1. Just being:An Introduction to Mindfulness and Its Role in Tending to the Dying Suzana KE Makowski MD MMM Assistant Professor of Medicine Palliative Care in the Cancer Center of Excellence Director, Lois Green Learning Community University of Massachusetts (Worcester, MA) Ronald M Epstein MD Professor of Family Medicine, Psychiatry, Oncology and Nursing Director, Rochester Center to Improve Communication in Health Care University of Rochester Medical Center (New York, USA)

2. Disclosure Statement Dr. R. Epstein and Dr. S. Makowski have no relevant financial relationships

3. What is Mindfulness? A process of regulating attention to bring a quality of non-elaborative awareness to current experience, with an orientation of curiosity, experiential openness, and acceptance. (Bishop)

5. Empathy as emotional labor To cultivate an acute ability to empathize with others, once needs patience, curiosity, and willingness to subject one’s mind to the patient’s world… Larson, Yao JAMA 2006

6. Exquisite Empathy “Highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement” Kearney et al, JAMA 2009

7. Self-awareness

8. To hold contradictory truths simultaneously

9. Great Questions Clashing discords Longing Loss of eQuiLibRium

10. Learning to stay through discomfort So I think healing has to do with slowing down, coming into the present, listening, accepting, forgiving, entering into community with, and healing is prevented by the opposites of those things.” - Balfour Mount, MD

11. This being human is a guest house.Every morning a new arrival.A joy, a depression, a meanness,some momentary awareness comesas an unexpected visitorWelcome and entertain them all!Even if they are a crowd of sorrows, who violently sweep your houseempty of its furniture,still, treat each guest honorably.He may be clearing you out for some new delight.The dark thought, the shame, the malice,meet them at the door laughing,and invite them in.Be grateful for whoever comes,because each has been sentas a guide from beyond. Jelalludin Rumi (1207-1273) The Guest House

12. Unexpected Visitors in Medicine Ambiguity and uncertainty Conflict between patient and clinician needs Strong emotions: the patient’s and yours Blame Errors Unanticipated serious illness Impermanence of knowledge Intractable problems Lack of control

13. Real or imagined threats induce a similar stress response: Imagined scenarios involving threat or failure Comparison of actual situation with ideal Degradation of self or present situation Recall of disturbing events Self-criticism Rumination Emotional avoidance Pessimism, denial

14. Burnout Definition Depersonalization Emotional exhaustion Sense of low personal accomplishment Effects Affects work life, relatively spares personal life Numbing, distancing, not noticing, empathic failure Associated with errors, leaving practice, suicidal ideation High prevalence 25% - 60% of practicing physicians 76% of internal medicine residents 49.6% of students – 11.2% with suicidal ideation Shanafelt et al. 2003 and 2005; Dyrbye LN et al 2008

15. Mindlessness: denial, self-deception and delusion … “the tendency of the mind to seek premature closure .. That quality of the mind that imposes a definition on things and then mistakes the definition for the actual experience” Epstein M 1995

16. Looking but failing to see

17. Mindful practice Moment-to-moment purposeful attentiveness to one’s own mental processes during every day work with the goal of practicing with clarity and compassion Epstein RM 1999

19. Orienting = assigning relevance to certain information, ignoring other information

20. Executive = noticing and integration of unanticipated eventsGusnard DA et al 2001

21. A mindful moment – attending to the quality of attention

22. Mindfulness lessons from Brahms

23. Why should mindfulness matter to clinicians?

24. Quality of care (vigilance vs. mindless errors) Physician well-being (resilience vs. burnout) Quality of caring (presence vs. abandonment) Shanafelt, T. D., et al. (2002). Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med, 136, 358-367; Shanafelt, T. D., et al. (2005). Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med, 20, 559-564.

25. Physician well-being (resilience vs. burnout) Quality of care (vigilance vs. mindless errors) Mindful practice Quality of caring (presence vs. abandonment)

26. Mindful practitioners Attitudes/behaviors Motivation Clear perception Openness Attenuation of reactivity Mental stability “Slowing down when you should” Qualities Attentive observation Critical curiosity Beginner’s mind Presence

27. Promoting mindfulness Formal practice Informal practice Situational awareness Mindful health systems

28. Informal practice (mindful moments) Stop – breathe – be 20 breaths Doorknobs and mirrors Just listening

31. Asking reflective questionsQuestions that “open up” and “tend not toward edification” “What feelings are affecting my ability to observe?” “What am I assuming that might not be true?” “How are prior experiences and expectations affecting how I view the situation?” “Did I use ‘fuzzy logic’ or ‘cognitive alibis’ to justify my actions?” “What would a trusted peer say about the way I managed this situation?” “Am I really done, or am I engaging in premature closure?”

35. One of the things that comes out of this too, is that when you establish a practice of thinking more honestly, thinking more clearly, speaking more honestly, that definitely leaks out into your work everyday… it certainly opens you up to being more ready with patients, colleagues, family, to have those kinds of conversations and to have that kind of a more intimate, more honest interaction with people and that certainly was the case for me that came out in the rest of my work… It certainly made it much more immediate and easy to do in my practice. Participant

36. …and patients notice Inner-city HIV-infected patients Observational study Mindful Attention Awareness Scale correlated with: Patient-centered communication, positive emotional tone, psychosocial orientation Patient ratings of communication, satisfaction Beach et al, 2010

37. Interpersonal mindfulness

38. What did you learn… About listening and being heard? About being mindful in stressful/challenging situations? About how you practice?

39. Two Kinds of Intelligence There are two kinds of intelligence: One acquired, as a child in school memorizes facts and concepts from books and from what the teacher says, collecting information from the traditional sciences as well as from the new sciences. With such intelligence you rise in the world. You get ranked ahead or behind others in regard to your competence in retaining information. You stroll with this intelligence in and out of fields of knowledge, getting always more marks on your preserving tablets.

40. There is another kind of tablet, one already completed and preserved inside you. A spring overflowing its springbox. A freshness in the center of the chest. This other intelligence does not turn yellow or stagnate. It’s fluid, and it doesn’t move from outside to inside through the conduits of plumbing-learning. This second knowing is a fountainhead from within you, moving out. Rumi

41. Acknowledgments Collaborators: Mick Krasner MD Fred Marshall MD Scott McDonald MD Tim Quill MD Tony Suchman MD Howard Beckman MD Ben Chapman PhD Chris Mooney MA Melissa Wendland Nancy Adams Mary Jane Milano Consultants / muses: Michael Baime MD Rita Charon MD Ron Hoffman Jon Kabat-Zinn PhD Saki Santorelli MA Penny Williamson ScD Funders / supporters: Physicians Fdn for Health Systems Excellence NY Chapter, American College of Physicians Monroe County Medical Society Rochester Individual Practice Association Arthur Vining Davis Foundations Arnold P. Gold Foundation Mannix Fund for Medical Education

42. Just being: Mindful Practice and the Ethics of the Moment Ron Epstein MD Departments of Family Medicine, Psychiatry and Oncology Rochester Center to Improve Communication in Health Care University of Rochester, NY, USA ronald_epstein@urmc.rochester.edu

50. Participants 70 Primary care physicans 54% Male, 46% Female 49% Internists, 41% FP, 10% Peds 71% suburban , 25% urban 15.9 years in practice