The Neurologist Is In, Ep. 4: Palliative Care and Challenging Conversations With Patients and Families

In episode 4, Rachel Marie E. Salas, MD, MEd, interviews Lauren Treat, MD, about Dr Treat's career journey through pediatric palliative care in neurology, tips for communicating and initiating challenging conversations with neurological patients and their families, when to contact a palliative care specialist, and the transition to palliative care via telehealth throughout the ongoing pandemic. A full transcript is provided below.

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About the Speakers:

Rachel Salas, MD

Rachel Salas, MD, MEd, is a professor of Neurology and Nursing; director of Interprofessional Education and Interprofessional Collaborative Practice; director of the Neurology Clerkship; and 2019-2021 Josiah Macy Jr. Faculty Scholar at Johns Hopkins University in Baltimore, Maryland.

Lauren Treat, MD

Lauren Treat, MD, is an assistant professor of pediatrics at the University of Colorado School of Medicine. She practices pediatric neurology and palliative medicine at Children's Hospital Colorado in Aurora, Colorado.

 

Transcript:

Dr Rachel Salas: Welcome back, everyone! I'm Rachel Salas. I am a sleep neurologist at Johns Hopkins.

With me today, I have Dr Lauren Treat. Dr Lauren Treat is a very unique neurologist. She is a child neurologist and palliative medicine physician. She's currently at the University of Colorado School of Medicine.

Hi, Dr Treat! Thanks for joining us!

Dr Lauren Treat:  Thanks so much, Dr Salas. I'm so happy to be here!

Dr Salas: I really am excited having you here today. When we think about palliative medicine, a lot of times we think about clinicians who are caring for an older population. Can you tell us a little bit about what pediatric neuropalliative care is? How is that different from what we all know, and where is it going?

Dr Treat: Absolutely. You're right that the most common perception of palliative medicine is to think about elderly adults, and for neurologists to think about the things that we see in the later decades of life.

Palliative care at its root—it's important to start there—is a practice that helps people live well. Many people hear those words, "palliative care," and they think about dying. They think about end of life, they think about hospice. Hospice falls under the umbrella of palliative care, but it is completely distinct from the work of palliative care as far as what people usually set out to do.

When palliative care is introduced to families, the emphasis is on living as well as possible for however much time someone has left, whether it's decades, or years, or even shorter amounts of time. That emphasis on living well, as you might imagine, in neurology can be very much more widely applied.

Neurologic disease affects the way that people interact with their world, with their loved ones, with their environment, the way they move, think, speak. That has a profound impact on how someone interprets their own identity, or feels like other people can recognize their identity.

It can have a big impact, as we all know, in the work of neurology, about how someone shows up. Also, in the pediatric realm, how you have a relationship with a child, what a parent's relationship is with their child can often be affected by a neurologic disease.

Those questions about, "How do I parent this child? How do I make decisions on their behalf? How do I care for their best interests and their future, and also their current existence? How do I make that as meaningful as possible, but also do what I feel is the job of a parent, to protect them, to advocate for them, and to think about planning their future?"

These questions are very deep. They run deep for families. They run deep for child neurologists.

Having the work of a palliative care specialist in that realm can really open up some of those doors to consider not just the physical aspect of things. Certainly, the physical aspect is incredibly important, but also the emotional, psychological, spiritual aspects of what it means to live in the context of neurologic diseases.

In pediatrics, there is just as much need for this kind of work as there is in adult neurology.

Dr Salas: Wow, that's a lot to unpack. Even I had my own thoughts of what palliative care medicine was and really hadn't thought about it in the context of pediatrics. It makes complete sense. It's wonderful that our field and our specialties has provided such a specialized group of experts in this area because it's vastly needed.

Dr Treat: It's funny because even when you talk to adult palliative care doctors and talk to them about pediatric palliative care and explain that we're in spaces as early as the prenatal consult, the perinatal space, it just blows people's minds to think that palliative care has expanded its reach so far.

Once you explain it, people say, "Of course, that makes so much sense," but you can imagine a congenital brain abnormality that's diagnosed prenatally. That has a huge impact on that pregnancy, on the delivery plan, on every single step of the way afterwards.

