Category Archives: Resources

The Mess of Doing Nothing

“I’ve noticed that it’s become easy to do nothing lately.”

These words took effect this afternoon while Cindy and I were driving back from the pizza shop with our Saturday “cheat.”

For months, possibly even years, it has been an awareness I only paid half attention too. As far back as maybe a decade ago, I had become aware that occasionally I would relish the idea of actually “doing nothing” as if that alone were an accomplishment. I would contemplate the options of “maybe tomorrow I will do absolutely nothing?”

Tomorrows come and todays go and before too long what started out as an unavoidable down time, crisis only option (due to illness or injury) shifted to willful decision. I would stay home, watch a movie, play a video game, or scroll randomly through vintage footage of concerts, history documentaries, or scientific extrapolations on what, why, when, how, where, and who. To some, this is “doing something.” In regard to an end result or specific goal of actually accomplishing something – the highest score or fleeting knowledge of trivia – my “doing nothing” produces the same.

Let me define my understanding of “doing nothing.” To me, doing nothing means that in place of doing something that can, should, or needs to be done, one simply does anything but.

To the bold-faced seeker of meaning, the reality of doing the things described above, may in fact be “somethings” each and every one. Granted, doing nothing itself is actually doing something right?

Do not discount the benefit of mindless distraction or enjoyable relaxation. One recipe of good heath is rest, exercise, and eating healthy. Volumes of data, debate, and proclamation stand ready to service your needs in these areas. But here is the problem with all this.

Doing nothing in the sense of leaving unattended a wider and larger portion of life’s responsibilities soon becomes more than just chill time. It leads to crisis.

Objects degrade, function declines, or conditions adapt to unsustainable proportions of endurance and stamina to perform basic tasks of life. Now things have become a mess. Just recently I used that phrase to describe the discovery of how to do something new with ease, “That was as easy as making a mess.” It stands to reason that the 2^nd easiest thing to do, besides nothing, is make a mess.

When weighing the outcomes of a given situation using the choice of doing nothing, compared to doing something with effort, hard work and attention, well, it is pretty obvious where the more positive resolution will exist. What healthy adult does not want a positive solution? Just look at the world today; look at the potential all around you for positive outcomes. Generalized in the world I bet there are millions of people going to bed every night hoping for just such a change. Yet how many are doing nothing?

I once went to see a speaker with very well established charitable efforts already existing in the treatment of the sick and poor. He had founded a free hospital and named it Gesundheit. His question to the group of attendees was “What are you doing?” There is always something that can be done to help others.

During one of my afternoon web scrolling marathons, I came upon an interview with Suzanne O’Brien RN who had started a group of End of Life Doulas. She was discussing the growing interest for more personalized control over the outcome of how we are coping and preparing for mortality. She teaches hope of peaceful surroundings and thoughtful arrangements for the often overlooked tasks of caring for a dependent loved one while their journey ends here with us. In addition to the professional guidance of a hospice, palliative medicine team, specialist, or family practitioner, trained Doulas educate, demonstrate and advocate for the care of patients, family and caregivers. Special lighting, music, and chosen items arranged in almost sacred tenderness, aid possible relief of symptoms that may occur. Suzanne’s doulagivers.com™ have become a worldwide network of loving hearts, “doing something.”

The basics of care for your loved one, friend, or client are detailed and offered for free. After reviewing the material Doulagivers™ provide, I eagerly joined and have become certified as a Level 3 Doula. Originally I had found this group by a desire to advance my own skills as an RN with end of life symptom management.

Now I wish to share this knowledge in hopes of helping those who do not wish to allow the “mess” that “doing nothing” can create.

In addition to our Elephant in the Room conversation guide elephant-inthe-room.org caringchoices.org Caring Choices offers experience and compassion within the complexities of dealing with death. Don’t let “nothing” stand in your way. Hope for the best, prepare for the worst. Just think about it. Knowing you’re safe and accepted for your wishes can lessen anxiety and stress. Knowing everyone around you is prepared brings peace of mind and comfort. Appreciation of the love makes the loss more palpable and even visceral, but is life at its fullest when facing the unknown absence of it? We comfort each other our whole lives.

The Grass is always Greener

The Grass is always Greener….

This phrase is one of many old adages expressing how the reality of something is really quite different than what you may have initially expected. A list of examples is unnecessary in this case as I am sure most everyone can come up with quite a few on their own.

