Day 2 Plenary Paper Presentation: Educational and Ethical Decision Making

who will uh moderate the uh next session. Uh Marshall is the Richard Pillo Family Distinguished Service Professor of Medicine. He's also the associate chief and director of general internal medicine research and director of the Chicago Center for Diabetes Translation Research and also uh an associate director of the MLAN Center. Um and so uh it's a pleasure to welcome Marshall. Thank you. Thanks very much Peter and first what what a wonderful panel that is a great great example of a collaborative effort among a number of different institutions and uh really a thoughtful conversation and I think a winner. So we should do these types of things in in the future. So thank you very much for the panels. So today's first plenary session is going to be on education and ethical decision-making. Our first speaker will be Heather Strobe who is a MLAN alumnus and a currently an associate professor of maternal fetal medicine at the University of Colorado, a faculty affiliate at its center for bioeththics and humanities and the director of the perinatal grand rounds program there. Heather's interests focus upon reproductive health ethics and the doctor patient relationship and patient autonomy. She's involved in a number of important educational initiatives, including a program that helps fourthyear students transition then to residency, including helping with difficult conversations around gender and reproductive care. Heather's talk this morning is entitled, "Novel multimodal OBGYn resident ethics curriculum improves resident and faculty confidence." Heather, good morning and thanks for letting me talk on this. Um, how do we change the slides? Do I need a >> Yeah. It's the big green button. >> Okay. Um I have no disclosures or conflicts of interest. Um so a little bit of background here. So as we all know, ethics education is an important part of any residency training, but in my paradigm OBGYn training for patient care, it's included in our CREOG, which is our national uh licensing body for resident education learning objectives and is required by some state licensing boards such as Texas. um based on the work that I did here with Dr. core at the University of Chicago and during our fellowship um we surveyed uh residency program directors and we found that nationally they wanted more ethics education although this was a little while ago slash like 12 years there isn't any evidence that that has changed and in fact I would argue given the current political landscape is probably more relevant than ever um barriers that we had found in our study were limited teaching time and then faculty discomfort with ethics topics which were the two um kind of uh lynch pins that I was looking at when we were starting to develop our program in Colorado. So to try and approach this strategically, we used the current curriculum development model. So this is kind of this diagram here. I guess that's a hexagon, right? Um so we identified the problem and did a general needs assessment. Then we targeted the needs assessment. We developed some goals and objectives. We looked at different educational strategies that had been used in other places. Um we implemented it and then we evaluated it. So our needs assessment um at the time was in uh 2020 2021. Um we reviewed the current state of our ethics education which spoiler alert really wasn't very much. Um we did a literature review and we wanted to make sure this was aligned with the CROG learning objectives as that was a metric that the residents um routinely get tested on. Um we surveyed our residents and faculty locally to get a baseline of where they wanted uh where they were at and where they wanted to be both on topics and a needs assessment on which ways they felt like were most appropriate for their learning styles. Um and then we had a couple of goals. So one was to increase the structure of residents e ethics education make it a little bit more formalized. Um we wanted to increase the involvement of trainees and faculty across the different divisions of OBGYn in creation of ethics education content. Um this also transcended beyond just our department into the ethics community at the university more widely. Um and then we wanted to increase resident and faculty confidence in residents ability. I would also argue faculty ability as well, but we didn't really assess that to handle ethically challenging situations. Um, for box D here, we did look at other strategies, um, that had been employed around the country such as reflective exercises, um, journaling and things like that. Um and we [sighs] um really got involved with utilization of anonymous audience polling which I think is um something that we have found great success with um in allowing people to truthfully or hopefully truthfully respond in a large forum zoom type setting um and realize that the person sitting next to them may have a slightly different but equally valid point of view. Um when I started at the university in 2018, the perinatal ethics grand rounds was really siloed at the children's hospital and it really was just talking about conflicts um in the maternal fetal diad particularly with medically complex