Mark Briesacher: Hi, I'm Mark Briesacher, the chief physician executive at Intermountain Healthcare, and thanks for joining this podcast again, this series of conversations that we're having with the people in healthcare at Intermountain.

And I'm really, really feeling great and feel kind of very lucky to have Dr. Dominic Moore here with us today. And Dominic is the associate medical director for palliative care, home care and hospice. Palliative care and hospice is a really important thing to me personally, and maybe we'll talk about that a little bit later.

Dominic and I actually share a common interest in music. Some of our conversations, I can tell we both have grown up with music being an important part of our lives and, as is usually the case, you have a much more exciting musical life than I have, although I think, you know, for people, music is really personal and actually exciting and very unique in individual ways.

So first of all, thanks for being here.

Dominic Moore: Thank you. Thanks for having me. It's great to be here.

Mark Briesacher: You got to tell everyone about what you do in music.

Dominic Moore: So music, like you mentioned, is a very personal thing, and so over time, I listened to music and then started making my own music, and have my own music that's just under my name, Dominic Moore. And then I play with a band here locally called The Lower Lights. And right now, as we record this, we have a series of shows that are happening up at Kingsbury Hall right now.

But I think you described it well, that we kind of tried to reinvent and re-listen to some of those classic songs that maybe people have from their childhood or from their traditions, whether it's, you know, the American tradition or their faith tradition or anything else. And so that's what we do. But really, I think music for me is a great outlet and a great therapy.

Mark Briesacher: Like I said, it's very personal with people. It enriches lives in very meaningful ways. And it strikes me that there's a correlation with music and palliative care and hospice. And maybe for those who don't know, I'm actually quite curious about how you describe what palliative care is, and then how you describe what hospice care is. And so, tell us about that.

Dominic Moore: Yeah. I think that my most concise way to describe palliative care is that it's a field of medicine that specializes in finding out what's important to you and then making sure that that is taken care of and that that's supported. My slightly longer version of that is that palliative care is a field of medicine that attends to the physical, psychosocial and spiritual aspects of what it means to be sick and to have a serious illness.

Hospice is, if palliative care is an umbrella or a tree, it's one of the branches, and it's specifically a branch that's intended to take care of people who are nearing the final stages of their disease and the final stages of their life. Specifically, it's defined here in the United States, is the last six months of their life.

And while palliative care focuses on kind of this larger philosophy of taking care of people, hospice is also partially defined by the rules and structures that we take care of people under. So Medicare and Medicaid say that hospice is for people who have six months of life or less, and also explains what services should be involved in hospice.

And so, I'd say that they're both very much connected, but if palliative care is the overarching tree, hospice is one of its important branches.

Mark Briesacher: So I'm always curious, and it's fascinating, it's interesting to me to hear why a physician or a nurse or a pharmacist chose to specialize in a specific area. So Dominic, tell me a little bit about how you came to say, "I'm going to make a career in palliative care and hospice."

Dominic Moore: Yeah, I mean, I guess to make a music reference, it was a long and winding road. It was a process.

So I come from a wonderful and very supportive family that was very emphatic that you find the thing that you love and that you're good at and then you work really hard at that thing. Nobody else in my family had gone into medicine, and so navigating what exactly I wanted out of medicine was a process.

My family also has the misfortune of having a lot of cancer come through my family. And so early in life, I was confronted by the realities of having this serious illness and what that means for your life and your enjoyment of your life. I ended up having a few friends through elementary school and junior high school and high school who died unfortunately.

And so, from various different directions, I have felt pushed into the place that I am at right now. And it really wasn't until medical school and kind of the final portions of medical school that I realized that what I wanted and what I needed to do was to take care of people in the setting of serious illness and that that should be in the form of being a palliative care doctor.

Mark Briesacher: You know, I'm not surprised to hear about the life events that are part of this. And I'm sorry to hear that there has been so much of it in your life, and yet it is actually why this is such an important topic because there's life events of joy and life events of sorrow, and in healthcare, we have such a important role to play in all those events. And I think as just humans, you gravitate towards obviously the joyful things, and yet we also have a real responsibility to do our very best in all of them.

So can you share with us a little bit about palliative care here at Intermountain? So you know, we meet each other before a concert somewhere and I ask you what you do, what's the answer to that question?

Dominic Moore: Yeah, so meeting each other in that way, I think I would say my job is to help people live their best life possible in kind of its shortest terms. My job is to make sure that however long or however short someone has that they're living the life that they want to live.

