Quality of Life, Finishing Well with Elena Prendergast, DNP, NP

Meet Elena Prendergast, DNP, Owner/Professional Quality of Life Navigator. Elena is Assistant Professor at Augusta University , at the College of Nursing
Department of Doctorate of Nursing Practice Program where she is equipping current and future nurses to deliver quality evidence-based care. Elena is dedicated to increasing awareness and access to EOL/Palliative Care through education, advocacy, and the delivery of holistic, person-centered care. In this episode we get to hear her expert view on Advanced Directives and the heart of Palliative Care.

As we default to extraordinary, we can get comfortable with these conversations. As we do, we have the opportunity to embrace our values - to live our our lives in a way that matters most to us, all the way to the finish line.

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You can find the resources mentioned in this episode and contact Elena here: 
https://treeoflifehealthconsultant.com/

Transcript

0:59

All right. It's time to default to your extraordinary self. I'm your host, Julie Reynolds, and I have a special guest today. My friend Elena. And I am so excited that for you to hear from her she's so smart, Energetic has a lot to offer us in probably any topic that you throw at her, she could talk about. And so I love that she's a nurse practitioner and we are in our part two of our. end of life conversation and talking about because we want to highlight national health information. Awareness was actually April 16th, right? But we are highlighting that conversation so that we can get comfortable. this is all part of defaulting to your extraordinary self is. Not just in the way we live, but how we live to the end, how we finish well as. Also so welcome. Thank you for having me. So tell us a little bit about yourself and your journey and how you ended up to be an end of life doula. I guess, going all the way back, honestly, as a child I grew up in New York City, and I tell people, I had three facilities across the street from our house. One was a homeless shelter. The other one was the Psychiatric Institute in New York, and then the other one was Columbia Presbyterian Hospital, which was attached to Columbia University. So at an early age, I was surrounded by a hospital, worked in a hospital, just really grew to love advocacy. Fast forward 1991 I had the first of five miscarriages and my statement at that time, which I guess is the thread that weaves this whole story together is, I don't think I could ever deal with death again. And little did I know that whole thing would follow me. In the next couple of years multiple miscarriages my grandmother died of sepsis. My mother died of melanoma. My mother in law died of ovarian cancer, and then my dad died of a PE. So what I Most feared the one thing I did not want to deal with was really the thing I had to deal with and I was forced to deal with it. But what I found was that nobody navigated me. No one informed me. And we really didn't talk about it, even though we went through all of this in our family and in my own personal life. We had not talked about it. After my mom had died, I had gone into nursing school. My dad died. She died before I got my acceptance letter. He died before I actually walked. So it's the book ends of that whole thing. I went into the ICU thinking I'm going to help people, as we all do when we go into nursing, right? What I found is in the ICU, I dealt with more body bags and loss than I thought I was going to deal with, and I felt very ill equipped. I also started to ask myself the question, is there anything between do everything and hospice? And so that kind of was the defining moment when someone said, yeah, palliative care. And I'd never heard the phrase, never heard it in nursing school, never heard it in the ICU. And I really became very intrigued about what is this thing called palliative care. So the rest of my career really was focused on not only finding out what it was, but really getting into that space. That's where I am now. Yeah, I so you took that, I'm anxious to hear a little bit more about that and that, that advocacy. This is actually how I got really involved. Keyed in or clued in to this topic is by working in the trauma unit and being exposed to so many and young deaths lives that were cut short and watching the families deal with it. And in that time with what going from doing everything into maybe a. You're going to have a really long period of navigating that end of a life cut short and how you go about doing that. So having all of those experiences, I'm always. Intrigued by the journeys that we take, And you have taken those, that pain, things that could have undone you and just Put out in the world, something beautiful and decided to help other people with that process. And that is so inspiring to me. And it also creates that thread of interdependence. That we have experts like yourself and people who've been through it to guide us through in a way that you didn't have those guides. 