Having a team that's there to be able to say, "You've heard the facts from the neurologist. Let's talk about how that hits you as a human, where you go with that psychologically, how does that impact on the choices that you're being presented with."

Our goal in palliative care is to be a neutral space for families to process through the medical information that they're being given. It is a medical specialty, so we bring all of our medical expertise to the table and allow families to ask questions. We do circle back with the specialists to be able to say...I often have another neurologists consulting with the family to talk about the prenatal.

We have prenatal experts. I am not a prenatal expert, but I am this communication expert within the different kinds of neurologic diseases, and so I partner with my other neurologists colleagues to be able to provide what I would consider goal‑concordant care for the families.

As a palliative care doctor, I'm not just interested in a comfort‑focused plan of care. Some people get that a little bit confused that palliative care doctors are always there to advocate for a comfort‑focused approach, and that's not true.

The bottom line of what I'm trying to do is understand the family's goals and values and help them understand how the medical options being presented either get them closer to those goals and values or farther away, using the medical expertise that I have to know what those medical interventions mean for them.

Dr Salas: That's amazing. Thanks for going into this field. With that, I want to take a step back and ask you, how did you get interested into this, and what's the training like? What was the journey to even get here?

Dr Treat: I actually thought I would be an adult neurologist when I entered medical school. Then, when I did my third‑year rotations, I did my pediatrics rotation.

I didn't plan to have that be any particular sequence in my third year out of strategy, but I did pediatrics. I thought, "Oh my gosh. This is so fun. Too bad I'm already going to be an adult neurologist, because it might have been fun to be a pediatrician."

Then, someone said, "You know, you can combine them." I truly had no idea that child neurology was a field, even with a huge interest in neurology in general. I've taken the championing of child neurology education for medical students on as a passion, now into my career. I think we don't expose medical students to this awesome career early enough.

Then, once I found child neurology, it was in my general pediatrics training. The child neurology residency is 2 years of general pediatrics and then 3 years of neurology training, which includes a year of adult neurology.

When I was in my general neurology training, it struck me, particularly for children with neurologic impairment, how incomplete some of the conversations felt around the offerings that we were proposing to families, whether it was something "routine" as a G‑tube or something higher‑level, with regard to clinical studies, or breathing support, or other things like that.

There was the mechanism explained, in terms of how the technology worked and the cure might look like, the number of feeds a day, and all the numbers, the rates, and the volumes, and all of these various different things.

No one paused to say, "How's this going to impact your marriage? How's this going to impact the siblings? How's this going to impact the way that you're able to perceive some normalcy for your life, for their life?" These more human questions.

I knew that was something that was important to me and so started looking for a way to be able to expand those conversations and found that in palliative medicine.

Dr Salas: That's wonderful. How long is palliative medicine? Is it different from adult and pediatrics, or do you get both child and adult? How does that work?

Dr Treat: Great question. Palliative medicine is actually the newest‑recognized boarded medical specialty. It usually is something that's coordinated under the Board of Internal Medicine, but neurologists can get the board certification through the neurology boards.

The fellowship is one year. It's a fully‑clinical fellowship, 12 months, through the ACGME in order to have that eligibility to sit for boards. There are many permutations of that fellowship popping up. I actually participated in the neuropalliative fellowship at the University of Colorado, which is the first of its kind in the country.

There are a handful of other neurologists who have done palliative medicine fellowship, but they often are in a fellowship program that is not tailored to neurology. Through the vision of Dr. Benzi Kluger and Dr. Christina Vaughan at the University of Colorado, we were able to offer this neuropalliative fellowship and actually are continuing to offer it, which is exciting.

There are particular programs across the country that are specific to pediatrics. We don't yet have a pediatric neuropalliative fellowship, but in any fellowship that you do, you'll get some exposure to pediatrics. It's mostly adult at the majority of palliative fellowships. If you do a specific pediatric track, then you'll obviously get a little more experience on the pediatric side.

Dr Salas: Wow, so it's still growing. Potentially, even in a couple years, maybe some of our newer listeners who are medical students or trainees may even find the possibility that there will be a child neurology palliative care fellowship.