And in some of my patients, that means taking care of kind of the physical aspects of care, their pain management, making sure that they have appropriate advanced care planning, that they've considered their various options that they have before them. For some folks, that means making sure that kind of those more personal points of meaning, whether it's spending time at a child's wedding or making sure that your treatments line up with being able to go on your 50th anniversary cruise, or whatever else, that those things are respected.

And if a person kind of wants to dig in more past that, I explain what a palliative care team looks like, and that's something that, under the process of becoming One Intermountain, I think palliative care has really benefited from and really grown.

So we came from this place where they were seeds that were kind of blooming where they were planted. And what that meant was that they were inpatient palliative care teams that were growing in this setting of our largest hospitals.

And as the influence and as the philosophy of creating One Intermountain has taken hold, what that means is that we are still thinking about those inpatient hospital settings, but we're really thinking about our whole catchment area as places that we need to be able to deliver and develop palliative care, and do that with not just doctors like me, but also do it with our APP providers, that we have a psychosocial support with our social workers, with our chaplains, that we have care management support, and that we develop those teams while making sure that we're partners with our health system, that we are reaching out and having a collaborative approach with those folks in our system who are most engaged with serious illness.

And over the last few months since I've started, the areas that we've really focused on are folks who are receiving care for cancer, advanced cardiac and pulmonary illness, and then advanced neurologic illness. And that's really been a rewarding process because you see how many good people there are, and it's really kind of overwhelming at how many people just want to do a good job and want to engage with these folks who are in such a vulnerable place.

Mark Briesacher: That really resonates with me. And you know, when I think about One Intermountain and our commitment to meet people where they're at and how they want that to look like, and that we're going to provide the absolute best care and the best experience of care in any place that you get care at Intermountain, I'm just really thankful that the team has come together under that idea and are moving things forward.

So I'm a pediatrician and that means that I've had so many joyful moments, and then some tough moments-

Dominic Moore: Yeah.

Mark Briesacher: Kids who get cancer and relapse, so then you begin to have those discussions about how do we live our best lives possible. And so, you know, for the pediatricians out there or the family docs, family medicine just is kind of the backbone of primary care in our state, for our internists and specialists, both physicians, advanced practice providers, the whole clinical team, right, if they think that maybe it's time to get some help with palliative care or with hospice, how do they do that?

Dominic Moore: So it depends on the setting. So if a patient is hospitalized in the hospital, reaching out directly to the palliative care team who is in that hospital in kind of the traditional way that a consult might be ordered. We have a central intake number for those who are not in a hospital setting, and so that can include a home-based palliative care, and where we have a fully functioning and developed clinic, it can include clinic care. And I can make sure that that number is as part of the notes of the podcast.

But we've tried to centralize that because, kind of to the same point about One Intermountain, we've had these amazing dedicated people who, before One Intermountain, I think were like reinventing the wheel in multiple places throughout our system, and really doing their best and doing really inspiring work, and I think our opportunity now is to bring that in and simplify it for our providers who've been working for so long.

And like you said, those folks who are in the front line, who are having that hard conversation about someone whose unborn child has been diagnosed with a potentially fatal anomaly, with that family medicine doctor who, you're right, is just absolutely the front line of providing great care in Intermountain West, and also to that specialist who feels like they know what's on the cutting edge, and even that technology or treatment that's on the cutting edge is not going to get the person where they want to be

Mark Briesacher: You mentioned earlier kind of the social aspects of this care and chaplaincy. And chaplaincy sometimes isn't well understood, and I have found it's not uncommon for physicians and advanced practice providers and all of our caregivers, they quickly equate chaplaincy with, you know, a religious faith. And yet, it's not that when it comes to healthcare. Can you tell us a little bit about that?

Dominic Moore: You bet. One of the comparisons that I make with chaplaincy and maybe a more traditional, in someone's mind, religious experience, is that often people engage with a religion or a faith tradition to receive information from that religion or that faith tradition.

Chaplains in healthcare can do some of that if they're asked to do it by the family, but really, the effort that's made by chaplains within our teams is not to necessarily teach someone a lesson or be understood by them, but to understand the person themselves, to understand that person who's in the patient role at that time and to know them more fully.

And I think when providers really lock into that truth that a chaplain's role is to be with and to hear from someone, and then help them from that place that they're at, I think that can feel a little bit more true and genuine to what we usually equate with a healthcare interaction.

And I guess kind of maybe to that point as well, I think our chaplains are great at uncoupling, when it's helpful to the patient, the idea of what it means to be a spiritual being, so to figure out what is the essence of who you are or how you see the world or what your philosophy is about what you do, and religion, which is the organization that engages with that philosophy and that comes with a set of rituals and ordinances that some people do feel very connected to spiritually, but may be very separate from other people's spiritual nature.

