Keeping the Human in Healthcare — Dying, Dignity & the Conversations That Matter

Death is one of the most certain parts of life — and yet in healthcare, it's often the hardest conversation to have. In this episode of SNF This, we sit down with Dr. Alfonso Gonzalez for an honest, compassionate, and long-overdue discussion about end-of-life care in the post-acute setting. Dr. Gonzalez walks us through how to approach conversations about death with patients and families — when to have them, how to frame them, and why avoiding them often does more harm than good.

He also clears up one of the most misunderstood areas of care: hospice. What it actually is, what it isn't, and why so many patients and families come to it too late — or not at all — because of fear and misinformation.

At the heart of this episode is a simple but urgent reminder: medicine is not just a clinical practice. It is a deeply human one. And when we strip away the paperwork, the protocols, and the pressure to treat at all costs, what remains is the responsibility to walk alongside our patients with honesty, dignity, and compassion — all the way to the end.

A must-listen for physicians, nurses, administrators, and anyone who has ever sat across from a family that needed someone to just tell them the truth.

Transcript

SPEAKER_01 0:02

Welcome to Sniff This, the podcast where we pull back the bed sheets on skilled nursing facilities, educating, entertaining, and occasionally risking being reported to HR. Welcome back to this episode of Sniff This. I'm happy to have my new friend, Dr. Gonzalez, on our podcast today and to learn from him. And we briefly interacted yesterday and talked today, and just overall excited to have you. So welcome to our podcast, Dr. Gonzalez. New friends here. But introduce yourself, tell us a little bit about yourself, your background, training. How did you get into long-term care, post-acute care, and then why do you stay? There's so many other areas you could go to.

SPEAKER_02 0:44

So it's actually a path that usually you don't look into going into it. Yeah. You end up being part of it. And once you start in that world, there's so many things happening and so many uh aspects that you get involved with that it keeps you like it captures you. I mean, once you start working there, regardless of the experience, in my case, I'm internal medicine by training. Um, so I originally practiced traditional medicine, hospital, outpatient care, home care services, hospice services. Um but when I transitioned into the United States, in which it was a little bit more fragmented, like you were in one of the fields of the international specialized. Correct. Um I had the opportunity to start working in nursing homes. I was like, I can give it a try. And giving a try was that that was 13 years ago. Um after I started working in the nursing homes, I was given the opportunity to become a medical director of my first facility back uh 13 years ago. Uh and that opened a totally different world and scenario. Um, as medical directors, we don't only take care of the patient, but also we need to keep in mind and work with the system, which sometimes is worse than working with the patients because patients we evaluate, treat, and monitor response. The system is dynamic. What is being done today not necessarily is what is gonna happen tomorrow. So that post-acute experience and working in the nursing homes actually helps you kind of see a different perspective of health care. It's providing the care from beginning to end, and the patients are yours from admission day until only God knows how long they're gonna be with you. Right. So it's a different uh experience. Right. And I mean, I don't regret it at all, and I love it. I mean, it's it's it becomes part of yourself, like like you you become, and actually that's what we're called sniffists, yeah. Uh is which is I think is still a kind of a new term, yeah. Um, but it's because once you start working in sniffs, it kind of that becomes your world.

SPEAKER_00 3:02

Yeah.

SPEAKER_02 3:02

Uh and you never stop learning because every experience is different.

SPEAKER_01 3:07

Well, and the patients are so complex, and they're each coming with their own backgrounds and life experiences, but now they're in this transition of care that they never thought they'd be in or want to be in, and the families are also having to navigate, so very complex.

SPEAKER_02 3:23

Unfortunately, we were all raised with a positive view of life. Yeah. Being successful financially, being successful with your health care, we um being successful with your family, like successful in your spiritual life. Like, there a lot of success is what we are all pursuing.

SPEAKER_00 3:42

Right.

SPEAKER_02 3:42

Unfortunately, that's not the reality of life. You there's gonna be a decline.

SPEAKER_00 3:47

Yeah.

SPEAKER_02 3:47

And that decline is very tough on some of the patients, and not only the patients, the family members, and even in some physicians. Not every physician is comfortable talking about every topic or talking about every stage in life. Right. Um, and when some of the patients that that you have been treating for a long time all of a sudden start declining, and they come back to you, like, what is going on? What am I to expect? What am what can I do? Um you still you need to start shifting your responses as well. It's it there's a point that it stops being like, I'm gonna prescribe you this or I'm gonna prescribe you that, and we're gonna try this therapy. And it's like, what how aggressive you want to be? Right. Like, how long do you want to continue trying something even though might not be working? Right. And my answer to them is like medicine offers a lot of opportunities. That doesn't mean that everything needs to be applied in every stage in life. Interesting. So so when I told them that, especially the patients, they look at me like, whoa, that that's uh interesting. So I don't need to go through XYC treatment. I was like, you're the patient. We give you a plan, we give you options. It's up to you what do you want to do or what do you want to accept? Kind of that shared decision-making model. Yeah. I mean, is the patient that is sick, is the patient that is trying to feel better, or is the patient that is entering a stage in life that unfortunately there's not coming back.