babies. Um and so this was an opportunity to expand that to a larger audience on campus and also expand beyond just pregnancy related ethics and OBGYn. Um we added additional ethics readings which were based on the work that Dr. core so generously shared with us because she had um surveyed um OBGYN's nationally to try and find some sentinel articles. Um we had some other case studies that were provided um from other institutions. Um and then this program initially ran from 2021 to 2023 with the goal of repeating key topics every two years. That is still a little bit of an idealistic situation, but we're working on it. We did survey um to evaluate this at one and two years. So we wanted to see what the volume uh was perceived as the content and the perceived level of comfort. Um and some of this allowed us to focus what the content was for the next uh year. Um so I I want to take a moment to talk about this concept of um perinatal ethics grand rounds. Um this is where we have sort of a semiformalized structure to them. Um so the first thing was making this at a time that was accessible to faculty and advertising it um far out as possible. Um so this was usually right after the OBGYn grand rounds which were tend to be very well attended. Um and it was during the mandatory resident teaching time. Um we also expanded the invitation to um bioeththics um chaplain Cy social work um niku anybody who was particularly interested and if there was a topic pertinent to a specific specialty such as psychiatry um pediatrics uh family planning um we had like a um a critical care and pulmonologist we would personally invite them and their team to come to the grounds to provide additional perspective. We also invite community members if appropriate. So this is the oh sorry my titles didn't come through there. I don't know why but the first part that should say topic. So these topics were a combination of things that myself and our faculty thought were important to make sure we covered over the period of time, but also these would kind of naturally evolve from conversations on labor and delivery or in clinic both from residents and fellows, but also from nursing staff and midwiffery and other groups that felt like this was a case that really highlighted some moral distress or some ethical dilemmas on the unit. Um the other part sorry about that this should say presenters. Um so all of these talks I was more of like the molder of the clay in the sense that it was really the residents med students fellows who were the ones who were doing the reflection and um presentation of these talks. So we would generally start um talking about hey are you interested in being involved with this or if there was a case that was brought to my attention I would look at who was directly involved in it to see if they wanted to talk about it and to dive in a little bit further. Um and uh the um interest and demand was more than the volume of time that we had which I thought was really um interesting. And then this last one here should say oop maybe it won't say it there. Okay. So this is the the structure of the presentation. And so the way that we have structured it is having um activity goals or like learning objectives of like three to five things that um at the end of this conference or at the end of this lecture, we want to have this be like the take-home. So OBGYN's we're fairly fast-paced on labor and delivery. We want like the too long didn't read and so this is um this is where we start and finish with this so that people have something actionable to go home with the cases are deidentified and progressively disclosed. So the format generally is we start with the beginning part of the case. Then we have here this anonymous polling of the audience and these questions are designed to get people to be maybe a little bit uncomfortable but they're also anonymous like completely anonymous. And so um people can reply and then you can see sort of what the the temperature of the room is. And it also gives us an opportunity for discussion not only real time at the end of the specific talk or or also sort of that real-time conversation that happens between colleagues outside of the lecture hall. And then we usually had the fellow or the more senior person kind of break it down into okay what does the literature say about this specific ethical topic or conflict and how do we integrate that in the experience or the modified experience we have with this person's cake. uh case. So these are some of our results. So this was in the 2021 to 2023. Um we had uh 13 lectures and activities. We actually had 14 because we had an introduction talking about um a way out of the ethical swamp where we talk about Dr. Seagler's four topics model and then we also talk about the Baylor model of clinical ethics to give the residents, faculty and trainees, attendees some tools to try and think about um moving forward. Um we had um 10 perinatal ethics grand rounds and four on specific ethics topics. So one of them is that um that intro lecture. I thought this was interesting. Um so maybe you do not know but OBGYn has several subsp specialties. So we've got maternal fetal medicine or high-risisk pregnancy. We have gynecologic oncology. We