The point, however, is expressly different.

Imagine what you think your death will be like. Will it be at home? Will you be surrounded by loving family, friends and cherished memories of your long and prosperous life? Will you be at peace with yourself? Will you be warm and comfortable in a soft cozy bed? Will there be the sweet fragrant aroma of incense permeating the air and tranquil melodies floating between hushed whispers of thanks and gratitude? Will you feel a growing excitement at joining the billions of other souls who have made this unique journey to a better place?

What wonderful ideas, right?

The reality of death is not quite so pretty for many people. Far from the above descriptions of how things could be are the actual ways many people face their last moments on earth.

My life experience including 10 plus years working Hospice (23 total years in nursing) have led me to this place today. A place where I am trying to help everyone understand that the above desires for end-of-life experiences are only possible with conscientious effort, planning and above all else CONVERSATIONS with others.

Too many people suffer needlessly at the hands of a system designed to keep people alive “no matter what.” Mechanical interventions replace natural processes. Legal checklists become substitutes for conversations and making real choices. Heathcare algorithm “clickfests” take the place of tender touch and genuine human interaction. These “interventions” are manipulating dying and death into becoming situations of cold, sterile, expensive states of suspended animation in order to wring every last breath out of a body long overdue for its final “resting place.”

Does this sound too harsh? Maybe an acronym to lessen the intensity of suffering? What could we call a system focused on longevity and not quality of life? What could be appropriate in our acronym-infested healthcare system? I know! Let’s call it,

S-ervices, A-gainst, D-eath … and what it really is: SAD!

Do not misinterpret my compassion for minimizing suffering as a fatalistic wish to end all happiness by “killing” everyone before their time. Such an assumption could possibly give strength to what pushes death even further into the abyss of denial.

There are wonders of technology and dedicated people everywhere that can save lives. The resources are almost limitless in both material effort and will when saving lives. When there is an opportunity, we almost all rush to the aide of anyone in distress.

But isn’t dying simply just life at its most amplified state? Isn’t everyone’s emotional, mental, physical, and spiritual culmination of lifetime energy at its most powerful when people are dying? Why is it that the one moment in life – that we get no other chance at repeating – is stripped of resources when they are most needed?

What I support is a preservation of that kindness and love we seek. While still capable and healthy, there is still time to offer a greater acceptance of dying and recognize it as the catalyst from which all appreciation of life began. When we can accept our limited existence, it intensifies each moment and delivers the “spirit” of living as no other act can. We can then set aside our fears and embrace the loss of a loved one with a renewed understanding of how important this end time is.

We have tossed death into the cold, damp corner of our minds where we hope we will never need to go again. We label our relief at not having been struck by lightning as good luck or the Grace of God, and some say we have “survivor’s guilt.” We feel even more relief to be alive.

Hourglass of Life and Death

We can learn to die better in this world. There are exceptions, for sure: trauma, sudden onset of disease, and the hateful violence of some people. But for the majority of human existence, there is a natural compassion and concern to help one another. Consider the shape of our life to look more like an hour glass instead of a funnel. Instead of narrowing options and resources as we circle nearer the tapered end there is an acceptance and an expansion of personal options once we pass through that point where quality of life reigns over quantity of days. We are embraced and comforted approaching the natural end of our life. Please have meaningful conversations with your family friends and loved ones about how you would want to die. Do not look across the fence of death and think that the grass will be any greener, less complicated or less problematic than the reality you live in here.

Priceless Care

Medicare recently announced that it would implement paying physicians for taking the time to have advance care planning conversations with their patients beginning in January 2016. This could have happened in 2009 but certain politicos and pundits warped the intention of this into “death panels” which knocked these important conversations off the table. Now that Medicare will reimburse physicians to have these conversations, I can’t help but wonder about the metrics and outcomes measurements that will also be implemented to track the occurrences of these conversations, as well as their efficacy.

It seems like a step in the right direction to reimburse physicians for the time they spend in these conversations with their patients. These conversations can provide important information for doctors, nurses, social workers, etc. about what their patients want as far as treatment, pain and symptom management, and end of life care. However, the majority of “care” that patients receive may not be provided by their doctor (oncologist, cardiologist, primary care doctor) or the nurses, social workers and psychologists who work inside the healthcare facility.

