I'm delighted to host Dr. Jamal Dagash here in the botanical ecological garden on Mount Carmel. Dr. Dagash is a specialist in palliative medicine and integrative medicine practitioner, director of Home Hospice Service. So thank you for coming. Thank you for inviting me, having me here. I'm also delighted to be in this gorgeous place. I would like to ask you about your your ideas, your perception regarding the concept of palliative care. What is palliative care and how it is different from classical oncological approach? So palliative care and palliative approach, it's not so young approach in the medical field here, I mean, in the world and in Israel, but it's still a new, still different from the traditional, the conventional way of dealing with people. So this approach is aiming to lessen and alleviate the people's suffering, patients' suffering and his family while they are facing incurable disease. When we talk about suffering, it means all the kind, the aspects of the human being that comes from a physical suffering, psychosocial suffering, and spiritual suffering. So we say that a palliative approach is the kind of medical practice that have this intention to listen and at the same time not to prolong people's life just to give them a quality of life. If we can compare it to the conventional medical practice, the intention is more about quality of life in comparison or regard the traditional approach to make every effort to prolong and to save people's life. So what differentiates between supportive cancer care and palliative cancer care? Even listening to the supportive, it's part from the palliative care at the same time sometimes we support people to life and at the same time trying to make their living as much bearable or accepted and to keep a kind of quality of life, but supportive medicine it's still having this intention to keep and to prolong people's life, to save people's life. It's a little bit different from palliative care where no intention to prolong and at the same time there is no intention to shorten people's lives. So it's kind of a little bit different aspect of the medical approach that we see it from curative until palliative. We're working here in this area with the patients that come from all sorts of communities from Arab-speaking communities and Hebrew-speaking patients, and I would like to ask you specifically regarding the barriers to palliative care provision in patients that come from Arab communities although I'm aware that we are talking about a wide range of cultural backgrounds with the Muslims and Christians and rules and so on. But still, what are the main barriers to provision of palliative care in these communities? So the main barrier that I see, it's still that medical teams who are working with Arab population are still educated and grown up as a Western doctors. They don't speak the traditional like the Arabic original medicine that we know from the past history. It's still there are kind of education that don't see the specific needs and the way the Arab population in this area using a lot of herbs. Their food, their way of living, it's still dealing with them from a Western perspective. At the same time I think the Western and the traditional medicine is using such a language that it's still far away from the people's life, I mean word of talking and accepting what does it mean holistic aspect of the Arab patient in this area? So I see the communication, the language, and having approach to his world, it's still far from that, and using all the skills that is based in conventional medicine, it's not so close to the Arab Middle, I would say the Middle Arabic patient that comes to the clinic. So it's one of them, and I think it's not the main stream of the medical practices that we use and we have enough knowledge about the herbs that we are using them in the context of integrative medicine if we can say, in the complementary medicine. This is what I see as mainly as the barrier. It seems to be that sometimes people use herbs in the context of improvement of quality of life, but we find that patients that are looking for something like a magic bullet. We've noticed with the use of specific herbs that people just they're looking for something that will heal them instantly. Why people are looking? I mean what's the motivation of people that come from the Arab community to look for these herbal magic bullets like. First of all, it's very, very close to their nature, their environment, it's there. Traditionally, it's accepted to recommend and even to give advice to somebody you can use it. This is the way people express their love, their care about other people and, at the same time, in face of devastating disease when there is no answer, there is no cure, people will look for something that can maybe can make a difference or magic. So, it's natural way people will use what they heard some way, some place or read about some kind of herbs that may prolong their life or help them to overcome this crisis that they have. So, it's naturally, I think it's natural everywhere to look for answers more than what we in the conventional medicine we offer for people. So, let's consider a typical scenario in our oncology department where a patient is referred to your consultation as an integrative physician, how does it look like? I mean, the intake of the integrative