Dr Treat: Absolutely. I see it as a wave of the next generation. I think the recognition right now that the technologies that we have are incredible, advanced, and continuing to move forward comes with a sense of, "But are they right? Are they right for every single person? Are they right for every single family?"

How do we have those conversations because we recognize that the task of declining something unavailable, offering for a family is a huge ask. To ask someone to decline something that exists that might prolong life is a very sensitive space. It takes skill to be able to say, "We have this. We can do it, but should we?"

It requires transparency and bravery and very clear and patient communication. That is something that all neurologists should be taught, but there's a higher‑level skill.

This is also something in the fields trying to figure out, what is the primary palliative care skills that all neurologists should know, and what is the specialty level that you engage your palliative team for? That's still something that's being worked out and defined across the country.

Dr Salas: That's great. I want to get your thoughts on something I just heard, actually, yesterday. We were having a meeting for one of the big conferences that are coming up for neurologists.

Someone mentioned that, "Why don't we have this talk on people that are out in either academia or in private practice that maybe even 5 to 10 years out in their practice and decide to go do a fellowship?"

Palliative care has been one of those things, maybe because it's one year, but also because it's so applicable no matter what specialty you're in. Have you seen that where people are coming back later in their career?

Dr Treat: Absolutely. I would say that that is a very regular occurrence for mid‑career/late‑career physicians to train in palliative care. It used to be something where you're more easily able to get that board eligibility before it became a certified fellowship.

Now, people sometimes are reluctant to go back for a year of clinical training, although there are some alternative pathways coming forward to allow people to do a master's course that then has some clinical work attached to it and get some board eligibility through that pathway.

The University of Colorado is one of the places that's working on that, which is very novel. But yes, it's very cool.

Just like you're saying, people throughout their careers recognize that these conversations are complex and an opportunity to get additional training, additional support, and just invest in yourself and your career to that degree to be able to do this work well, really adds that extra dimension of meaningfulness to the work that we do as neurologists.

It is incredibly satisfying to be able to partner with families in this way. I tell people that it's the truest expression of how I could practice medicine because that human connection to me, to all of us, we go into this field to be able to help people, to connect with them, to have our lives touched by other people, and vice versa.

This type of communication improves connection with each other, with our patients. It increases our engagement and our sense of meaning and our work. In that way also, there's such an emphasis on burnout right now.

It helps to combat those feelings of burnout, of meaninglessness, of powerlessness. We can't fix. We can't cure in a lot of situations, but we can always come alongside and provide support, comfort, and guidance to our patients.

Dr Salas: Well said. That's just perfect. This is great. Some of our listeners out there, for one, at least know a lot more about what palliative medicine is. It's very much so could be adult but also pediatric‑centric. Perhaps, even some of our listeners are maybe even going to look into either doing the fellowship or getting some more training. That's great.

Why don't we segue a little bit more into practice? Many of our listeners are in clinical practice, and many of them are general neurologists. I'd like to do a Dr. Treat palliative care module, if you will, but in a fun way. I know we had you speak to our medical students at Johns Hopkins this past summer, and we wanted you to give strategies.

How do you even initiate challenging conversations, whether it's diagnosis or prognosis or treatment plans? What are some tips, some phrases that we could help to pull some of those more challenging discussions out? Why don't we segue there?

I'll leave it open, and you can take it where you want, but we just want to focus on some tips and recommendations for the general neurologists to think about implementing in their own practice.

Dr Treat: I think that's hugely important. Thanks for segueing that way. One of the first foundational things to recognize is that we do have so many challenges to good communication in neurology. Recognizing those challenges, there's the first step to understanding where maybe extra attention is needed in neurology.

For a moment to talk about that aspect of things, it's normal to be worried about having a hard conversation with people. That's reflective of our connection to one another, the pressure we put on ourselves to do a good job, that continuous self‑improvement feeling.

We, as neurologists, deal with news that can be really bad. It can really affect futures. It can change the course of people's lives. It can impact—like we talked about earlier in the podcast—personhood, independence, these sorts of things.

Pausing to recognize that within yourself, not from an impulse to say, "Oh, no, more pressure on the situation," but just to say, "I'm going to pause to prepare myself to the degree that I need to in order to have this conversation go well," is a foundational step in this.