Medicare’s decision to reimburse physicians for their time may encourage more physicians to take the time to talk with their patients in more depth than time has so far allowed. Physicians and other healthcare providers certainly have a role in discussing risk vs. benefit of treatments, rates of survival, efficacy of drugs, places to receive care, etc. This reimbursement will probably not entice physicians already reluctant to talk about “care vs. cure”. It will not instill the comfort and confidence needed to have these kinds of conversations with patients in some physicians who have not found that comfort and confidence already in their approach.

A conversation in a healthcare setting is only a beginning of much needed consistent and continuing conversations to help a patient and his/her family through chronic illness management and decisions. Physician-led conversations will likely not be as frequent (or appropriate) in the midst of a medical crisis, accident or trauma. Conversations must occur long before these situations happen. There must be more to these conversations than medical considerations.

I continue to believe that the most important aspect of care conversations is the information shared among family and friends who will be the in-home caregivers providing the majority of care. Family and friends who will serve in the role of surrogate decision-maker when the patient is no longer able to make decisions or needs known will reap the benefit of these conversations. There are rare instances where financial reimbursement is available for the time family and friends will spend in caring for a loved one. But when care choices are discussed and prepared for, those experiences can be priceless.

Caring Choices knows that asking questions about values and beliefs can start deep, loving conversations. We created Elephant in the Room™ to help individuals and families begin these important conversations. Start with these three questions from Elephant in the Room™ and see where your conversations lead:

What gives your life purpose or meaning?
Where do you want to be cared for at the end of your life?
If you were suddenly unable to communicate, would your family know what kinds of care you want (or don’t want)?

Not Always about Dying and Death

I recently had the opportunity to provide a Caring Choices presentation titled “Decision-Making for a Loved One.” The people in attendance were strong advocates for elder loved ones in fluctuating phases of aging and health. Some are dealing with varying stages of dementia; others are in end stages of chronic illnesses. Still others have recently experienced acute illnesses that thrust their family members into decision-making roles sooner than they anticipated.

Since becoming a Certified Dementia Practitioner, I’ve also presented a staff in-service and community seminars on the complex, multi-faceted umbrella of neurocognitive disorders (dementias) that afflict many individuals and their loved ones.

I’ve come to really enjoy teaching these sessions and offering educational opportunities to people who are trying to understand the disease process a loved one is going through as well as coming to grips with their role as caregiver or decision-maker.

Caring Choices offers education and support to individuals and their families in order to prepare for whatever their future health concerns might be. We’re not solely focused on the “end stage” of diseases, dying process, or the death bed experience.

Our goal is to help people have conversations about what’s important to them in every stage of their lives as age advances and health declines. Below is one of the slides I presented which seemed to best illustrate the purpose of the conversations we’re promoting. These are some of the decision-making criteria that are important to me. As we reviewed this slide, I could see the “lightbulb moment” for some of my presentation attendees. They started thinking about their own criteria to help their families make decisions if they’re unable due to an acute crisis or other medical emergency. It’s not always about dying and death … sometimes it’s just about what matters most at a particular moment.

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Caring Choices is available to provide education to your group as well as personal consulting to individuals/families. Conversations are important in determining your decision-making criteria. The presentations we offer can help you figure that out and help your loved ones have the knowledge and courage to make decisions when they most need it.

When “Shoot First, Ask Questions Later” isn’t Effective

The answer seems kind of obvious, right? If you shoot first and it’s fatal, you won’t be able ask questions later. The idiom itself is extremely reactionary. My interpretation is that someone who shoots first and asks questions later is likely reacting to an intense fear of a perceived imposing, immediate threat. Certainly there may be circumstances in life when shooting first is the best option and I’ll let you, the reader, determine what they may be for yourself. Where I strongly believe “shooting first” is NOT the best option – actually, for me, it is never an option – is in making healthcare decisions.

While reading my digital New York Times this morning, I came across an article on dialysis later in life. Embedded in that article is a link to a comprehensive online resource which provides lists of five (or more) things that physicians and patients can use to spark conversation, to help inform of risks and benefits, and to make “right” decisions based on individual circumstances. The resource was created by the American Board of Internal Medicine Foundation (and their partners) and they aptly titled their initiative Choosing Wisely®. From the Choosing Wisely® website:

Choosing Wisely^® aims to promote conversations between providers and patients by helping patients choose care that is:

• Supported by evidence

• Not duplicative of other tests or procedures already received

• Free from harm

• Truly necessary

The advance care planning geek in me is ecstatic to have found this resource! I plan to download the entire collection of PDFs for use with Caring Choices clients. I encourage you to share this site with people you love and your healthcare team for better informed, shared decision making.