physician, can you just elaborate on that? What happens there? What are your objectives? How do you communicate with patients, caregivers, oncologists, family physicians, nurses, social workers, and so on? How do you do that? First of all, I would say that like setup connection, relationship with the person, the human being that's in front of you. So, connection with him. Connection on the human living, where he's coming from, what he's name, what does it mean sometimes to this name that is different from what I'm usually hearing. So, for me, as a medical practitioner, a doctor, I would love to connect and to be more connected to his life, to his world, to know where he's coming from. Then the next step, it will be much more to know what matters to him when he's coming to me. It's kind of what distress, what symptoms bothering him. I would be curious about what he's using and why he came to us. Sometimes it's to know if somebody sent him to us and why he thinks that it's important to come to us. So, it's the idea of getting a holistic perspective on the human being that is in front of me. It's not just the physical distress or suffering, but to get much more knowledge and relationship to him, this is the first. So, it could be sometimes a kind of dance with whatever comes to you. It's being with his caregiver that can give you much more information about who is the person in front of you. So, probably, you get it's not the traditional way of meeting somebody in your clinic like, "I have 10 minutes." If you have much more time to connect and to be really interested in what he is as a human being, at that level, I would be much more intentional about trying to plan a treatment, plan for him that suits him, that can really meet his view in life, what he needs as a suffering person. So, hopefully, you get the idea. It's not just about what bothers you and then I prescribing something, but it's trying to get and trying also to measure this suffering and to put it in sometimes in a scale that can give me an idea where we are starting. Probably at some point, we will be measuring it again and to see if what we are doing is something that probably can help and alleviate his suffering. So, you're talking about assessment through valid questionnaires. Yeah, absolutely, yeah. That guides you into that process of defining the treatment goals? Sometimes all these assessment skills, you have to use them in a wise way that can the other side get it and give you really the answer that he is really as much authentic to his way of seeing that. So, following the conclusion of that phase in the interview of the integrative physician interview, when you define the treatment goals like fatigue or anxiety or neuropathy and so on, how do you tailor specifically the treatment plan? What are the considerations that you have in order to decide if to suggest herbs or other complementary modalities like touch, movement, acupuncture, and so on? So, really, it's again checking if what I see that the patient gave me as a feedback from my answers. If the fatigue, I will check again with him if this is what is stressing him, what makes his life miserable. So, I would love to check again with him. This is what he really chose to make us taking care of him. So, this is an important thing. Giving him, the patient, the control of choosing what kind of treatment. The other thing, I would check with an Arab patient, if giving him a permission to think that there is a wider arsenal of tools that we have including the herbs. If it's something that will he'd love to use it. It's like opening door or permission to include that things that we can offer him. So, yeah, I would see even in the interview if this is something that's close to his heart, to his word and then from there to come and to be opened and willing to check with him if this is something acceptable and be willing to try it. This is something that will make difference and probably from my practice, probably people would love seeing a doctor or tradition, I mean, conventional doctor like us opening the door for more possibilities, more tools or instruments of treatment. Is your impression with Arab patient is that herbal medicine is like a port of entry into their health belief model? Is that the way you can enter into their heart in a sense? It's built in their life and acknowledging that and giving it a really appreciation that make difference, sometimes it's surprising for people and they would love that and they will be much more open for that. When it's coming from us doctors, conventional doctors, it makes much more bigger difference. They will use it and enforce it much more in their life, and they will be much more close to deal and to negotiate with you the treatment plan or the therapy plan about the next steps of what they are dealing with. So, yeah, it makes much more open relationship to be willing to take what you are offering them and to be much more curious and open to ask more questions. So, you describe the process of formulating the treatment plan as a shared decision-making, I would say? Absolutely. It's such a shared and it's kind of we are together in this. Not it's not just my suggestion, it's let's do it together. So, how do you communicate with the other health care providers like the oncologists, the nurse, the psycho-oncologist, the family physician, the