.

06:28 - When we're having conversations about hospice and palliative care.

06:33 - the next barrier is fear of deportation.

06:36 - There is no requirement of we do not,

06:39 - these programs do not ask about citizenship or residency.

06:43 - But again, this can keep people from

06:46 - even seeking these programs out.

06:49 - The next one is religious beliefs.

06:51 - And, devil talks in some more detail about that.

06:54 - But, you know, just one of the things that I hear a lot from my Latina, patients

07:00 - and family members is things like, well, I'm leaving it in God's hands.

07:04 - So I don't want to talk about this or I don't want to give up my faith.

07:08 - I don't want to give up hope. So I don't want to talk about hospice.

07:13 - And then there's, a few other widely held myths.

07:16 - These are statements that we've heard in talking with different Latino,

07:20 - patients and family members.

07:22 - And so we'll go into more detail on those.

07:26 - So some of these myths, the first one is

07:28 - that all medication and all treatments are going to be stopped.

07:32 - And that includes even the comfort medicines.

07:36 - and I think this can be attributed in large part

07:38 - to the language barrier when somebody's doctor is saying to them

07:43 - there's no more treatment or there's nothing more we can offer you.

07:47 - what a Latino person hears is

07:50 - literally there's no more treatment, no more medication.

07:54 - So even the medication that's helping me be comfortable is going to be stopped.

07:59 - so we I always like to emphasize that it's

08:02 - not that your medical care is stopping, it's that the focus is changing.

08:08 - Instead of focusing on curing.

08:10 - Now we're focusing on managing symptoms and helping you live your life,

08:14 - helping you live comfortably.

08:18 - The next myth, I

08:19 - think, also has a lot to do with the language barrier

08:22 - is that people think that they have to move to a hospice,

08:26 - they think hospice is a place that they move to.

08:28 - And again, I think that's because when providers are talking about hospice,

08:33 - they use terms like transferring to hospice or transitioning to hospice.

08:39 - So if that is getting interpreted,

08:42 - depending on the interpreter, they might the Latina family member

08:46 - or patient might think that they have to physically go to a hospice location.

08:51 - So one of the first things I do when I'm explaining hospice

08:54 - or palliative services is make sure people understand that

08:58 - these services can be given wherever you live.

09:01 - And if your goal is to stay at home through end of life, then that is what we

09:04 - want to work. to accomplish.

09:08 - And then on the

09:09 - other end of that, sometimes we hear that people believe

09:13 - that the patient has to be homebound while they're on hospice care.

09:17 - you know, they're sick, they're dying, so they have to stay home.

09:20 - And I think some of that is because

09:22 - that is one of the requirements for home health.

09:25 - home health is offered to people that are can't go see their doctors.

09:29 - that is not a requirement for hospice.

09:32 - And it's not a requirement for palliative care.

09:35 - the opposite is true.

09:37 - Again, we want them to be able to live their lives.

09:40 - So if they have a good day and the weather's nice

09:44 - and they want to go out for lunch or they want to go out for a drive,

09:47 - we encourage them to do that and maybe cancel our visit or reschedule

09:51 - our visit, because we want them to be able to do the things that they enjoy.

09:57 - And this is probably the biggest myth

10:00 - that we struggle to to debunk in the Latino community.

10:05 - This is something that we hear very often,

10:08 - and that is that hospice is going to use medications

10:12 - like morphine to help my loved one die faster.

10:16 - I've had countless conversations with patients and their loved ones

10:21 - when, you know, it's a serious concern, they think that hospice

10:25 - is going to give him a medicine that's going to make him die faster.

10:29 - And that is just not true.

10:31 - I think what happens is that morphine is a medicine

10:35 - that is used for trouble breathing and for pain.

10:39 - When someone is at end of life.

10:43 - the way we use it in a home, it comes in a liquid

10:46 - and it dissolves under your tongue so you don't even have to swallow it.