One of the largest growing groups in the United States right now is designated in a way that not everybody loves, and I think that's fair, but there's a group who think of themselves as spiritual but not religious. And sometimes in our chaplain's notes, you'll see SNR, spiritual, not religious.

And I think that our chaplains are also amazing at working with folks in that space and folks that have kind of no tie to a traditional religious philosophy or anything else.

I think of a family that we had who are scientists and who connected to kind of their life to their child's life through science. And they thought about the principle of the conservation of energy, right? So energy is neither created or destroyed. It just, it is. And part of them making sense of their child's death was that their child had died and their life was completed, but they were this amazing energy in their life, which could neither be destroyed nor created, right? And so that was how they coped with and made sense of what life was going to look like the day after their child died.

Mark Briesacher: This is what I love about these conversations is I always learn something and I, you know, I knew how music and this work and healthcare all came together, now you've thrown physics in there, and that's pretty cool as well.

You know, for me, I've experienced, as you have, hospice and chaplaincy, and I can tell you that when my mother-in-law was dying and the chaplain came to visit, I would say in that moment, it didn't really mean that much to me. As you describe what they do, that's exactly how they showed up, you know, to help and to listen, to serve.

And I can also tell you that as I reflected on the whole, just the whole thing, and it's been two years now, if I saw that chaplain today, I would warmly, warmly shake their hand. Because my wife and I talked about it afterwards and, yeah, in that moment, the contribution was small, but in the moments that followed and as we thought about Eleanor and her passing, that actually ended up being a much more important moment. And so we have warm, very warm thoughts and feelings, you know, when we talk about it.

So these actions, I guess the point I'm curious about to see if you agree with this, is that these actions by you and your team, the chaplains, they have a lasting effect over time.

Dominic Moore: They do. And I think that one of the things, and one of the most important things that we can do for people, and this includes everybody in healthcare, is to see a person as a person and not a patient. And so I think for that chaplain to go in and get to know Eleanor instead of getting to know the blank year old woman with blank, it is incredibly re-humanizing.

You know, we talk about things that dehumanize us in healthcare, there are ways for us to rehumanize this situation. And I think sitting down with someone and saying, "Tell me about you. Tell me about what makes you you and makes your life, this entire world and cosmos that I have no knowledge of."

And I think a lot of providers think about those situations and think about maybe a patient who brings up their spiritual identity in some way, and think, "Uh oh, this is hard," or a patient who becomes especially emotional during an interaction.

And I would say this about palliative care in general. When a person is in that position where they've opened themselves up in such a true and honest way, you are hard-pressed to find a better opportunity to support a person than when they are feeling that way. And you are also hard-pressed to find a situation where a person feels less vulnerable to you. Because whether it's expressing our spirituality or our emotion or whatever else, it's kind of the piece of us that's the easiest to make fun of, right?

Mark Briesacher: Yeah.

Dominic Moore: And it's also the piece of us that we kind of let slip sometimes and then think, "Oh, what'd I just do?" And so for someone to lean into that interaction and say, "You're fascinating and you have value in what you said just has value, will you please tell me more about this?" And I think that phrase, "Will you tell me more," is one of the most important phrases in palliative care because it turns over the keys to the car, to the patient and says, "Hey, your insight is so valuable that I'm just going to give it over to you."

And I find that really with very few exceptions, patients take that as kind of a sacred interaction. And a lot of providers worry, "How am I going to still see a clinic filled with kids or filled with anybody else and give people this space?" But I find that often, they take that space, they realize how important it is, and they're actually pretty brief. And so those are just some really great moments that reconnect you with what's really happening with a person.

To your point about, do I feel that our teams are making an impact in that way? Absolutely. And I also think that we are in a place where we have walked that path with folks, and so we're kind of, in a little ways, like a Sherpa, and to say, "Oh, you're coming up to a pretty jagged corner, and I'm going to remind you of this again, but I want you to be careful, and I want you to be tender with yourself as we go through this."

I was just before I came here talking to a family who is considering a withdrawal of a ventilator, and one of their questions was how they were going to wake up the next day and go on in their life knowing that that had happened. And that's an experience that I haven't had personally, right? I haven't had to make that decision, but I have walked with families through those decisions and was able to share the wisdom that I've gathered through those folks.

There is a beautiful thing that a father said that I think encapsulates a lot of the philosophy of palliative care. So we were working through some end of life care decisions for this father's child, and he said, "You know, I planned so much for how my child entered this life. I feel just as much responsibility to plan and care for my child as they leave this life."