The tools that you're talking about can be very easily practiced. Practice is a huge key to having better communication. Part of that is yourself, knowing what resources you have to be able to pause and prepare for those conversations, but it's also having an internal self‑practice of reflection and whether that's debriefing with another trusted individual or running it by someone.

"Hey, I'm about to go into this situation. This is the news that I have to deliver. I'm a little bit worried about how it will go for this reason or the other reason." That honors within yourself the heaviness that it might feel and truly honors the patient to be able to say I'm going to take that degree of preparation in order to have that conversation.

One of the biggest tools, if I could give a tool right now, is to consider your headline. Just consider whether you're coming in with a simple or complex piece of news to boil it down for yourself before you go into the room. What is your headline, and then every single thing that you say within that encounter should feed back into the headline.

We often, as neurologists, have such complex understanding of what's going on, but sometimes we can lead conversations that are fairly confusing for families, whether we mean to or not, whether it's the use of jargon or just trying to explain pathophysiology to a level that is complex or perplexing for families.

Dr Salas: That's great. I definitely can see the challenges there. Can you provide an example? I think that may be helpful to hear what you're trying to say.

Dr Treat: I think oftentimes, our impulse is to tie together everything that we're bringing into the room. You can say we want to explain the reasons why we've gotten to our decision. We want to round out what we're saying.

This simple summary phrase might be, "Based on your testing, the most likely diagnosis in this case with the symptoms you've told me about, is Parkinson's disease." Just let that sit. Let that sit for a moment.

I think we often times feel like we need to launch into then all of the explanation around it, but that piece of news has changed this person's life most likely. You will get there. You will get to all of the questions. You have the time to be able to step through the whys and what that means, and you should get to those things. It's important not to ignore them.

Just to give that headline and then pause for a moment allows that recognition on both sides that this is something that we're both taking very seriously and can help cement the clarity of what you're trying to communicate in your next steps.

Dr Salas: That's great. It's something that we could all do today. You could immediately start practicing it. I totally agree with that pause. The pause even helps give people a chance to get their thoughts together to even ask that next question or even just share some emotion.

Dr Treat: Absolutely. I think that it allows them to feel that they're not being rushed either. Often, our patients feel like they are trying to keep up with us. Some of them, it's more natural to have a fast pace than others.

By pausing there, you're saying that this is allowed. We're allowed to process through. We're allowed to get in touch with our emotions. It's OK if your next sentence to the patient is something about emotions.

This is big news. It's important not to label that it's a particular negative news. Sometimes it can be unexpected news, or it can be just heavy news, or big news.

I try not to say this is sad news or that this is some other way that they need to feel, but using some of those other descriptors that can capture the degree of what you've just told them can help again cement that partnership and that connection.

Dr Salas: That's great. What about like if you were to give some news and the patient or even maybe the patient's family member quickly went into denial and said, "No, that's not right. You don't know what you're talking about. That's totally not it," because it happens.

Dr Treat: That happens. It does. It absolutely happens. Again, if you had just launched into your reasons why, they wouldn't have heard all of that stuff without that pause. They already know how they're going to respond in those situations.

Taking a moment to de‑escalate that emotion to the degree possible is the most productive stuff in that situation. You give your headline. You pause. They might come back with a denial. Then, you can say something that says, "This is really shocking."

Trying to label. Don't go into fight mode. Don't go into combat mode of saying this reason, and this reason, and this reason. Again, you'll get there.

The best thing to do in that moment is to say, "This is really shocking. This is really surprising. I can understand how it would make you feel confused," trying again not to use the labels that would feel punitive or diminutive or anything like that, but just to say this is a hard thing to comprehend, and I'm here with you.

Then, they sometimes self‑soothe to that degree, sometimes not. Sometimes, you continue to deal with the anger, but as long as that anger is present, the cognitive knowledge is not going to get through truly.

You might end up trying, if they ask you for particular facts, "Well, why? This doesn't make sense with this particular symptom." Then, you can say, "Yeah, I agree," or "Yes, actually, it does make sense," or anything like that, but until you get to the point where they can calmly engage in conversation with you, those cognitive facts are just going to bounce off that the emotion that they're feeling.