10:50 - So it's very effective for someone that is in their last days or last stages,

10:55 - because they can still get that relief without having to swallow medicine.

11:00 - so I think it's just

11:02 - timing and coincidence that people are already

11:05 - in that dying phase when they when we start the morphine.

11:09 - And that's how this myth comes about.

11:11 - so this is a sensitive subject.

11:13 - This is something that we spend a lot of time,

11:16 - reassuring families that that is not the case.

11:19 - and some of the things that I like to say is that we start at the, at the lowest

11:25 - possible dose and then move up as needed.

11:28 - The other thing to keep in mind is that the hospice team

11:31 - is going to be there to support you.

11:32 - They're going to be checking in pretty frequently to see

11:35 - how this medicine is helping.

11:40 - The other thing that I've noticed is that sometimes the thing that families

11:43 - are more comfortable with other medicines that are very similar, they're just not

11:47 - the m-word.

11:49 - so sometimes we've, we've used that.

11:52 - And then the other thing is that oftentimes

11:54 - they would ask for oxygen and that's okay.

11:58 - It might not be helping the patient, but it's helping the family.

12:02 - feel like the patient is getting that support.

12:06 - and we also keep in mind that Latino families

12:09 - will sometimes not want to use morphine because they feel like it's

12:12 - going to create an addiction.

12:16 - So at this point, I'm going to turn it over to Deb

12:19 - so she can talk some more about the role of religion.

12:22 - Thank you. Jessica.

12:24 - Yeah, thank you for coming today.

12:27 - So we all know that when we have difficult situations,

12:31 - mostly the Latino community look for their leaders.

12:34 - And the leaders are their pastors, their priest,

12:39 - you know, the group from church.

12:41 - So these are very important,

12:44 - people in the community which we partner with.

12:48 - we want them to understand what hospice is.

12:51 - We want them to support their families where they're at.

12:56 - and also

12:57 - talk about the faith and hope component.

13:00 - Right.

13:01 - And and we are we do talk a lot about hope

13:05 - because we talk about how hope can change.

13:09 - And a very,

13:11 - example that I give is

13:13 - when you go to the doctor and you receive this diagnosis,

13:16 - so you hope that you have a treatment and the treatment is going to go well.

13:22 - And then when you are in treatment and it's not going well,

13:24 - so at least you hope that the next thing can help you.

13:28 - So your hope is changing all the time.

13:32 - when you're at your home being care for hospice,

13:35 - you hope that your pain is managed and that things are going to feel

13:39 - well right into your family is going to be taking care of.

13:42 - So these are things that, through hope

13:45 - and faith are important to us as well.

13:48 - And we are not diminishing or, minimizing the hope and faith.

13:55 - What is very difficult sometimes is when families are praying

13:59 - for a miracle to happen, and that miracle doesn't come the way that

14:03 - they think they should come, right by curing the person that is ill.

14:09 - But I tell people, you know, the miracles can happen in different ways.

14:13 - when the family reunite, when they are estrangement

14:16 - in the family, and now the family's gathering again.

14:19 - So that is a miracle that can happen in different ways.

14:23 - So we do not discourage faith, hope and miracles.

14:26 - We talk about them and we also reframe

14:31 - probably how that's going to look for the family and for the patient.

14:38 - Cultural sensitivity.

14:39 - Right.

14:40 - Today, we have learned how important it is for us to understand, the culture

14:45 - barriers, not only a language, but also many other determinants of health.

14:51 - So when we practice cultural humility,

14:55 - what we are doing as a we have curious minds.

14:58 - We are coming to them asking, you know, tell me your story.

15:02 - Tell me how your have been seeing this illness.

15:06 - tell me what can help you.

15:08 - So these are the questions that we are going to be asking.

15:12 - we don't know everyone.

15:14 - We don't know the context that they had had before,

15:18 - what the prior experiences with death had been before.

15:23 - So just utilizing that sense of curiosity

15:26 - and being there with the patient makes a difference.