1 of the things that I had vowed, just like you said, was to never. Have a family sit there as blindsided or uninformed as I was, I didn't understand when my mother was on her third line of treatment. And when she was being offered experimental treatments, that really meant we were at the end of the line. We really just thought they were continuing with very aggressive treatment, never ever understanding that this was palliative. All along. I mean her cancer her melanoma and this is back in 2004, where we didn't have the immunotherapies and everything that we have now, it had already metastasized you know she was stage four when she was diagnosed, but we never knew We didn't quite understood that this was just buying us time. We, every time they told us she was responding, we thought that meant she was getting cured. We didn't understand that was keeping it at bay, and they were happy that it was not progressing more aggressively. So that's just the simple thing that families just don't understand our language, and what we're saying. So I found myself when I became a nurse in those situations, as we all have many of us that are in nurses or in healthcare, where we sit there biting our tongue because they'll say, how are they doing? They're doing well. And, or as well as can be expected, what we didn't tell them is what was the expected, right? So when I went into hospice, because I did go into hospice after ICU, I thought I'm going to go into hospice. This is going to help solve this problem because I'm going to be part of the solution. I'm going to get them on hospice. What I didn't realize is the stigma. that people have when you even mention the word hospice or when you mention end of life. So they have this perception that if you sign on hospice, then your loved one's going to die about two days later. And unfortunately that's something that we created as a healthcare system, because we put people on hospice way too late. So we do get that Outcome where someone gets put on hospice and next thing they have died. So I Then like I said, I started to struggle within myself because I was saying We're not getting people in time what I started to find You know, we joke around that if you have a nurse or a doctor, in the family everybody calls you. That happens with your colleagues too. I found myself, fielding a lot of phone calls from physicians and friends and nurse practitioners, nurses. All kind of healthcare professionals that you would think would know better that you would think would know how to navigate through this system of end of life, and they couldn't, they had not been trained for that they were not prepared for that with their own parents with their, their own loved ones. And so I really started doing a lot of this work independently. Of any role that I was in. And I said, then how do I do this? Because we have to be very careful when we do things outside of the work environment that we're not crossing over our roles and not working outside our scope, how do I do this in such a way that one people will embrace it and not be afraid of it. And two, I am not giving medical advice because really what I was doing for people, I was just either navigating them or I was accompanying them. Either one, was outside of the realm of doing my nursing work. And then I heard this term end of life doula and I'm like, what is that? And so that was another defining moment where I said, What is this? And so as I went through the training, I thought, this is what I'm doing. This is exactly what I'm doing. I'm helping people make those decisions, but what we want them to have is informed decisions. All of the information they need to make that decision. More recently, because I do end of life do the work because I'm a nurse practitioner because I'm an educator of nurses. People were like so exactly what do you do, I could not put a finger on the one thing that I do the most. And I came up with a term that I've coined, and I tell people I'm a professional quality of life navigator. And what I feel that is so many times we come up with a plan of care some type of plan. We move forward with aggressive therapies, aggressive treatments, all of these things. And I remember sitting in meetings at times saying, did we ask the patient? What they wanted. And I get these looks like they came to us. So we know exactly what they want. They want cure, but that was never clearly defined. And if you look in a chart or anything else, we're not going to see that. So where I think we need to start the first question. We cannot develop a plan of care, unless we know the goal of care. We've always said that, except that the goal of care starts with. One question, and that is, tell me what quality of life means to you. Because I can't define it. Great question. And I bet that is a hard question too. Absolutely. Absolutely. And that's where the navigation takes place. That's where advanced directives and having conversations with your loved ones and your healthcare team really is pivotal. This is a process. It's not a one day thing. This is a conversation that takes place over time and helps you really narrow in and define when I would go in and see patients in the ICU and they'd ask, What do you do? Because they always want to know, what are you doing on the team? I tell them I'm the person that helps you define the line in the sand. And then I tell you, we're coming up to it. And that's probably the most powerful thing about my experience is what really made me want to get on the solution side of this or the right side of this the more peaceful and natural or. Aligned side of this is that there were a lot of families that didn't know where that, what that was. And you spoke to that a little bit with, we don't, whether it's knowledge deficit or if it's just comfort or time, sometimes the barrier with the healthcare, I'm curious what you think, where do we need to change in healthcare? What is the thing that When you talk to your provider, what is the thing that you need to look for or the question to ask or the thing that needs to change to make those conversations happen? And, I'm obviously we can get someone like you on our side, on our team, but not all of us get that. I think the first thing we start with is listening. We have to ask a question and we have to be prepared to listen. I was talking to a group of students yesterday and I talked about the awkward silence, the silence is only