Labeling that emotion, naming it, trying to respond to that particular piece, and trying to understand where they're coming from is the most productive next step. It will save you time in the long run, even though it might feel like you're getting a little derailed from what you set out to do at the beginning of the conversation.

There are several mnemonics that can help with people preparing or understanding their own skill set with regards to responding to that emotion. The one that most quickly comes to mind is an acronym called NURSE, which stands for naming the emotion, trying to understand the emotion, respecting the emotion, trying to offer some support, and then exploring that emotion.

Those things don't have to happen like in linear steps one by one, but those are the important components of trying to de‑escalate an emotional response.

Dr Salas: That's really helpful. Again, something that we all may see in our practice in a different way, depending on who the patient is and what the diagnosis is.

You had mentioned earlier on in the introduction about spirituality and understanding where they are. Before you even have this challenging conversation, it's very likely that you've already established some type of relationship, at least one visit before this to order whatever tests, most of the time, not always, but most of the time.

What are some things that you can do or recommendations you might have for when you're meeting a patient for the first time to start building that rapport and starting off on the right foot?

Dr Treat: That's a great question. There are opportunities early on. You don't have to wait until someone is in crisis. When someone comes to you, it's with a problem. They come to us with a symptom or something that's bothering them. It's OK to ask, "How are you coping with this? How do you make meaning of what's going on?"

That's that lead into a spirituality‑type of question. Some people say it's my faith. It's my religious practice, but more often, I would say that people interpret that question as how do I, as a human, understand what it's like to have health or have sickness or cope with a hard thing, and that will give you a great insight into whether they're being supported at all.

Oftentimes, our patients feel, especially in the current pandemic circumstances, a great degree of isolation because other people might not understand what they're going through even in their own nuclear family. Offering that degree of support by even just inquiring about it or listening to what their particular experiences, goes a long way towards building that therapeutic relationship.

Dr Salas: I think that really helps to set that relationship together and show you care. If you know that patient's undergoing some some tests and you're pretty positive it's going to be a surprise diagnosis, would you encourage your patient the next time to bring someone with them, or is that something people do in practice?

Dr Treat: It absolutely is something that people do. I think that it can feel scary to the patient to say you're going to want to have a person with you at the next appointment, but it can tie into that last question of, "How are you coping? Who is your support person? Who are you going to when this is getting in the way of you living your life?"

Encouraging them to get in touch with someone if they don't have someone, whether it's a paid therapist or a friend or a connection that way. That can be a nice bridge into we're going to work together to find out what's going on. No matter what we find, in our next step in testing, I want you to have some more support.

We know that people who feel anxious or feel unsupported or feel isolated have a harder time with physical symptoms. It's in your best interest to start plugging into this support now whatever we find on our testing.

You are welcome to bring that person to our next appointment that would help you understand more about whatever we find. Couching it in that kind of proactive, supportive manner can really be a way that feels not scary and very beneficial.

Dr Salas: I like that. I think that makes sense. They would take it as like, "Yeah, it's just bring in more support," and then also just another set of ears and somebody else to ask some questions because the patient, a lot of times, is just scared or worried or anxious, and they may forget to ask questions. Having another person there is always helpful for the most part.

Dr Treat: Validating that that's normal. It's normal to tune out the stuff that's happening in the doctor's office because of all those emotions, whether you have an answer or not, that's normal. That's common, and that's something that we can expect and prepare for in a way that supports the patient to a higher degree.

Dr Salas: Great. I remember hearing a talk. It was by some palliative medicine physician. This is what you were saying earlier, where a lot of times, we think that palliative care really comes at the end. It's with death and dying.

They had made a comment about there are a lot of resources that could be used a lot earlier. Can you speak to that? Maybe say what are the things that besides these challenging conversations that arise, and you started talking about the support system that patients may have, and how to tap into those earlier.

What are some other things that patients should be thinking about, and neurologists, that we should be thinking about, whether that's physical therapy...There's a lot of other things that I don't think people think about until the very end, even things like hospice. A lot of times, doesn't that get started a lot of times way late or later than it should?