We need to be asking questions before “shooting” into tests, treatments and procedures. Asking questions first doesn’t mean that we won’t go ahead with a test, treatment, or procedure. But it does mean that we are making informed decisions based on valid information, examining our situation and our wishes; not simply proceeding because the test/treatment/procedure is available. Some basic questions to ask might be:

Is it necessary?
How will it help me?
How will it hurt me?
How will it impact my quality of life?
How much time do I have to make a decision?
What evidence does research provide about it?

Shooting first and asking questions later is a gut reaction. In healthcare options and decisions, we need to be consulting more than our gut. As individuals, we are the only one going through the physical act of a test, treatment or procedure. However, we are encumbering those we love with the emotional and psychological outcomes of the test, treatment and procedure. These outcomes may involve complex and complicated caregiving, especially in later years. It will be important to know the how-what-why-when-where of caregiving needs when making decisions. Get informed about tests, treatments and procedures. Then, choose wisely.

Caring Choices understands that time can be of the essence when needing to make healthcare decisions. We know that there are times when following our gut makes sense. We also know that sharing conversations about healthcare options and decisions provides a sense of security even if we don’t all agree on the course of action. Making your decisions known to your loved ones and healthcare team will prevent them from the reactionary shooting first and hoping to be able to ask questions later.

Paralysis of Analysis

Wikipedia: Analysis paralysis or paralysis of analysis is an anti-pattern, the state of over-analyzing (or over-thinking) a situation so that a decision or action is never taken, in effect paralyzing the outcome. A decision can be treated as over-complicated, with too many detailed options, so that a choice is never made, rather than try something and change if a major problem arises. A person might be seeking the optimal or “perfect” solution upfront, and fear making any decision which could lead to erroneous results, when on the way to a better solution.

This phrase seemed comical when I heard the studio engineer use it in reference to the final mix-down phase of my recently completed CD. I had never heard this before, at least not to a degree where it actually resonated in my mind at all. But here, in the final stages of my CD production, the meaning sunk home with the impact of a slap to the face. I have always been hyper critical of my performances, and had never felt satisfied with any of my previous attempts.

And so the process of mixing my songs into a state of digestible consumption continued in the most basic format. I made the choice to substitute the paralysis of analysis with trust and intuition in the combination of the expertise of the studio engineer, thousands of edits, and a few “happy mistakes”. Now my CD project is complete! As I sat pondering a topic for today’s blog, I was suddenly aware of how characteristically similar this concept carries into just about any subject. In this case, conversations about health care, advanced care planning, and end of life discussions.

Anyone reasonably concerned with preparing for the future would begin with an assessment of the currently available resources and forecasting of probable future needs. Following up with a plan and then evaluation of the implementation of our wishes is where the paralysis is most likely to occur. We will not know what the outcome will be. We will not know until it happens what we will likely need. There are a growing number of studies now that support the importance of advanced care planning but there are no survivors who can testify as to the quality of life they received during their last moments. Only the surviving family, friends, and caregivers remain with whatever bias they may or may not be reporting from. History is written by the victorious. But in this case of preparation for death, no one gets out alive. The finite nature of this fact alone can cause people to go numb and be unable to make choices or act. The national median hospice length of stay is frighteningly low at 18.5 days (NHPCO). I have admitted many people to hospice in my 10 years of service who do not live even a week, thereby missing the majority of support available emotionally, physically and spiritually.

Caring Choices offers the motivation to avoid the gridlock of indecision and the stagnation of inertia before it can stall the benefits of having expressed your feelings, emotional fears, and concerns while you are able. Often just a few minutes of listening can make a huge difference for someone who is struggling with the fear of death, advancing disease, or general decline of aging.