have eurog gynecology. We have minimally invasive gynecologic surgery. We have uh pediatric gynecology. We have reproductive endocrinology and infertility. We even have hospitalists. So you know in a big academic institution sometimes these things are all siloed even though many of the cross care of patients involve some of these other sort of subsp specialties. And so this um this uh this series of lectures and um activities we had six fellows not all of those were my MFM fellows. So it wasn't just MFM. We have six residents and then five faculty from other um divisions. And here are um different um oops sorry clearly I'm not fasile with this. Um but these are you know these are some other things. This is um the Boulder Abortion Clinic which is an outside entity that was directly involved in in a case that we had them attend so that um it was kind of open uh discussion. So then we look at so that was like the content of what we developed and then here are some of our survey results. So we had 29 residents and 44 faculty completing the baseline survey. I apologize I don't have the response rate. um it's probably pretty low. So, this is obviously skewed uh data. But what I thought was um interesting is most residents and all faculty uh 96%ish reported that they felt that ethics education should be offered and/or required to complete residency. It makes me wonder about that 4% who didn't feel like ethics education should be required, but we didn't really dive into that. Um that baseline survey we did in 2021 was very similar to the survey that we had done in 2013 2014 that residents wanted more education in ethics. Um at the 2-year mark um it seemed like most of the residents wanted either a little more or the same and none of the residents felt like this was a time burden or that they were you know getting too much ethics kind of you know in their training. um more residents felt somewhat prepared to deal with ethically challenging situations after the program. So that's the 71% versus 56% that was statistically significant. So this is a little bit of a busy slide, but these are the CREOG learning objectives and we looked at our pre-ervey and our post survey and none of these were significant. Um the dark blue is uncomfortable or somewhat uncomfortable. The uh light blue is neutral and the green is somewhat comfortable or very comfortable. Many of them trended towards more people being comfortable with the exception of ethical principles, accountability to patient society and professions and uncompromising honesty. I have some thoughts around that. Um again, this is 2021 to 2023. Dob's decision was 2022. Um very relevant to my field of work. Um and then this is looking at the topics that people felt like were important. I think this is also interesting where residents felt that their top three topics were a little bit different than what the faculty thought was important. So and um residents their top three were uh and these were all significant um so doctor patient relationship was important foregoing life support this is actually a typo it should be um uh where is it access to health care so residents really felt like that was an important no sorry that's health policy that's the one that was more uh this one was also significantly different but this was the the top of the third and then um faculty felt like informed consent, doctor patient relationship and abortion was important too. Now, University of Colorado is very progressive when it comes to abortion care and uh we have a fairly progressive state. So, um the baseline training for residents around abortion care is is pretty robust um prior to this and continues to be robust. Um so some discussion so integrating residents and faculty and and fellows I would argue into a structured ethics education curriculum improve the perceived needs of OBGYn residents and faculty. Um involving faculty as both developers and participants may improve faculty comfort with teaching ethical topics. This was one of the barriers we had seen. Um the again as I mentioned the ethical principles of accountability to patients in society and uncompromising honesty were slightly more discomfort after the program and I don't know what to make of that other than to say like again the world changed pretty significantly for our field in 2022 and I think that brought up a lot more questions than answers for some of us um regarding um how we navigate that Um and then some next steps. So we have this collection of cases that we're going to deidentify further and um they will be locally on a shared drive. We're looking to scale this more nationally to make it more accessible to people. I actually attended a really interesting talk about online escape rooms for a mechanism for learning which I think this could fit in nicely to. So you know we'll see what that looks like. Um we also went through the standard resident lectures for the next year and went through and suggested that the topic the talk the speakers could put in you know a little blurb or side slide about an ethical component to that talk so it's even more integrated um and you know at the after talking at this conference here and listening to everybody um having these discussions about