awkward for us. Because generally, if they, if there is silence, it will be broken by the patient because they will say, what do you mean, I don't understand what we need to do is learn to ask these questions to get them to really contemplate and think about what's important to them. But then we have to stop and wait to hear that answer. And then we have to tell them that we don't expect that answer immediately. Short of being in the ICU, where we have decisions that might have to be made more rapidly when we're in primary care settings, where we're in other areas. It's good to ask them those questions and say, think on that, because what they want to feel is that you're not pressuring them. They don't want to feel like a lot of times we hear patients say yeah the surgeon always wants to do surgery or the oncologist always wants to do chemo. And that's not necessarily the truth that's a generalization, but that is their perception that whoever it is, even if it's hospice wants to get me on hospice that they have. A vested interest in whatever they're representing. I tell people, remember, you're going to a surgeon. And so the tool that he brings or she brings to the table is surgery. And so you're going to talk about their expertise and remember that they're just going to tell you what they know about the solution. And I think there's a fear in if I take their hope away, or if I say something, they're just going to go somewhere else. or I. There's a lot of things that people hear incorrectly in those times of crisis. What are your thoughts? I love that. Holding space and really listening in that silence that people can process that. Where have you seen that? What would you say to a provider that says, I don't want to take away anybody's hope by telling them they're at the end or they're at that line. I love that question. I love that question. Because it's been asked of me so many times, but what I tell people is we take hope away every day. We do. Why? Because we make choices for people, and when a person doesn't have a choice to make, they have no hope. And so our job is to present All sides, and then help that person process and honor their wishes. When we tell them only one side, we've already taken away the hope because we don't know that overriding that chemo that might make them really sick. They're thinking they're going to get cured. If they did not know they were only being bought time, then we took away the hope that maybe they might've gone on that vacation that they always said they were going to go on. They may have made amends with that family member that they have been estranged from for five years, if they knew they only had six months. And so by providing people the entire, we don't have to sit there and say it in such a way that it is one without feeling. Or to say there are no options, sorry, good luck, but to tell someone I'm here with you, no matter what happens on this journey, I'm accompanying me, you, whether it's aggressive treatment or whether we no longer have curative treatment to offer. We're going to aggressively pursue palliative care and the mind will key in on that word aggressive. And that aggressive gives them hope. Now hope changes. And I may have had this conversation with you in the past about When we're younger we hope we get out of our parents house because, we know it all and we're gonna just rule the world. When we go through nursing school, we hope we pass and we pass NCLEX. When we get married, we hope we have a good marriage that lasts a long time. When we have children, we hope they're healthy. But as we age, our hopes and our dreams, they start to change also. We no longer, hope that we're gonna live till we're 99. We start hoping that we live a pain free or symptom free life for as long as we live. And so that's really where our obligation is to help people define what hope looks based on where they're at in their life. You can't have someone that says I hope to run a marathon. And they're sitting, they've got they can barely walk and all of these things. Okay. Let's redefine your goals. To get you to have something to hope for that is going to be more realistic. And I think that when we do that, we don't take away hope. We just redefine what hope is going to look based on their circumstances. Yeah. And that all goes back to your question about the quality of life, really helping people answer that question. And it's not really even giving them the answer. It's just basically that comes to asking the question, and giving them the space to define that. I love that you said that's where it should start too, is that we can offer options and guide them through their course. Whatever they choose, if we already know what they value, right? And sometimes people have to be reminded of what their values are in the midst of everything. And that's why I keep saying it's an ongoing thing. You just don't call palliative care in if you're in the hospital, or if you're a provider having these discussions in a clinic or even a family member, you can't hang on to mom said, do everything, but, and forget the other side of the conversation. But she doesn't want to live in a vegetative state. She doesn't want to lose her independence. She doesn't want to stop going out with her friends. So that's where sometimes we have to remind them, like we can't listen to one part of the conversation and not accept the whole part because generally most people are not afraid of dying. They're afraid of suffering. And that's where, having these discussions about, quality of life, that includes what does suffering mean to you? Because suffering for one person is going to look completely different than what suffering looks like for another person. I'm curious to I had somebody