Handling the Elephant in the Room

You’ve probably heard the idiom “elephant in the room” at least once in your lifetime. People use that phrase to describe something that is (1) an obvious problem which remains unaddressed or (2) a topic that no one wants to discuss. We believe that the specter of DEATH is certainly at the top of those lists even though we will all face death many times in our lifetimes. Jim and I have experienced the deaths of our grandparents, parents, friends, aunts, uncles, cousins, a sister, a niece, and hundreds of hospice patients and/or nursing home residents. We have drawn on our combined experiences with our family members and people we’ve aided through hospice to create something we believe wholeheartedly can be very helpful to everyone who will experience changes in health and independence (which is every one of us!).

We call it Elephant in the Rööm™ and we’re offering it now on our new website at http://elephant-inthe-room.org. We are certain our Elephant in the Rööm™ will aid individuals, families and groups in thinking about and discussing healthcare needs in a variety of physical and emotional states. The purpose of Elephant in the Rööm™ is to help people begin meaningful conversations about the kinds of care they want (or are willing/able to provide) when health conditions change. We know talking about future health problems and eventual death can be scary. With Elephant in the Rööm™, we believe you CAN talk about it without fear or trepidation.

Handle the elephant in your room with our Elephant in the Rööm™ and make plans with your loved ones while you can talk about these things. It can never be too early to talk about health and aging issues, but it can become too late.
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Where are the answers?

“Elephant in the Room ™” is a new discussion and decision tool my wife created and I have helped bring to existence. It involves a series of 96 cards in 4 categories:

Values and Beliefs: to entice thought on one’s belief systems of life without restrictions.
Complex Care: using multiple real and potential “what if” situations which could possibly impact the care and needs of a dependent, critically advanced, complex disease or care circumstances.
Definitions and Resources: to assist in the exploration of who-what-where-when-how-why of caregiving and preparation for future needs as time, trauma or disease dictates.

4: People and Places: to stimulate an examination of the resources, discover and help establish a plan for the utilization of resources for current and/or future needs.

Each of the 24 cards are formed in the shape of an Elephant Footprint in representative of the “steps” that are often necessary to achieve the most positive outcome for easing the stress of sudden or chronic life changes we all will eventually face someday.

During a recent conversation about “The Elephant in the Room^TM” I was asked the question: “Where are the answers?” Every time I have an opportunity to discuss end of life issues, advanced care planning or general care for the declining independence of someone, I am always eager to share our Elephant and offer it as an additional motivator to encourage continued discussion and thought.

The variety of reaction from people after they see the Elephant is as individual as each personality could be. The most important impression I try to make on everyone is that there are no answers that will apply to everyone in every situation. What is best for me may not be best for you. What is desired by me may not be acceptable to someone else. What is needed for each of us may be impossible to determine ahead of time. But what is most important of all is that there are discussions along these lines to help families and caregivers understand where to begin in coming up with answers.

Life is too short to ignore the inevitable consequences of living. And to spend all day focused on death is certainly no aim I have intended. After 20 plus years in healthcare, in a host of different environments, I can only say that the softest path for an exit from this earth is not always the easiest. I once read something that said we have replaced the need for comfort above the need for happiness. In relation to pain, planning, and lifestyle, I can see the truth in that statement. There is certainly a time for pain medication to ease suffering, but not at the expense of a little exercise to eliminate potentially avoidable, severe pain if possible. And not with a complete disregard for the benefits of behavior modification or non-narcotic alternatives. Not all plans are perfect; ongoing discussion and change is needed to adjust plans as options become available and progress brings about more choices. I understand the right of everyone to make their own lifestyle choices, but there are very few of us who are incapable of learning new ways to live if we are facing serious consequences from the “normal” routine of our habits.

Caring Choices has developed “Elephant in the Room™” to be a guide for the inspiration of thought. Not to give answers. We are hopeful that the tool we have created will bring a sense of relief and comfort to a discussion that is all too often filled with fear and despair. Please join us in the hope we share that review of the Elephant can bring family, friends, and caregivers a little closer to understanding what is important to all of us when there becomes a need to finally acknowledge that there really is an “Elephant in the Room™.”

Where theres smoke…

Re-watching Escape Fire has triggered the cascade of emotional reaction it initially did in me, with the resolve to apply it even more into my life. Considering that my total time in and around the healthcare system is approaching 30 years, one might suspect a certain degree of comprehension and expertise to follow. What I have painfully come to realize is there is so much more to the old adage “Practice what you preach” than most are willing to admit. This, of course, includes me. When you have an opportunity, and if you have ever found yourself asking one or both of two questions (Why are things this way? Is there a better way to do things?), please take 90 minutes and watch this documentary.