moral distress I I wondered if for the residents and fellows being involved olved in um these educational topics. If this helps potentially mitigate some of their moral distress that they are feeling because many of the topics are brought to me because of a clinical situation that the residents feel uncomfortable with and the discussion around it. Um I wonder if it gives them potentially some validity to you know instead [clears throat] of say did we do the right thing did we do a right thing right like there is the scope of reasonable are we within it with what we did and if not how could we mitigate that um I want to say thanks to my co-re reacher researchers Dr. Braverman and um Dr. Lejuski's actually got her PhD since I made these slides so she's a doctor now. Um these are all the fellow faculty, residents and staff who presented. Thanks again for Dr. Core for sharing those Sentinel OBGYN ethics articles and Dr. Lauren Sers um for sharing her sample cases. Um here are my references and I'm open for any questions. Um thanks Heather. That's uh really great work. And um my question is how do you sort of see this moving forward um since you you sort of it's hard to keep doing the same you know whatever it is 10 topics you know every two years or every year or so so you know I understand bringing different cases that exemplify them but how do you see it as sort of a long-term uh program? Yeah, that's a good question and I think that's kind of where we're at right now trying to mitigate I think we definitely um having these cases more accessible um kind of remotely will make sure we still hit on so so there's two parts right so one is making sure every resident in that four-year cycle gets exposed to sort of the critical topics and the other is the novel component of you know what are we dealing with today and now and so What I would say is what we have been doing is sort of cannibalizing some of the like some of the um the ethics literature parts for the topic and having a new case as it comes and evolves because there's certain things that are definitely cyclic right like there's always going to be drama in the maternal fetal diet right is that a baby with anphily is that a baby with renal aenesis right so you know I can see that as a way to make it a little bit more sustainable I've also got more help so we've got Dr. Braverman is coming up doing more of this and then Dr. um I'm blanking on his name, Dr. S is also very interested and so having more of a community, more different people is helpful. >> Thanks. >> Thank you and great work working in that space that's very challenging. My question for you is what you've done in ethics is there a parallel in communication paliotative and hospice? I as a young surgeon I've heard many senior surgeons synonymize paliotative with hospice and it really makes things very difficult for treating patients and also for people learning how to get better at communication how to distinguish paliotative and hospice. Is there a resident level curriculum for this that could be developed? >> Yes. So our gyn one of our gynongs specializes in paliotative care and she actually led um instead of calling it paliotative care she called it a goals of care discussion course um and so that's integrated in some of their oncology and we also have some of that within our maternal fetal medicine with our perinatal pali of care sort of goals of care conversation and so there is some of that infrastructure sort of kind of with the hoffern effect sort of emerging within the greater community that I'm not particular particularly specifically involved in but I am aware having talked to other colleagues about integrating that into the space of gynon discussions and also complex uh neonatal discussions. >> Hi Heather such great work. Um, have you been thinking at all about doing like an OSKI, right? Because the assessing um, attitudes, knowledge, behavior um, you know, gets you so far. Um, but kind of in the trenches and an OSI type um, setting, you know, are are the these trainings and workshops like translating to how um, residents are interacting with patients? And um it's kind of a planting the seeds of like let's talk about that and developing that. >> Yes, I would definitely be interested in that. I mean we do that for the um transition to residency for the medical students. We do like I just revamped all of the serious news for like all the specialties and there's been some flux in the leadership of the OBGYn and residency but I definitely think there's a space for that because they are doing sims in other areas and I feel like that's um definitely something we can do and I'm happy to talk more about it. So >> great job. Thanks. >> Thanks very much Heather. Our second speaker is Hans Bar who is a third-year otoarangology head and neck surgery resident at the University of Minnesota. Hans's interests are at the intersection of surgical care and and medical humanities with including difficult conversations complex conversations around surgical decision-m cancer and end of life care. He plans on doing in the future a fellowship in reconstructive surgery. And today he's presenting on behalf of his colleagues at Children's Minnesota with a special recognition