15:29 - We are not going to fix it.

15:31 - when I say we are not going to fix it, is we not going to fix family dynamics

15:34 - that had been there for years?

15:36 - We are not going to fix many other things that may be occurring at this time.

15:41 - But when we are, when we are present and we are curious,

15:46 - we are asking the important questions and not making our own.

15:52 - yeah.

15:53 - Then making or imposing our own values and beliefs.

15:57 - And that is important not only for the patient,

15:59 - but also for the family.

16:08 - As I know, even back.

16:11 - Okay.

16:13 - so these are areas that are very important again

16:17 - about culture, humility, right to self-awareness.

16:19 - How do I react to things? And I'm a Latina

16:23 - that before I even say something you can see it in my face, right?

16:27 - If I don't like it, if I like it.

16:28 - So that nonverbal is there.

16:31 - So I have to practice aid,

16:34 - that I'm going to deliver whatever news or sit down with someone

16:38 - that is going to be talking from the deepest contact of their heart.

16:42 - Right.

16:43 - And I need to check in my own balance.

16:45 - Right. What am I doing? How am I projecting?

16:49 - And I say

16:49 - these things because sometimes we don't even notice.

16:52 - but nonverbal communication is a 90%

16:55 - of the communication that we deliver.

16:58 - active listening.

17:00 - You know, this is something that I also practice a lot.

17:04 - so be more quiet and listen, sometimes we have to listen

17:08 - their stories, validate their stories, validate where they're at.

17:12 - and we honor them by listening their stories.

17:17 - so, you know, be aware that if you're talking to them in their

17:22 - the message is one and you're seeing and another

17:25 - to ask a little bit more questions, you know, what is for you today.

17:29 - How are you feeling today?

17:31 - and probably they might not want to talk about today,

17:34 - but they want to talk about how they felt before when they have good health.

17:37 - Right?

17:38 - So just being there and listening sometimes that's not the line

17:42 - of your questions.

17:43 - They're going to go by it.

17:44 - It will be however the client is telling you their story.

17:49 - The other is bearing witness.

17:51 - we do this a lot.

17:53 - We can't fix the problem.

17:55 - We can make it different.

17:57 - We have just to be here and hold the space.

18:00 - And that is important for the patients and for the families.

18:03 - That's the gift that hospice gave.

18:05 - Give them being quality of life, holding the space for them

18:10 - and taking care of the family and the patient.

18:18 - Who? We could do this together.

18:20 - Yeah. Yeah.

18:21 - So these are some things that we came up with in our practice as far as how to have

18:26 - effective communication, specifically with Latino family.

18:31 - and also when we're talking about difficult topics

18:33 - like we're introducing hospice or we're recommending palliative care.

18:38 - So one of the first things is to allow yourself plenty of time.

18:42 - This is going to be a long conversation.

18:45 - This is not something that you can rush through.

18:48 - don't make assumptions.

18:52 - I think in the American health care culture, we're so used to the patient

18:57 - being the driver of their decisions, of their care.

19:01 - we're very patient centered.

19:03 - But in the Latino culture, oftentimes

19:07 - the patient does not want to be their own decision maker.

19:10 - They don't want to know their prognosis.

19:12 - They don't want to know details about their diagnosis.

19:15 - Oftentimes they'll say, well, why don't you talk to my children?

19:18 - I don't know, I don't want to know about this treatment.

19:21 - Ask my children.

19:22 - So the first thing we need to do when we enter a room

19:26 - is ask the patient, do you want to be part of this conversation?

19:30 - And who do you want me to have this conversation with?

19:34 - Which leads to the third one, which is family.

19:36 - We family is very important to Latino people. So,

19:42 - oftentimes this conversation is going to be held

19:44 - with not only the patient and their spouse, but also their children.

19:49 - could be, you know, family, could be neighbors, could be a long time friend.

19:54 - and everybody wants to be included in this conversation.