Without going into a litany of statistics, I will focus on a just a few of my favorite statements throughout the program. The first and most important to me is a comment from Senator Ron Wyden on the overall nature of change in human behavior. He said in part, “People, so to speak, have a constitutional right to be foolish … we have to respect that.” Steve Burd, CEO of Safeway, said, “70% of health care costs are driven by people’s behaviors.” A statement in the opening comment by Dr. Don Berwick, former head of Medicare and Medicaid from 2010-2011, “They can’t give up their old habits,” speaks to me personally. The light came on even brighter than the first time I viewed the show. Finally, I’ll end my review with words from Dr. Andrew Weil: “We don’t have a healthcare system in the country; we have a disease management system.” Adding some numerical facts like “$300 Billion per year on drugs” and “30% of healthcare spending (roughly $750 Billion annually) is wasted and does not improve health (Institute of Medicine 2011), makes me wonder how end-of-life care planning fits into the plan for improved disease prevention. For me, end-of-life planning could be another “escape fire” added to the disease prevention that the show recommends and from which it highlights successes.

We have an expectation that we all are individually “accountable” for ourselves in this country. But, it seems to me that there are many people who would rather shift responsibility for their end-of-life management onto unsuspecting family, friends, doctors, and/or other institutions. In other words, prevention of disease is not the only concern having an impact on the available medical resources currently being taxed beyond limits. Having no plan or an outdated plan for your care can also burden the system which has proven to be stretched beyond its limits today.

Simple choices can be powerful. And the most basic of all choices are how you want to feel. No one wants to be in pain, stressed, or exhausted. With that in mind, what were to happen to you, your family, or your support system of medical, financial, emotional, and spiritual designees in the face of dramatic change?

Caring Choices has seen the smoke, and can recognize that a fire could start at any moment for any one of us. Prevent the catastrophic consequence of doubt from falling on the unprepared. Make the most of the proven impact of changed behavior to strengthen your health as well as the relationships with your family and friends. You CAN talk about this. Let’s talk.

Elephant in the Room

Caring Choices was conceived as an avenue for exploration of unknown paths. Emotional passages in the minds of those who are either forced, or choose, to face the decisions surrounding the logistics of dying. To say this is an unpopular topic is to minimize the reactions we have had to date. To say that this is a fact everyone must face eventually is a fact as unavoidable as death itself. And on and on then go the Blogs and dialog, questions and scenarios in hopes of preparing for this end. Not as if to assume the answers are easily found. In fact, the answers are often never known. More important than the correct answer are the psychological benefits of the discussion itself.

And naturally after most conceptions, comes birth. The birth for us has come in the form of an idea. An idea that unknown to me was developing slowly year after year in my wife’s mind. While listening to me repeat over and over the same phrase to describe the often devastating impact of my discussions (with patients and families during my Home Care, Hospice and Transitional Care admissions), a seed was planted. “Elephant in the Room” was that phrase. To me, it represented the unspoken understanding that life-altering changes were rapidly at hand, and repeatedly never addressed. Most always, these changes had been a long time coming, and too often the consequences remained unknown. Certain formal planning had been made of course, including my presence which indicated discharge planning or outpatient referrals that acknowledged needs at hand. But often the long-range outcomes and personal emotional impacts were just never talked about.

Enter the birth of “The Elephant”. Elephant in the Room™ is our combined effort to help fill the voids and gaps in communication among family members and loved ones who struggle with discussing and planning for these inevitable changes. Four specialized categories of 96 questions/scenarios represent our collaborative experience as hospice nurse, medical social worker, family caregiver, friend and sibling in a series of questions we encountered at some point in our lives and careers. The answers to these questions are up to each individual as they explore their own unique set of circumstances. Currently in the production stage (and Patent/Trademark Pending) we offer this concept as a guide for use in almost every situation calling for the thoughtful consideration of how life’s changes will affect us.

Caring Choices offers Elephant in the Room™ as an opportunity to engage family and friends in meaningful exploration of the emotional and logistical preparations that life changes will require of all of us. Time and again the situations around us change, and sometimes suddenly without expectation. Please contact us for more information on how to bring attention to and thoughtful discussion about the Elephant in your room.