Dr Treat: There are so many different aspects of how we can help families and patients live well that sometimes don't get introduced until...We miss some opportunities. I'll say that way.

I think one of the differences in the way that palliative medicine physicians are trained or practitioners are trained is to step away from all of the diagnostic testing, not to say that it's not beneficial in certain phases for patients, but it's to focus on the patient as they exist in the world.

Whether that's at home, or whether that's in the clinic, or whatever else, asking them what makes a good day for them. Oftentimes, its physical symptoms that get in the way to make a bad day versus a good day, but asking them what makes a good day, you'll get a lot of things, you'll get a lot of really practical things.

If it's inability to hold a soup spoon to be able to get it to your mouth, then you can hone in a little bit more on what exactly the support is. I tell families, my goal is to get you as many good days as I can. People can resonate with that. People can really grab on to it.

They have to know what their days look like in order to get into that level, and so sometimes I have to go back and forth to all these appointments. That's getting in the way of me living a good and meaningful life. That then can introduce, "Well, what if we brought a team to you?"

Now if we have telemedicine, we can do that a little bit differently, which has been a great improvement recently, but that team...When someone says something about, "I don't want to keep coming back and forth. That really interrupts how I'm able to live."

That's my entree really to talk about a home‑based team. We call that team hospice.

Now, hospice has a lot of particular regulations about it with regard to when the payers think that a patient is eligible for it, but philosophically hospice care is a type of medical care that comes to you in your home, wherever you're at, and focuses most on your comfort, on your ability to have good days at the exclusion...

The way that it is set up in the US medical system with the payers, it's often at the exclusion of some of those interventions that are intensive or require hospital‑based treatment. That's the operationalization that's been required in order to have insurance payers approve it.

There are specific eligibility pieces about how long the prognosis is in most places on the adult side, and this is true to an extent too on the pediatric side, but they are asking for a prognosis of 6 months or less if the condition follows its natural course.

There is things that come into that about people being worried to scare someone with that prognosis or being willing themselves to commit to a number. That's a really challenging thing as a physician. That often gets in the way of people getting that support.

I tell families, my goal is to get you hospice support as early as you're eligible, because that degree of support will help you live as best as you can during a really precious time and not have the burden of a lot of trips back and forth.

This is getting very specific about hospice, but I think it's important to recognize that introduction of hospice as early as possible is actually in the patient's best interest.

There is a lot of cognitive factors on both sides—the family side, the physician side, about reconciling that we're at that step, that we're in that place, but it is an incredible asset to families who are enrolled with hospice to be able to protect that time.

If people then graduate from hospice, if they live longer or their eligibility, they plateau, they have an unexpected improvement or something like this, that's not wrong, that's not a failure. It's never a failure to get palliative care involved, "too early."

There isn't really too early for palliative care and even for hospice. When you're thinking about it, it's reasonable to think about what the eligibility pieces are.

That would be, I would say, a palliative care specialist question, and that would be when you could engage with that team to be able to talk through, "Is it the right time? What should I be looking for?"

Dr Salas: That was a wonderful piece of information there. It showcases like, "When do we contact the palliative care specialists, and how soon is too soon?" These are all important questions that we all think about for our patients. I think that was very helpful.

Dr Treat: Yeah, those are really important questions and, just to clarify, I want to make sure I say that you should not wait until you're considering hospice to invite palliative care teams into the conversation.

 

In an ideal world, where a palliative care specialists are readily available, it would be absolutely appropriate to introduce them at the time of diagnosis of a life-altering or life-limited condition. That way, the patient and the medical teams have the most support possible whenever complications arise.

 

And in most centers, palliative care teams are more set up not necessarily to be there right at diagnosis, but to be engaged whenever there are decisions to make about the future of course of care—so, something like, “should we get a G-tube?” or, “should we undergo surgery?” or even something like, “should we just consider a comfort-focused approach at this point in light of this news?” Those would all be good reasons to reach out to palliative care.

 

Dr Salas: You had mentioned a comment about telehealth or telemedicine. Obviously, many of us are doing that now in the global pandemic, so tell me what have been some advantages to doing telehealth now with your patient practice?