And you know, I could not say that in a better or more concise way. I really believe that every day and every moment of our life is a sacred gift. And part of what keeps me coming back to palliative care, even after there are some hard cases, is that seeing the way that people choose to use that gift and live that gift is amazing.

And to see, so for all of the sadness and all of the tears that we share with families, to see somebody have days or weeks left and watch them choose with dignity the way that they're cared for and the way that they interact with their family, and even their expressions of love and forgiveness, that is incredible. And I can't imagine being more lucky than I am right now to have those opportunities with families.

Mark Briesacher: So the Center to Advance Palliative Care ranks Utah as number seven in the nation in palliative care, they use the word saturation-

Dominic Moore: Yeah.

Mark Briesacher: In hospitals. And obviously, you and the team's work has such a big part of that. And so I'm wondering, how can all of us out in primary care and in specialty care, what can we do to help you get Utah to be number one? Not that I'm competitive-

Dominic Moore: Yeah.

Mark Briesacher: But, you know, been being top 10 is great and being number one is really great.

Dominic Moore: Yeah. I agree.

Mark Briesacher: Because it's great for our patients, right?

Dominic Moore: I agree.

Mark Briesacher: It's great for those that we have the honor of serving.

Dominic Moore: 28:30 So that's a great question. And I am also a little bit competitive, so I will say we are number one west of the Mississippi-

Mark Briesacher: Okay, I'll take that.

Dominic Moore: So we're number one in the western states, and I think a lot of that work has come from Intermountain as a system being committed to palliative care. Palliative care is one of those sub-specialties that doesn't really impact the value equation in the traditional way of healthcare. We impact the quality of care and we decrease the cost of care, but where we're moving from like a fee for service kind of model, which I think grossly underestimates the value of palliative care.

Mark Briesacher: I agree.

Dominic Moore: I think Intermountain has moved, not only with palliative care, but with primary care and other places, into thinking more wholly about what it means for value.

And so for us, I think that one of the ways we can partner more efficiently and effectively with our primary care providers in the system is through, is through, as simple as it sounds, referrals. So whether it's the American Heart Association or the major bodies of cancer care administration, bodies governing neurology, all of these groups have advocated for palliative care from the time of diagnosis of a potentially life-limiting or life-altering illness.

We're certainly not there in our country or in our system, and so I think that might be a place to help folks to connect patients more efficiently with us. And one of the things that I do want to make clear is that palliative care is a consultation service that comes in and should make it easier to take care of your patients across the continuum. And for some of our patients, that means that we take care of them while they're undergoing treatment for a serious illness, and some of them are cured or some of them receive a heart transplant.

I can think of, you know, several of our families that I've taken care of [inaudible 00:31:09] who we gave great palliative care while families were waiting on a heart and going through that process, and we cheered them on the day that they received their heart. And we've continued to kind of be a lifeline to them and their PCPs, but we really have stepped back quite a bit from their care now that they've received their transplant.

I think about patients who have gone through cancer treatment throughout the system and who may have had hard odds that they were up against and received good palliative care to make sure that they could sustain and put up with treatments, and those treatments were amazing and successful because we have amazing doctors in our system and APPs and providers throughout.

And so I think one ask that I would have in addition to just thinking of us is to maybe have a consideration or a frame shift in your mind about palliative care, not as the final hope or the final thing on your checkbox once you've done everything else, but to think of us as a partner to make sure that as your patients going through their treatment for CHF or COPD or advanced dementia, that we're there with you as you need us, and also there with you from the beginning.

You know, to use another musical comparison, I think sometimes as you're recording music about a crossfade, so you bring up one instrument or one piece as another fades out, and sometimes that crossfade is for one to fade out completely and one to take over, and sometimes that crossfade is to blend and to mix that music. And I see palliative care as more a crossfade that might come in kind of in very small ways early on, and then as a disease progresses, that's a conversation with the primary provider who can say, "Boy, I'd sure like a little bit more of you in the symptom management side of things."

Mark Briesacher: We started with a long and winding road and The Beatles, when you were describing the crossfade, I was thinking of Adagio for Strings in the way the violins and the viola come-

Dominic Moore: Yeah.

Mark Briesacher: And each has a moment where their voice is the strongest. And I want to thank you for what you do here at Intermountain, for our patients and our families. I knew I was going to have a great conversation with an amazing palliative care physician and musician, but then to also find out that you're a physicist and a philosopher as well, that's a good thing. So thank you so much, Dominic.

Dominic Moore: Thank you. What a great conversation. It was great to sit down with you. Thanks.