19:59 - And then as we touched on,

20:01 - earlier, religion can be very important to a Latino family.

20:05 - So sometimes one of the things that, we've done

20:08 - is that we rely on those, community

20:12 - pastors, clergy men to be our ally.

20:16 - oftentimes they can be part of that conversation

20:19 - with us and the family,

20:23 - and then interpretation services.

20:24 - I can't say this enough.

20:26 - a lot of times family members will say, well,

20:29 - my son speaks English, so he's going to go ahead and translate.

20:32 - And that's great.

20:33 - You know, sometimes they've had a bad experience with interpretation.

20:37 - And so they would rather have a family member that they know and trust.

20:41 - the problem with that

20:42 - is that it puts that family member in a very compromised position.

20:46 - they might not want to interpret everything, appropriately,

20:50 - or they might not know the right medical terms in the right medical words.

20:54 - So for that reason, we always recommend that you always have an interpreter

20:58 - present and listening and even if they're not actively interpreting,

21:03 - but just to make sure that the message is being said,

21:08 - and then to

21:09 - that point, also practicing teach back.

21:13 - a lot of times in Latino culture

21:15 - it is considered rude to ask questions,

21:19 - of their doctors.

21:20 - And so we just want to make sure

21:22 - that they really are understanding what is being said.

21:26 - Okay.

21:29 - And so this is the end of our presentation.

21:33 - again, this is our contact information.

21:34 - I'm actually the nurse coordinator for a program called Choices Palliative Care.

21:41 - and as I said before,

21:42 - Deb is the bereavement counselor at the Pathway Center for Grief and Loss.

21:47 - So we are available.

21:48 - If you all have any questions, you can call or email us.

21:52 - and we'll open it up now to questions. Now.

21:59 - No questions. Yes.

22:03 - I think that was.

22:07 - Yeah.

22:08 - It's like.

22:14 - I'm just curious on your thoughts on death

22:16 - doulas, as they kind of are becoming a little bit more common in practice.

22:19 - I know we're like, PA is doing a lot more to,

22:21 - you know, put birthing doulas out there.

22:23 - So just curious on, like, what do you think uptake would be and

22:27 - in maybe this community. Yeah.

22:30 - I personally

22:30 - think the concept of death doulas is great.

22:33 - I don't think we see that very often

22:36 - because of the reimbursement issues.

22:39 - it's not currently reimbursed by Medicare or Medicaid.

22:42 - I think that there's a lot of overlap in what a death

22:45 - doula can offer and a hospice team can offer.

22:49 - I think that just like with hospice care, it's going to be tough

22:52 - to get the Latino community to one, understand what it is

22:56 - and then to take that leap of faith to to use it.

23:00 - But one thing, especially Deb can speak to this is the one thing about Latinas

23:04 - is that we like to talk, we talk to each other.

23:07 - So if one of us has

23:08 - a good experience with it, then it will it will get out there.

23:11 - Yeah.

23:14 - Find your allies in the community.

23:16 - That is very important.

23:18 - You know, your pastors, you have people in the community,

23:20 - the people that work in housing.

23:22 - All those things are important, you know, for you to do your job.

23:26 - You don't want your job to be harder.

23:28 - This is hard already.

23:29 - Okay?

23:30 - So finding the people that connect with you in the community

23:33 - is the best thing for you to do.

23:36 - another part of this in the pride that is, I don't know

23:39 - if anybody has another question before I talk about end of life.

23:42 - Yeah.

23:44 - What is the support?

23:50 - For so that's nine.

23:54 - Yeah, that's my area.

23:55 - So I meet with people and,

23:59 - sit down with, you know, what's happening?

24:02 - What do you know? What do you want to know?

24:05 - I don't talk a lot

24:06 - about the medical area, but I do speak about the emotional part.

24:10 - Right? And,

24:12 - behaviors and family dynamics.

24:15 - Right.

