Beyond Mandatory Autonomy: When to Stop Asking
The asking is the easy part. It's the move that lets you leave the room with clean hands, a documented preference, and a man who will get chest compressions he never wanted.
Latest
The Question That Ends With a Period
There are two options that are good for you. Both are disagreeable. My job is not to invent a third or to make you pronounce the medical conclusion so I don't have to be the one who said it. My job is to tell you why the boundary exists, in language you can argue with.
Time to Move On From The Buckets
The delivery models our best researchers are building don't use the binary. They use tiers, triggers, defaults, dose-response logic, and precision targeting.
The Taxonomy Is Lagging the Trials
A continuum framework doesn't abandon non-specialist training. It specifies it: which competencies, for which clinicians, at which moments, with what infrastructure.
Palliative Care’s Real Power Skill Is Systems Translation
Palliative care must keep the bullshit filter intact, and stop letting our most consequential work get filed under "support." That is systems translation: converting symptoms, values, family dynamics, prognostic reality, and institutional constraints into care plans the system can actually execute.
The Rise and Fall of San Diego Hospice — Part 3
A nine‑figure proof of claim became the public’s north star—filed months after SDH had already stopped caring for patients—while the Medicare audit later released via FOIA documented > $10M in overpayments. Different artifacts. Different implications.
Shared Decision-Making Is Ours. Don't Let Them Break It.
The distinction between a recommendation and a coercion is the moral architecture of palliative care. When that distinction collapses in the broader culture, we lose the ground we stand on.
The Room You Can't Curate
I have to make an argument, hear a counterargument, lose a vote, and then sit next to the person who beat me at dinner. And then come back the next morning and do it again.
The Peptide Temptation
“Peptide therapy” sounds scientific enough to borrow the prestige of translational medicine and vague enough to hold almost any hope someone wants to pour into it. And that is part of the appeal.
The 2 a.m. Second Opinion
Here's what I think is happening—quietly, unevenly, and faster than our field is tracking: the foundational architecture of serious illness communication is being restructured by a force we didn't design, don't control, and in many cases don't even know is in the room.
Kratom In the Chart
Kratom becomes clinically relevant because millions of people live in a health system where pain care is uneven and access to thoughtful longitudinal symptom care is thin.
The Disappearing Specialty, Part III
The AI infrastructure that will drive the next decade of cancer care doesn't have a signal for the work specialty palliative care does. As the AI hardens, the field gets quieter — not because anyone decided to silence us, but because the algorithm has no pattern for the patient who needs us.
Hows & Whys
The Disappearing Specialty, Part II
Walk into the website of any cancer center built or rebranded in the last five years and you will find palliative care's vocabulary doing work it didn't sign up for. Symptom management. Whole-person care. Goals of care. Supportive care. The words are everywhere. The specialty is harder to find.
Health Policy
The Disappearing Specialty, Part I
The biggest cancer centers don't get to be biggest because they decided to be. They are accredited. Each of their accreditation regimes carries floor requirements. Some of those floors are clinical. Some of those floors include specialty palliative care.
Changing the World
You Will Not Be the Person Who Filled Out That Form
What if the reason ACP underdelivers isn't that we do too little of it, but that we've misunderstood what it's for? The answer lives in an unlikely place for a clinical field: behavioral economics.
Communication Skills
Beyond Mandatory Autonomy: Truth Without Abandonment
Honesty and hope aren’t opposing forces. They are a matched set: hope for the best and prepare for the worst—paired with an explicit promise of nonabandonment.
Hows & Whys
AI Won't De-Skill Palliative Care
The de-skilling threat is real and asymmetric across specialties. Palliative care sits on the protected side of that asymmetry—because the highest-value things we do are the things machines are worst at.
Hospice
The Rise and Fall of San Diego Hospice — Part 2
This is what happened at San Diego Hospice between November 2012 and February 2013. Leadership made a series of irreversible operational decisions — public disclosure, inpatient closure, live discharges, admission restrictions — while sailing entirely on estimated position.
Health Policy
The Sectarian Temptation
We work in the places where evidence gets thin, emotions run hot, and the mysteries are real. It is the exact territory where sectarian certainty rushes in with confident answers, unfalsifiable frameworks, and the seductive promise that someone, somewhere, has figured it all out.
Hospice Was Never Built for Kids
💡No, gentle readers, you're not hallucinating. Those of you subscribed to the newsletter email got a preview of this one last week due to a publication scheduling error. Probably won't be the last time that happens! Maybe I'll call it a "subscriber perk.
Communication Skills
Teams, Not Saviors: Protecting Each Other from Compassion’s Edge States
Every team thinks they’re compassionate. Fewer can name the cliffs embedded in compassion—and fewer still can stop one another from going over the edge in the middle of a messy consult.
Hospice
The Rise and Fall of San Diego Hospice — Part 1
How a “Mother Ship” Was Built: Ethos, Scale, and Blind Spots I trained at San Diego Hospice. In fact I was part of the last class of fellows. That sentence carries weight I've been unpacking ever since. SDH shaped how I think about dying, how I talk to
Beyond Mandatory Autonomy: Clinician‑Guided Care Without Guilt
💡This is Part 2 of an ongoing series on the concepts and innovations that are challenging decision-making in serious illness. Part 1 laid out why "mandatory autonomy" is failing patients and families, and introduced Kon's shared decision-making continuum as a practical alternative. The Word
Hospice ROI Lives in Relationships, Not Throughput & Widgets
If you want real returns, invest in earlier hospice enrollment, stable teams, and time to do the relational work—then use tech to buy clinicians that time. I read the Hospice News piece celebrating AI’s promise in hospice—faster admissions, smarter documentation, and “efficiency” to stretch scarce clinicians. The