SPEAKER_01 5:16

Yeah. And we talked about this briefly before we started recording, was this concept in medicine, and all of us go through some form of medical training where you do everything you can to keep a patient alive. I mean, uh I did a brief fellowship in critical care management, and we could keep a patient alive for a long time, but we miss the broader scope of like what is our goal here in terms of the goals of care. But it's hard as treating clinicians, providers, to like shift that mindset that like I need to be doing something to be prolonging or making their life better, but sometimes we're making it worse.

SPEAKER_02 5:57

And actually the question is what is the meaning of doing something? What is expected to be done? Yeah. And that is where we're, I think, creating a plan since day one, like, okay, this is where we are today. This is where we're planning, this is where we're foreseeing the care, and this is kind of the timeline that we're looking into.

SPEAKER_00 6:18

Yeah.

SPEAKER_02 6:18

But every day there's an opportunity or a chance of that changing.

SPEAKER_00 6:23

Right.

SPEAKER_02 6:24

Because it depends how the patient starts responding. And and sometimes the patients, they're tired, sometimes they are they're um frustrated, which is different from being depressed, being in a state of mind like that that you need to have other kinds of interventions to see if you can bring them back, because there's other psychiatric issues that can happen with the patients. But talking about that, the patient that is not having any psychiatric uh situation, they go through through analyzing their current state. And then you were mentioning a key component, which was working with life extension, with life preservation. But what about working with the quality of life? I mean, is the patient gonna have more quality with the extension, or is not gonna have quality at all, and it's gonna be like, I just want to die. Uh like, where are we heading with our patients? Right. So that conversation needs to be a comfortable conversation at one point between the circle of trust, right? The patient, the caregiver. Sometimes it's interesting because as physicians, we have also uh support with nurse practitioners, with with uh PAs. And sometimes that conversation, even though we all have the knowledge on how to have that conversation, not everybody sometimes feels comfortable with having the conversation. So it's like identify within your team who is the most I don't want to say qualified, but but but the person that have those traits to have that conversation first to listen to the patient and validate the patient's feelings.

SPEAKER_00 8:04

Right.

SPEAKER_02 8:04

Second, to to get that that um incorporate what the patient is asking or or what the patient's goals are into what you want to propose, right? And then discuss that plan, have the family member involved. Sometimes it's the family member that is like, no, do everything possible. I want my mom alive, of course. I mean, it's very it's normal that that's what we want. Uh like we're it doesn't matter our age, we're kids. Right. And we it doesn't matter our parents' age, here or if they're gone. I mean, like it doesn't matter at what age in our life they're they live, hers the same way. So yeah, we understand they want them alive. Yeah, the question is they want them alive and they want them happy. Yeah, so having that conversation was okay, this condition is progressing, this condition is happening, but the quality of life is hard to transform it into a positive one if we don't start putting elements into the equation.

SPEAKER_01 9:06

Yeah, so let's separate maybe the patient versus the family because I think they're two dynamic like individuals. How do you approach a patient who we've done everything that we medically can, and our interventions or doing something is prolonging their life, but obviously maybe not improving their quality of life? Like, how do you approach? And I know a lot of providers, physicians feel uncomfortable approaching this conversation. How do you approach that with the patient?

SPEAKER_02 9:36

I think the first element that should always prevail is first listen to your patient. Sometimes are the patients are the ones that start asking, like, can we stop this? Can we? I mean, I and sometimes you go with a plan in your mind, like, this is what we're gonna discuss, and then the patient comes like, hey, I'm I need to have a conversation with you because they trust on their clinician. There's there's trust there. Um, so first is listening to the patient. What what where does the patient see himself or herself at that time? Yeah, how did they perceive some of them? I had a patient that I will never forget. She was a retired teacher from up north, uh, from one of the northeastern states. She was in Florida at that time. Um, she was diagnosed with a terminal illness, and she was rejecting all kinds of treatment. Then nurses told me I was gonna meet her for the first time. So I went to see her, and honestly, she gave more than what I gave her during that conversation. I mean, she was like, Doctor, my kids are grown already, they're successful in life, they have their careers, they have their families. I um worked many years, was very successful in my professional career, and retired. I don't regret any single moment of my life. And she's like, That's cool. It doesn't matter how much time I have left, I will live it happy and just let it be. I'm not gonna submit myself to a treatment that she knew. I mean, she was very, very educated. Um, she was like, I don't want to go through all the side effects and all this, the the the possible real um actions of the medications or the treatment that will deteriorate her quality. She was like, she wanted quality over quantity, and I was like, wow, and and I was like, and how do you feel about that? And I was like, I'm happy, yeah. I mean, I live my life, and I was like, whoa, okay. So I was like, I and I told her, I I admire you, and I and I told her, like, I I as God for for for the ability and the blessing to react that way if I'm in your situation, right? Um and it's that it's like give the patient the opportunity to talk, to see what they want, where they see their their lives, um, which, as you mentioned, is very different from the family members. Right. The family members.