asked me, what's the difference between palliative care and hospice? And then you said earlier, you said people don't aren't offered the option early enough. So that goes to maybe people that are chronically. A long battle with cancer or dementia, Alzheimer's, like what speak to that a little, tell me a little bit more about that. First of all, how you would answer the question, palliative care hospice, are they interchangeable? And and what do you, when is the right time to look at that option? That's a great question. To be flippant I used to joke around when patients would ask me that question and I would say insurance. And they'd say, what? And I was like, that's the difference insurance. The reason I say that is. All of it is palliative care. Palliative care is to palliate symptom management, improving quality of life based on what that patient defines as quality of life. So whatever it takes to do that, then that's what we're going to do palliatively, right? That could be pain management, that can be existential pain. And so it's all addressed under that umbrella. Hospice, on the other hand, is a Medicare benefit. It is a benefit that kicks in when the expectancy is that the patient has six months or less to live, should the disease process take its natural course. Now, with that said, we have an excellent example of someone that's on hospice and has been so over a year, and that's former President Jimmy Carter, who has been he just celebrated his one year anniversary of being on hospice. And so there's very specific rules that Medicare say, you have to be showing decline, you're not you're not seeking curative treatment for that disease. That doesn't mean they don't address it with care. therapies, you can have palliative radiation if you had a tumor in your throat, because that is going to improve the quality of your life and allow you to swallow, right? So those things can be covered. And so that's why I say it's very, it's a philosophy. is all palliative care, which is how do we address your symptoms? The difference is that hospice has very specific parameters based on the Medicare guideline of what can and cannot be pursued as a therapy. And also with that, Are benefits that kick in such as a nurse and a CNA, a chaplain, a social worker equipment to the home. So it is very beneficial for people that are within that window that has to be certified by 2 physicians. And when they're within that window to turn around and say, yes, this person, in my clinical judgment and all of the things that we see has 6 months or less, and they're not pursuing aggressive cure to treatment. Dementia. You mentioned dementia. Dementia is probably our hardest one because as we know the caregiver burden is huge. The resources are scarce and it is such a complex disease that really with Medicare. It is not until the very, very end when a person is nonverbal, unable to do ADLs and those things where hospice would. kick in. By then, unfortunately, the family is strained, their finances are drained. And so we do need to do a lot better advocating for either the coverage of palliative care for the dementia patient or in, earlier hospice coverage for those patients. What do you think most needs to change in our culture for, to make this a more comfortable and natural process to Even having conversations with, within the family and with your friends or colleagues, what would you say is the root cause of some of our root cause? It well, and actually it's really our discomfort in Western society. Other societies actually do talk about death. They consider it a sacred, passage. And it is in their poetry. It is in, all of these things. Ironically in a society that Scribes to more than Judeo Christian, right? They, there's this belief that there's something better to come, but yet that segment is actually the least likely to have these conversations. Evidence has shown us. And so what I tell people is that's why I love the term end of life doula. When you think of a doula, right? Most people think of birth doulas, right? And they think of this person who is a non medical person who is really just serving as your advocate and your guide in this very natural process, right? We've medicalized the birthing process. It used to take place at home. We had our midwives that came in and helped with this and then we medicalized it and we put it in hospitals. We've done exactly the same thing with death. We have medicalized it. Most people will tell you if you ask them if I couldn't offer you anything, what is your ideal thought of how you would like to die? They all say the same thing. I want to die at home and I want to die in my sleep, right? No one really says, I want to die hooked up to a vent with my family coming in two at a time with noise and lights and everything else. The reality is that most people do die. In a more clinical setting. So the first thing we need to do is just the words that you used is to recognize this is a natural process. And I usually with families, colleagues, I'm able to sit down and help them. And just be able to correlate that birthing cycle that process with the dying cycle. And, quickly going through that is, I tell people, okay, when you get pregnant, there was just like this event that happens that sets off the whole chain of events. For someone that's dying, that event could be cancer. It could be heart, failure. It could be dialysis, not dialysis kidney problems. Whatever it is, there's this, it's irreversible. This chain is going to happen. We don't know how long the difference is that, in pregnancy, we know nine month period, more or less. But even in the dying process we have a general idea of what the period is going to be short of a sudden heart attack a stroke or an