to Dr. Andrew Redmond. Hans, thank you. Yeah. So, I'm Hans Burch and like uh he said, I'm a thirdyear ENT resident at the University of Minnesota. Um and kind of in the theme of what we've been hearing, I have very little education in ethics at all. But um in even the short course of my residency so far, I've dealt with a lot of complicated discussions regarding airways especially oftentimes in the middle of the night. And I've been very fortunate to have a mentor in Dr. Redmond um who has been able to kind of help me think through these situations and get me interested in this space. So uh all that being said, I'm very grateful to be uh here today talking on our experience trying to enhance value aligned decision-m in pediatric tracheosttomy utilizing the best case worst case scenario planning uh tool. See green so we have no disclosures. Uh I want to start with this quote by Winnie the Pooh. I love Winnie the Pooh and I think it uh captures the essence of really what we're trying to do. [clears throat] When you're a bear of ve a bear of very little brain, you'll sometimes find that a thing which seemed very thingish inside you is quite different when it gets out into the open. And obviously this isn't to say that our patients or their families are bearsers of l very little brain, but um when they're in a hospital setting or the ICU and they're navigating complex decisions with uh uncertain outcomes, uh a lot of different variables which seem very abstract and difficult to hold. They can seem very thingish and our job really is to help get those things out into the open and truthfully we we really often don't. Um, and so that's the point of the best case worst case scenario planning tool which I hope to demonstrate through just a single case today. So this case is an 8-year-old patient x24e premature infant who uh has multiple coorbidities associated including lethal cord paralysis, severe aspiration and a history of necroizing teracolitis. All of which uh led to her having a tracheosttomy for many years which the family cared for at home. Um and were recently able to decanulate which was a great success for them a big milestone. Um and unfortunately shortly thereafter thereafter she developed a bowel obstruction which ultimately led to need for reintubation and then uh inability to exabate despite four attempts. So here we are as ENT consulted again to discuss re revision or repeat tracheiotomy with the family and this was really a traumatic situation for them because they thought that chapter was behind them. Uh on top of that the situation was complicated by the fact that the endoscopy revealed unfavorable anatomy such that the risk of a tracheon nominate fissula was um more significant than even normal. So briefly this is a uh image just showing the tracheominal fistula for context. On the left you see the anominant artery crossing over the trachea and on the right you see the end of the tracheal end tracheal tube or um trache tube eroding through the enominate artery uh causing catastrophic bleeding into the airway and this is a severe complication with mortality reaching 100%. And in this situation, the family really had to consider this um kind of at the forefront of the mind given their unfavorable anatomy and in in the context of uh recent decanulation and the need for revision. Um it was all quite stressful for them. So just a little bit of context about pediat pediatric tracheosttomy as kind of a optimal scenario for use utilizing this model. uh it's not uncommon especially in our world four to 5,000 are performed uh each year and compared to adult tracheiotomy it has a significantly higher morbidity and mortality. Uh on top of that the burden on the family and often times the length of the tracheiotomy can be significantly more. Despite all that, only 29% of families receive a dedicated conference and only 10% of those include the actual surgeon who's going to be doing the uh operation. And this is important because uh the decision is often complex with a lot of anmatic outcomes um and not necessarily it's not super clear what the consequences of that treatment are going to be. the patients have to manage not only the clinical complexity including the diagnosis, the indications, the risks um but also they're doing this communication oftentimes in an ICU with multiple teams uh multiple providers with different experiences, different priorities um in you know uh helping them at different aspects of their care, different phases of their care and often times the the actual consequences or long-term implic Applications of having the TRA are not discussed and really the patient this results in the families having a significant uh feeling of unpreparedness at home for the tracheosttomy care which leads to persistent discomfort and significant uh measurable post-decision regret in these families. And so this really brings us to the core problem of informed consent uh which is that it was really designed to ensure patients understand the nature of the procedure like the risks, benefits and alternatives. Uh but it was not designed to understand how the consequence of that treatment will impact their life, how it maps on to their life going forward. And there's no uh