surgeon. How do you do that? Thanks God, we have a lot of tools to communicate today, so you shouldn't spend a whole day to communicate with the whole team and you have the electronic record that you can just copy paste and send it all the information that you've gathered in this interview and it takes maybe two or three minutes just to share all this knowledge. It's a precious knowledge that every one of the team will be interested to know. Even just to know that somebody's taking care of that patient. Even a little on short notice that, "Thank you for letting me know that," and "Okay, maybe you can redirect your plans." It's so precious and they think it's valuable and it's becoming a little bit easier to deal with such big journey facing the cancer when you are together with other specialists, you are not alone. People feel the same, so it's vice versa. It's not just about you, about the whole team who's dealing with that they will appreciate that, love that. I would also like to ask you, I mean you have like two hats. Yeah. Or three, you are a family physician, specialist in family medicine, you are palliative care physician and you're also integrative oncology physician. So, with those three hats, how would you consider the relationship between integrative medicine and palliative care? Are those two distinct disciplines or should it be together? How do you see that in practice in your own work? Absolutely, in my point of view, it should be integrated. It's part of the palliative medicine. Every instrument or tool that can make a difference or lessen the suffering, it's welcome. Including Chinese point in the acupuncture or pressure that you can do it at home with people. It makes a bigger difference for this patient. So, use it. Why not include it? So, I'm about integration, inclusiveness of different aspects of our wisdom that we gathered as a human being in this universe. So, my relationship is as it should be in a way and in a very systematic way, it's a part of the palliative care. At the same time, I'm willing to put it in the perspective of evidence-based medicine to be much more assisting that, checking that, how much this, what we use is really making a difference in the bigger population. So, my answer is a big yes for that. If you consider palliative care is not only about end of life as you described it, it covers the whole spectrum of quality of life, but if you look at that extreme side of pole of the spectrum in end of life treatment, where are the symptoms concerns that you think that integrative medicine can augment or supplement palliative care? What are specifically you can envision the contribution of complementary medicine in end of life care? Mainly, I can see it in specific symptoms like anxiety, fatigue, and people, it's taking a big chunk of their life. Making the difference with that, it's so important to include the complementary medicine in these aspects of anxiety, release, and depression including, and fatigue, and pain. So, I see it's very much making a bigger difference if we can include these tools in the conventional medicine and the mainstream medical practice. So, what is your vision concerning multidisciplinary teams that work in palliative care? Who would you like to see within this multidisciplinary team? I would love to see everybody including the medical nurses, the social workers, the doctors and everybody who is taking care including the care giver, to give him much more tools to deal with this huge mission, like being in the person's journey facing cancer or other devastating disease. So I will invite everybody to be using, to be updated, to be able to use these tools. So, nobody excluded in that. Would you expect complementary medicine trained physicians or practitioners to join this team? Yeah. In which areas of expertise you think that they can fill in the half empty cup of symptoms concerns that you don't have optimal answers in palliative care? I think, first of all, let's start with the community work that we do as family doctors. We can really use these tools easily, even in the clinics in the community. It could be a big gift to give our patients using so simple tools. Let's start with that. Even training imagery guidance using acupuncture, it's so simple, it's so easy. Having teams that are trained to do that, it can really expand the ability to reach much more beyond just medical centers in specific areas. It can be wide enough and even my dream to see these practices inside the homes of people who are dying at home. So for me, it's very close to my practice to see these tools built-in in our team taking it to the houses of people who are in their last part of their life. So which of these complementary medicine professions you think are important in that precious time of end of life? Would you like to see inside the room when the patient is going to die within a few weeks or days or hours, I mean, beyond the conventional palliative practitioners. Absolutely. Who would you like to invite to that setting? Mainly, I would love to see the spiritual caregivers who are taking so much. They are giving space to the family and the dying patient to be with them and I think this is the main people that I would love include. Thank you for coming and sharing with us your insights. Thank you, I loved being with you and thank you for inviting me.