accident. The first part of that process really only impacts that person. The being pregnant, feeling the flutters, maybe the nausea, the vomiting. People can see it, but they're not impacted by it. The later part of that process really does start to impact other people, whether you need a coach, whether it's insurance, financial, it's, it's not free to have a baby in this country and it's not free to die, unfortunately. And we. Think about that. And then the body starts to prepare for pregnancy. Delivery, all of these changes take place in preparation for this final act, right? So does the same thing happen at the end of life, right? We have this preparation of the body to die. And then finally, what happens is, most people opt to be by themselves. Same thing. We cannot prevent death, but we can support those that are going through that process by helping them with closure, helping them with symptom management. Now, what's our role as healthcare providers? In the birthing process, we really should not intervene unless the life of the mother or the, the fetus is in danger, in which case, then we do interventions to make them more comfortable and make it safe. Same thing with end of life. We hear things like morphine and people get really nervous, but I call morphine the epidural of death. Because it does not cause death, just like an epidural does not cause delivery, but it does relax that person for that natural process to continue until you know the final outcome, which is either birth or death. So like I said, getting people to understand that. Now in birthing, we have a birth plan. In death, we have advanced directives. Both of those guide both the health care team and our loved ones to understand what are our values and what are our values. Last time I checked when I did my birth plan, I did not go up, pay my copay and have my baby. So the same thing, and that's where we have to normalize this. Doing advanced directives does not mean that you're close to dying, you're going to die right now, it just means that eventually, and that could be 30 years from now this is what you would want done if, when that process starts. So I, that was a lot but I hope that explained where I'm coming from. Yeah. And of course I'm getting curious. First of all, you mentioned the Judeo Christian population tends to be the ones that maybe are most uncomfortable with that. And as far as our culture goes and it led me, it connected with me, like the same thing that makes us puts us. In the medical experience of death instead of the natural experience is we look to experts to tell us what to do. And in the church, we look to experts to tell us if we're on track, are we going to heaven or hell? Are we behaving? Are we behaving in a way that is going to give us that hope of eternity and it gets confusing and people hear things. That, don't that aren't true. And if you use the issue and then lean to make you feel like you cannot make this decision, this isn't a decision you get to make yourself. So you go to a provider and you don't get to make that decision yourself. They are going to tell you what is going to happen and what is available to you. And this is how it's going to go. And it's the same thing. Maybe. When we're as a spiritual experience, we're looking to experts to say this is what you do or don't do is that we do. We look for somebody to tell us what to do instead of stepping into our own power and our own experience and really embracing our own values. And I know that a lot of people that I talk to don't know what their own values are because they've never, ever looked at that or been asked or defined them and. And so I love that. Again, going back to that, just ask the question and sit there until they know the answer because they do know the answer of what's important. You mentioned advanced directives. How would you, like, when I know that I asked my patients Every patient gets asked about advanced directives because it's a regulation now and we have to screen for that and we have a form that is very generic and it's basically, and people fill it out quickly and they get it notarized or whatever their process is. But it doesn't really answer the questions that we're talking about now, and it doesn't speak to the process that you're saying needs to be in place to allow that to be a beautiful, natural process for everyone as painful as it is, don't want to make light of that at all. But so what, how do you go about advanced directives to make, to lead us in that direction? I love that you said earlier, people come to us for our expertise. And we know that plans of care and conversations are not cookie cutter. We really have to define, where that person's at with their health literacy. Even their, just their literacy where they are in their beliefs. You know where their struggles are. So I honestly, even when I asked someone, have you completed advanced directives, I still give them a different type of document, I may not give them the legal document, because they may have just signed that. Like you said, generically in a hospital without a conversation, without really thinking and contemplating and having discussions with their loved ones, because as we know, as healthcare providers, it doesn't necessarily matter what you say you want, because if your healthcare advocate, if your proxy comes in and makes a different decision, they can legally do and that's disturbing that causes a lot of moral distress at times with rest of the family or the health care team. And we've seen it happen time and time again. And that's why I continue to hammer home that discussion that this is a conversation, a discussion that has to take place so that everybody really understands the values that are important to