grounded framework upon which to discuss with the patient such that it surfaces their values and makes them feel um engaged and uh sound in the decision-m process. In the setting of pediatric tracheiotomy, uh what families typically hear are risks of bleeding, infection, loss of the airway, and then they're always wondering about the likelihood of decanulation. But often the consequences like the equipment needs, the suctioning, the need for supervision, and the impact that can have on um employment. the rest of the family unit are not clearly described in in addition to the reality of possibly needing to manage manage complications in the home setting. And all of these things on the right side of of the screen remain very thingish without any framework to get them out into the open. And so that's where best case worst case scenario planning comes in. Um this was originally developed by Dr. Schwarzy who we'll hear from shortly. And um kind of what we're presenting today is a simplified um manifestation of it that just allows us to use it frequently and uh in a lot of different situations. And the framework has three different components. Uh scenario planning in which the different options and possible trajectories are clearly laid out in the clinical context uh for the patient. Then a graphic visual aid which is a very simple diagram in our case just essentially a spectrum from best case on the left to worst case on the right and then the most likely scenarios in the middle which really allows visualization and direct comparison of the options for the patient such that they can see it on paper, point at it, discuss it with the provider, with the other family members and then upon that uh have an opportunity for values clarification where they can emphasize the things that are important to them, determine what risks are worthwhile or not. And uh this is fairly evidence-based framework and most surgeons who have been trained in it and are using it find that it is superior to just standard informed consent process and continue using it thereafter. So returning to our patient, there were two real course uh options which seems fairly simple on the surface. In option A, um they could attempt one more attempt at exhibition. the non-invasive positive pressure ventilation with the hope of avoiding a tracheosttomy um with the knowledge that this is very unlikely to be successful and that a tracheosttomy would need to be the backup plan and in the setting of repeated exhibition intubation attempts uh carries greater and greater risk especially with their unfavorable anatomy versus option B accept the need for a tracheiotomy forgo the ideal situation ation and do it in a safe and complicated setting. So here is the uh graphic aid that we use. It's very it looks just like this very simple two lines on the paper with the best case on the far left and the worst case on the right. Um in both options the worst case scenario was tracheomomenula with likely death. In option A which was attempted another exhibition there's a best case on the far left which would be the ideal case avoiding a trachea altogether and then in the middle slightly towards the right you see the most likely which would be a failed exhibition given four previously failed excavations and then a revision tracheiotomy um though with increased risk of complication and in option B the best case would be safe uncomplicated controlled tracheiotomy with short-term decanulation um and then most likely likely discanul um going home with the tracheiotomy. So and having this framework for this patient really um helped them compare and contrast these options. Obviously it makes most sense to try to avoid tracheiostomy alto together but with that you're kind of accepting an increased uh you have an increased risk tolerance and that is the real question that I brought into light for the family and facilitated discussion revolving around that specific topic and [clears throat] ultimately that's what the family decided to do which was accept that increased risk pursue one more attempted exhibition Um and somewhat expectedly that failed. Fortunately um the patient got a tracheosttomy without complications and in you know some time was able to be decanulated and [snorts] uh despite this nonoptimal outcome the family really expressed genuine peace uh with that because they felt confident that they had considered all the different possibilities and made a choice that was really you know theirs. They were active participant in that decision. Um and then when we uh queried the the family and the care team about the tool specifically the the actual scenario planning and writing down or drawing out the graphic visual aid. The the four major themes that came to light were that it really helped clarify the options, contextualize uncertainty, provide a piece of the final decision, and then ultimately in uh transform the informed consent process more into a values-based uh discussion. And this framework addresses some of the main ethical principles. Um, it helps patients feel that they're actively participating in the informed consent process rather than just being uh directed and that surfaces values. Um, it lays out the full spectrum of possible