24:16 - the one thing that I always say to people, and when I'm in this kind of work.

24:20 - Right, I am at the end of the movie.

24:23 - Okay? Everything has happened before.

24:25 - So I'm not going to be able to fix family dynamics

24:28 - or anything like that that had been there forever, right?

24:32 - We acknowledge them,

24:34 - mention them when they speak about the family issues.

24:38 - I said, well, how long this has been happening?

24:40 - And of course, they say I'm entire life right?

24:44 - So now is not a moment to fix those kind of things.

24:47 - So in my intervention is about normalizing,

24:51 - providing, resources in the community.

24:54 - Right.

24:55 - These are the things that are important, reframing things, you know,

24:59 - especially when people say, oh, hospice is when people are going to die.

25:03 - And I say, hospice is now when people are going to die.

25:06 - Hospice is for people that want to live

25:08 - with a quality of life while they are dying.

25:12 - Okay?

25:13 - And we are dying, by the way, every day is every day.

25:18 - So I say these things because they present urgency for you.

25:22 - You know, to have these things, to prepare yourself for these events.

25:27 - I think that we all prepare for birthdays

25:30 - Quinceaneras wedding, but we don't prepare for death.

25:33 - And this is a big life event as well.

25:37 - So start by with yourself and then when your loved ones.

25:40 - Yeah.

25:41 - The other thing I wanted to add to that, as far as how we support the caregivers

25:45 - and the family while someone is under a hospice program

25:48 - or also a palliative program, that is a big role

25:52 - or a big part of the role of the social worker and the chaplain,

25:55 - a lot of times a social worker might not even meet with the patient themselves.

25:59 - They are there to support the family member.

26:02 - I know every organization is different, but in our organization

26:06 - we also have caregiver support groups that are either in person or virtual.

26:11 - And I facilitate those. Okay. Yeah.

26:17 - some of those people

26:19 - get really good question.

26:21 - Oh, so the question was, are there organizations

26:24 - that will help people with no insurance?

26:26 - And the answer is yes.

26:28 - the hospice that we work for, hospice

26:31 - and community care, as well as HCP

26:34 - Hospice of Central PA, we are nonprofit organizations.

26:38 - so if somebody is not insured,

26:40 - we do have a sliding scale, a fee reduction, up to 0%.

26:45 - So some of our patients do not pay for our services.

26:52 - And I came in a little late.

26:54 - But when it comes to the counseling piece

26:56 - for caregivers, how long does that counseling take place?

26:58 - And is it also offered to other family members?

27:01 - Yes. So during while the person is under hospice services,

27:06 - they can have, some support visits

27:09 - from their social worker after person passes.

27:12 - That is that what you're referring to?

27:14 - So I'll let Deb speak to that because again, she's the one doing it.

27:18 - Yeah.

27:18 - So like I said before, I work as a grief counselors.

27:22 - So we receive, a referral

27:25 - from everyone that has died through our program.

27:29 - And, so we make a phone call.

27:31 - That's the first thing that we do eight weeks after the person has passed,

27:36 - you know, just to offer condolences and reminder, remind them of our

27:40 - counseling services.

27:43 - counseling

27:43 - services could be as a group, or it could be individual.

27:47 - Right.

27:47 - And, so we meet with people one on one, assess what they need.

27:53 - We do counseling and education, but we don't do grief therapy.

27:57 - That's a little different thing.

27:58 - So we send them to the community if that's needed.

28:01 - And sometimes that's needed because they had been traumatized

28:05 - during the passing of the person. Right.

28:08 - So it's more complicated.

28:10 - And like I spoke before about family dynamics,

28:13 - we grieve differently in our families

28:17 - because of the kind of relationship that we had with that person.

28:21 - That's how we grieve.

28:22 - So even if you love them or hate them, you are going to grieve that loss.

28:27 - And sometimes people don't have that understanding like,

28:30 - oh, I never spoke to my dad and I don't care.

28:33 - Yeah, you care.