you and that really drive your life up until the last moment last breath that you take. So I have actually several ones that I use. I may use five wishes with one person. I may turn around and use the conversation project with another person. I may give somebody that has completed advanced directives a document that's called prepare for your care, because. It generates and stimulates some discussions. I also have, there are cards out there, card games, so to speak. I don't want to call it a game when you're, but it stimulates conversations amongst family members. Instead of sitting there with a document saying, let's talk about this document, it may sit down and have a conversation about some of the things that we've said. If you knew that. You only had a limited time to live. What would you want to do? That's not necessarily narrowing down, saying, Okay, tell me exactly. But that is giving you a general idea of some values that they have. Those conversations can then drive you into saying, Those are great points. I didn't know that, mom. Why don't we put that down on paper? Because I think that's important for your team to know, I never knew that this was important to you and I want to make sure that I honor that. Maybe it could be something as simple that person says my faith is very important to me, and I would like hymns played while I'm in a hospital while I'm dying. That's important and that should be honored. So I think we have to pick the person and pick the area that's going to help the most. So sometimes at completing advanced directives is best done by a chaplain because that person has some more existential pain or some spiritual distress that maybe they need to work through. And there are, a lot of, Chaplains on our team. They're amazing members that can sit down and help them work through that and help them complete advanced directives. Maybe somebody else has a really sticky social situation that really needs to be worked through, a estranged husband, current, A partner that is unmarried and we know how sticky those things can get because legally that person will not be able to make those decisions unless it's in writing. Maybe the social worker would be the best person to help them. So I think it's important that we find the best person. Sometimes it's having the conversation with that advocate in the family. So there may be three siblings and only one of them is really being realistic about what is taking place. And where the course of the disease is heading. So maybe equipping that person. To have the conversation is best. So that's why I say there's not a one size fits all. And that's why certainly getting out there and recognizing that there are many paths to one thing. And the one thing being having those conversations and defining what's important to you. The examples that you shared gave me a picture of that would also give the family members that don't know what to do or are uncomfortable something to do. So if mom says, I know it's really important that I have hymns playing. I like, I'd like that to be the thing, then some family member who doesn't And then if they're not comfortable, maybe feel comfortable in hospital setting or in a medical setting or with the thing. Or it's just does not know what to do with themselves or for their loved one. They can go find some hymns and keep, that's something that we can do for our loved one that we know is important even in the time when they can't tell us that, that it's important. So I think that's great. Yeah. It brings a good point. Yeah, I was going to say that brings up a point we always it just, it curls me my hair. When I hear people say there's nothing left to do, there's nothing else we can do, or they are stopping care. We never stop. We just change the direction and focus of what we're doing. And just like you said, we do not stop. There's always something we can do in our comfort, in our support of that person. And it could be oral care. It could be finding the hymns. It could be just helping that person reminisce about their life. It could be laughing with them. Sometimes laughter is the best medicine. And when a When the person who is dying perceives that their family is going to be okay. Oftentimes, they are more at peace. And so what we don't realize is it is vitally important during those times to really make sure that we're addressing the needs of the family, because that will ultimately help it, bring peace and closure to the patient who's actually, dying. Yeah. And I think a lot of people don't know that there is actually, like I know in the intensive care units, there's actually a nurse assigned every day to stop care. Like you said and that does not mean it's an unfortunate way. We put things maybe because on that day, that's when family members are there and a lot is going on those days. And sometimes it's not just one day, obviously, but. I think that's really something else we don't understand is that a lot of times if we have that opportunity, we know that's coming. It would be nice if, yeah, with the advanced directives. how they can participate and how they can be there. And yeah, no, that their loved one is okay, because they're getting the things that they were, that were important to them. I think that's something you can carry forward to, in the grieving process to set, to know that you were part of that beautiful transition. Or make absolutely what is not beautiful. I, okay. So I say that. And every time I say that, I think sometimes that's not true. We can do everything we can to make it beautiful and natural. And it goes it doesn't go that way and it's not beautiful, but it's still natural. People when it comes to the end, really buck at the last moment, they don't want to leave. And