Dr Treat: I do half of my time in general neurology clinic, and I have I'd say about half‑and‑half telehealth and in‑person visits. Obviously, there is a lot of things as neurologists that we need to have hands‑on exam findings to be able to sort through.

For my palliative care practice, I was really nervous to move at all to telehealth. That was the way we were forced to go at the start of the pandemic, and I really worried about the ability to connect with patients when we're not face to face.

I have been incredibly pleasantly surprised by how powerful it has been to have these conversations with people over telehealth.

To be able to see their home and see what they're dealing with in terms of the support that they have, the resources that they have. Also for them to be comfortable in their home environment has been such an incredible tool to have people go to different places in their conversations.

In the exam room, particularly for pediatrics, they're bringing in a usually a very medically complex child who often isn't participating with us in the conversation in pediatrics, and so it becomes a very small clinic space with a wheelchair, with feeding pumps, with all the supplies with everything that's happening.

There's a feeling of being trapped in the 4 walls with the child immediately positioned next to you. Whereas in the home, they are in their own space, they can put the child all set up in front of a show, or with another caregiver, or doing therapies, or something like that.

I still want to see the child. I need to be able to examine how things are going for them over telehealth, and they can often show me the things that they're worried about.

But then they're able to lift up the laptop and go into another room and have these conversations that are very challenging often or just sensitive. They don't necessarily want to have them in front of their child, even if there is not a sense that the child understands or hears what they're saying.

It's a different psychological space to be able to feel like you're in the comfort and safety of your home, and can have privacy, and can have some coping skills that are at your disposal that would not be that way when you're in a medical office.

Dr Salas: Based on that and your experience during this time, do you think that even after things go back to a lot of more in‑person that you're going to keep a large portion of telehealth?

Dr Treat: I do. I think that my patients have really expressed a high degree of satisfaction with the telehealth, and I feel the same way. I've been really happy with the connection that I've been able to make with people over telehealth and to engage with them in a meaningful way.

Dr Salas: I couldn't agree with you more. Being a sleep neurologist, it's given me a insight and more information as well, if the patients are willing to share their sleep environment and even aspects of their home, that may not be as conducive to sleep.

I've always been a believer in telehealth, and I expect my practice to significantly stay in the telehealth modality, moving forward, regardless of whether we're in a pandemic or not.

Dr Treat: That makes so much sense.

Dr Salas: Yeah. As we're getting close to wrapping up, I want to give you some time and some space and take that pause for you to think and maybe share some last thoughts or tips or whatever. What are some things you would want to share with your colleagues out there that are neurologists?

Dr Treat: One of the things that really resonates with me that I'd love to encourage neurologists out there is to validate that part of yourself that feels like our work is heavy.

Particularly, with the strain of the news that we give, the patient population that we have, the diseases that we manage, it's a necessary self‑preservation skill to be able to have that self‑reflection and to be able to partner with each other.

I think neurologists often are introverts and often feel certainly a sense of connection to other people, but a sense of recharging by being by oneself and to explore that sense of connection and meaning with each other, to have just some open conversations about the pieces of our work that feel emotional or impactful.

That goes a long way towards your longevity in your career and being able to trust and know your colleagues and feel like you are each humans. The work that we do, I think medicine sometimes makes us feel pressure to put those feelings aside for the sake of professionalism, or for the sake of professionalism, or for the sake of efficiency, or whatever else it is, but they're important.

They're what keep us in this work and connecting with one another and with our patients, it's important to come back to that.

Dr Salas: Wonderful. Thank you, Dr Treat. I continue to learn so many new things every time I hear you talk about palliative care, and child neurology, for that matter. I want to thank you. The audience will have picked up some helpful tips and even a little bit more information about palliative care.

Who knows? Maybe, you'll have some new colleagues in this specialty. You just don't know. It's a rising field of very much interest, and happy to have it in our field of neurology.

Dr Treat: I would love that. I welcome anybody to reach out to their friendly palliative care doctor and/or neuropalliative care colleague. We would love to engage with you.

Dr Salas: Thank you so much.

Dr Treat: Happy to be here! Thanks for the opportunity.