28:35 - And for those that bury their grief,

28:38 - you will come back and the next dad everything will come back.

28:43 - So that's why I say to people, it's okay if you don't want to work your grief right

28:47 - now, but you will be confronted with it at some point that you need

28:51 - to work with it.

28:53 - yeah.

28:53 - So the services are there for it for them up

28:57 - to 16 months after the passing?

29:00 - Yes. And also just to point out that every hospice part

29:04 - of the Medicare guidelines says that every hospice has to offer

29:08 - bereavement services to the community for free. Yes.

29:11 - And we do that.

29:12 - We're not involved in the hospice service.

29:14 - We run, sudden death groups and suicide group

29:20 - pedal, pet loss groups.

29:23 - So we do that.

29:25 - yeah.

29:25 - In the community is our biggest supported.

29:28 - Yeah.

29:30 - Are there any other questions you.

29:35 - yeah.

29:35 - So we we are based out of Lancaster and York

29:39 - and parts of Chester and Berks and Adams counties.

29:43 - but hospice as a concept and palliative

29:45 - care as a whole, as a concept can be found nationwide.

29:48 - So you just have to search for the one that is near you.

29:53 - It's just it's

29:54 - hard finding thing in Los Angeles.

29:57 - Oh, I know that.

29:58 - We know, we know. Yes.

30:01 - I know,

30:03 - where you guys,

30:05 - is, feedback about what she said.

30:09 - How does someone refer to themselves

30:11 - to be an expert in this type of field?

30:16 - so we can, Yes.

30:19 - Thank you for that question.

30:21 - So in my case, I'm sorry, the question.

30:26 - how do you prepare yourself, right, for this field

30:30 - to become an expert in hospice and palliative care? So,

30:35 - I just to begin with, I have a master's in social work.

30:40 - Right.

30:40 - And that's how I came part of this world, because it's a whole different world

30:45 - working here. Okay.

30:47 - And then I further my education.

30:52 - by studying

30:54 - for a certification in ten ontologies,

30:57 - which is the study of death and dying.

31:00 - Okay.

31:01 - And then I did a test on that, and then I got a certification.

31:05 - So the studies gives you

31:08 - that theory for you to understand what you're getting into

31:12 - when when you work on it, that's where you really learn.

31:15 - Okay.

31:16 - So the passion that you have for your clients,

31:20 - this is not an

31:20 - area that a lot of people know of.

31:23 - not a large Latinos are going to say, I'm going to study death and dying.

31:27 - That's not our thing at all.

31:30 - We do parties better than this, right?

31:32 - So you invited me out for a party?

31:34 - Yeah, we are going to go.

31:35 - But for this is like, no,

31:37 - I don't want to even talk about that because it's going to happen.

31:40 - Right.

31:41 - So furthering your education in it in the areas,

31:46 - several social workers, they had written books

31:50 - in Spanish and English about the subject of death and dying.

31:54 - So if you want to get more information, I, you know, we could talk more about it.

31:59 - The other thing that I will add for other disciplines like nursing and social work,

32:04 - there is an organization that is the Hospice and Palliative Care

32:08 - Nursing Association, and they offer a certification in this.

32:12 - So, a lot of our staff at HCC

32:16 - are certified in hospice and palliative care.

32:19 - you have to study and take a test and then you renew every five years.

32:24 - But that's also a way that we stay on top of of the latest trends in this field

32:30 - and conference.

32:31 - I just was in a conference in Texas,

32:34 - three days, and I got to see everybody that had written

32:38 - a book and Death and Dying that we you seen in colleges and university.

32:42 - And that is a great way to mingle

32:46 - with them, pick their brains, and talk about issues

32:49 - that might not be in the books, but they you have more questions.

32:52 - Very down to earth people. Yes.

32:55 - So I think that's all the time we have, we're we're here.

32:58 - If you guys have any other questions and we thank you for joining us.

33:17 - This.