it shows, and it's painful to watch and to observe. And it has nothing to do with. Not doing everything that you could or not doing everything. That's part of the process too. Yeah it's just like pregnancy. You could have planned for that normal, right. Delivery. And you have these beautiful dreams of swaddling your baby and all of this. Nobody planned for the emergency C section. The other things that could go wrong in spite of all of our, best efforts. But in those cases, what we find is that it is vitally important to help people understand by communicating with them, educating them that, we can do everything we can do, but there's still nature that takes its course in spite of our best efforts. So I think that's an excellent point that doesn't it's always not the beautiful and not only that we have to recognize every patient does not want to die at home. And we have to stop making it seem everybody wants to die at home for reasons and some of them very valid some people don't want to die at home, they might have young children, and they don't want their children to have that memory, of every time they pass that bedroom, that's where mom died. And so we have to recognize and be able to support even when people, put that in their advanced directives and so those are conversations because coordination, as has to take place for that not to happen. So once again, why it's important to have those conversations. Yeah. I love that. This is such an important topic and thank you for having it with us. And thank you for the way that you show up in the world and move this forward, because I just, I think it's. That spectrum, it makes it a little, the mystery of life enables us to really embrace it and make it beautiful and just experience it in the way we're meant to. Even when it doesn't go the way we would write it out ourselves, maybe sometimes it can be better. Exactly. But yeah, thank you. And this is obviously something that was really on my heart and my mind. I want to get better at this. And so I appreciate having resources and can we share those links? I can share those links then to the resources. Are those all there? Absolutely. Or are they? Yes. Those are all accessible links. And I can send you that information. One of the things I on my webpage, which I it's in progress but tree of life health consultant. And I will share some of those links on there so that people can readily go to them. There are other things. There's a project that I was involved in being a veteran myself and the spouse of a retired veteran. I'm very The veteran space is very important to me and so there is a organization called psych armor, and they created a three course series carry caring for veterans through end of life. And those are three free courses for family members providers and the community to understand how to care for our veterans. I was honored to serve as an advisor on that project I don't. Get anything for it. Once again, we do what we do because we want to get the education out there for those that need it. That's another resource. Should we just go to your website to find all those resources or do you, yes. Yes. Okay. Nope. That's fine. Okay. All right. So I will make sure I upload those links. Yeah. I'll, we'll put the then the website is what again? treeoflifehealthconsultant. com Okay. And the link is below in the show notes. So if you're driving right now, listening, save this. And definitely make sure you share this share this episode with your friends, let have your family members listen to it, and maybe that will be enough to spark conversations, make someone else curious and get that conversation started. The link will be in the show notes. You can access all of the resources that were mentioned here today. So I. I have one more question for you. And I know that you have done this before. I've shared your default to yes story on the podcast before. I don't remember what episode is it. We'll see if she answers it differently this time. what does it look like for you to default to yes, to your extraordinary self, how would you answer that? It's interesting because yesterday I was doing VR, I know this seems like completely left field, even though I knew it was VR, and it wasn't real, when I got to the edge of, I was on a cliff, I was hesitant to step off, even though I knew, This is VR. And so I think really for me, defaulting to yes is stepping off. It's going ahead. And recognizing that there's going to be a safety net whether I know it or not, in the back of my mind, I need to remember that it's going to be okay. And so that when you said that I thought that was my thought yesterday like. It's VR. You're in your living room. But our mind is so powerful to worry about the, the unexplained, the unexpected, what I don't know. I'm going to get hurt. I'm going to lose. I'm going to make mistakes. And so I think, in light of what happened yesterday, I have to wake up each day, remind myself it's going to be okay. Just do it. And so for me, Taking a lot of chances going into a field that most people are thinking like, what are you doing? This is so sad. But in the midst of all of that, it's bought me so much joy to help people find closure and to find peace and find quality of life that, yeah, I'm glad I said yes back then, and pursued this. So I think for me, that's what it would look like is just to remember there's, it's going to be okay. I love that. I love that you coined the term quality of life navigator. You are an amazing one. Thank you so much for sharing your story with us and sharing your expertise. And I hope all of you listening will visit her website. Take advantage of all that you've learned and put that into action. And yeah, step off Thank you so much for having me.