scenarios and makes sure that they are clearly communicated. It uh necessitates the discussion of the worst case scenario which helps avoid unexpected or shocking outcomes and that ultimately helps reduce decisional regret and peace with whatever situation occurs. And then it having a grounded visual framework really uh gives the family um it it creates a standard platform to communicate upon uh between various teams between patients with various healthcare literacies and language disparities which overall I think reduces disparity as a whole. So in summary, uh pediatric tracheosttomy decisions are are a great use case for using a tool like this because in our world they're fairly common. the the not only the decision of when and how to do it is complicated, but also the consequences are complicated and poorly communicated and uh often, you know, have a disproportionate burden on the family. And uh best case, worst case scenario planning provides a structured evidence-based framework that enables providers to communicate the treatment pathways and likely outcomes in a way that helps surface the values and engages the family rather than just uh transferring information which I think is a trap that we often fall into. and and then it also fosters care team cohesion and uh opera operationalizes respect for autonomy while reducing um decisional regret. So going forward, we have started to uh implement this for all pediatric tracheiotomy discussions at Children's Minnesota um and are hoping over the next year to kind of um gather buy in and start gathering some survey data to see what the impressions of both patients and the providers utilizing it are. It's also being used um Dr. Dr. Reman does a lot of complex adult airway surgery as well and so he often times utilizes it in that setting. In my own experience as a resident, I often use a brief version of it uh talking about headneck cancer decision- making like lingial preservation for example um in larynx cancer. And um we hopefully we'll get this integrated into the resident education cuz uh similar to other places it sounds like we really don't get any um ethical framework teaching. Um and I and I personally after learning about this have found it extraordinarily useful. Um and found that patients really just fall into a sense of peace um even in a setting of a lot of hectic things going on. Um so you know we encourage other institutions to standardize the training and spread it across service line as well. Um, in the future, who knows, maybe something like augmented reality might augment it, but really the core tool is so simple as two lines on a piece of paper and just a willingness to bring the things out into the open. Um, I want to thank the MLAN Center for the opportunity, Dr. Redmond of course for his mentorship, my co-authors, Dr. Schwarzi for developing the the basis for this tool that we're using. And then I'll just leave you where I started with uh this image from Winnie the Pooh. Um and just, you know, just like this extraordinarily simple exchange between Piglet and Pooh uh helps Piglet become sure of Pooh, this extraordinarily simple tool can really help patients and families become sure of sure of us and sure of themselves as well. So, thank you. Yeah, >> there's a terrific conversation or in presentation hunts and I'll ask you one question that you had one slide which talked about ideally you the families would be aware of them like life at home if if it was a tracheiotomy that lived experience and in the slide you had of the two timelines. It was mostly focused upon like the clinical setting as opposed to them that post turkeys experience. And so how might that be incorporated? >> So just to reiterate your question, um you're asking about how the kind of the emphasis that I was placing on the long-term understanding the long-term outcomes can be incorporated in the tool. Is that correct? Yeah. So that that um graphic is essentially the starting point um and then upon that you can essentially use it as a scratch pad to discuss with the family. So you start with the the different initial decision points, the possible uh outcomes and then you can talk to the family about what those outcomes actually mean. And I think that the graphic doesn't necessarily need to include all of the details. In fact, that I think kind of gets us back into the weeds again. Um, but rather just serve as a point for for discussion. And I think also in this specific case, um, you know, the family already had a tracheiotomy and so they knew a lot of those implications. And so for this for this specific circumstance um the emphasis was really on trying to help them feel at peace with the fact that they needed to have a tracheosttomy again um by using that >> nade. Yeah. It made me think of the last panel where there was like one of the suggestions about like well the lived experience and so if you if there was the opportunity to you know whether it's video or whether it's like um a program where people could talk to parents who were in that situation um that made another possibility or your point about augmented reality you know very interesting but a fantastic presentation congratulations and Heather also two wonderful presentations