SPEAKER_01 12:06

So I'm supposed it's easier to help the patient come to that conclusion and listen to them that this is what I want. 100%. But then you have the daughter or the son who wants the best for that. They love them, right? How do you approach it with a family member?

SPEAKER_02 12:18

You will see patients that will ask actually ask you, can you talk to my daughter?

SPEAKER_01 12:24

Like I've been trying to tell her, and she's like making me do all these things.

SPEAKER_02 12:28

And um, in my family, my I have a sister, she's a nurse, and um, she, her husband is also a nurse. So, and and there was a time in life that they were kind of assisting people with terminal illnesses in our community, kind of uh supporting them. Yeah, and um a patient with terminal cancer asked them to go and have a family meeting with all the family members, and they were like, Why do you want us to meet with them? I was like, Because I needed them to understand that I'm okay. I mean, I know what is going on, I I understand where where the path is heading. Um, and and I'm okay with that process. I need them to be okay with the process. Yeah, she was the patient, right?

SPEAKER_01 13:10

And my sister so much emotional intelligence, that's crazy.

SPEAKER_02 13:14

It was crazy, and um, my sister and her husband, both of them were like, okay, let's have the family meeting. It was a heartbreaking conversation because it was like telling the family, like, hey, she just wants the situation to just let it be. Don't fight the situation, just enjoy your moments that you might still have. Um, and that came that that came from the patient. Yeah, so the family members, we want our best for our loved one. Yeah, and there's this also a self-emotion of I want them with me forever, that you want to kind of avoid any kind of risk of that space kind of being being being harmed.

SPEAKER_00 14:00

Yeah.

SPEAKER_02 14:01

So there's a lot of dynamics that you need to take into consideration when you're dealing with the family members, because not necessarily the most emotionally attached is the one that is always taking care of the patient, or not necessarily the the one that that is the decision maker is even available around.

SPEAKER_00 14:20

Right.

SPEAKER_02 14:21

And then are they, let's say, is a father or all the kids from the same mom, and do they get along with each other? Right. Because everybody's gonna ask for something different. Um, and I think my my in my experience, communication from day one is key when you are trying to get into that conversation. Like, you also need to keep in mind that you need that trust of the caregiver, of the family member. Yeah, and my recommendation to every physician when they're gonna have that conversation is try to avoid individual conversations. Sometimes there's a phrase that is divide and conquer. Uh-huh. In this case, I recommend the clinicians like bring all the family members together at the same time in the same place, and then have the conversation there. Why? Because then emotions are gonna come out, um, reactions are gonna come out, and your goal is to have some kind of consensus at the end of the conversation.

SPEAKER_00 15:18

Yeah.

SPEAKER_02 15:19

Like, okay, this is where your mom is at, or this is where your dad or grandma is at, this is what has been done, this is what we have identified, this is this is a prognosis, this is what we are expecting.

SPEAKER_00 15:30

Yeah.

SPEAKER_02 15:32

We want to make sure everybody that we are on the same page and that the plan aligns with what we all have in mind.

SPEAKER_00 15:39

Right.

SPEAKER_02 15:39

Um, and those conversations uh are interesting. Yeah. Are interesting because you learn a lot about the family dynamics that are gonna prevail through the entire process. And some of them might get worse as the situation uh declines. Right. But having that conversation kind of empowers you because from that moment on, you will make reference to the conversation that you have with the entire family, family circle. Um, so I think that that communication and transparency from day one when you start treating any kind of patient will help you lead any kind of conversation moving forward, regardless of what the uh and and uh uh the outcomes are.

SPEAKER_01 16:22

Yeah, and sometimes leads to the importance of having those conversations early. Because it's really hard for families, I think, in the moment to make the decision to pull the plug, right? Which is like a horrible term, but like that would be an impossible decision unless you've had some of those conversations or you have that trust.

SPEAKER_02 16:39

Yes, I have I have two life experiences that I use a lot in my career. Um, the first one, my dad used to have a funeral home. Uh-huh. So I was able to kind of be there with a lot of family members that were going through the what Dr. Elizabeth Krugler Russ used to mention about that the steps of death and dying and the separation and the lost steps. Yeah. Um, when you're going through different stage emotional stages until you get to kind of at ease with what happened. Um and I usually tell the family members, I used to do it when at my dad's funeral home, like what is happening, the strength is gonna come from within your circle. And ideally, try to step ahead. Things are gonna happen. Let's try to get ready for that. And ready doesn't mean that it's not gonna hurt, right? It's gonna hurt. You just get prepared. Right. Uh, so so that I apply in my career because I tell the family members from the one, these are the risks. Right. We need to be aware that this can happen. And if it happens, what are we gonna do? What is the plan? Um, and and in the beginning, they might be like, she's gonna be okay in denial, which is part of the process. Correct. Uh so so we're keeping that in mind is like you're not gonna push them against the wall, like you need to believe what I'm telling you. No, give them time. But if you start early, you will have time.

SPEAKER_01 18:05

Right.

SPEAKER_02 18:06

The worst thing that can happen is taking a decision, like when it's immediate jeopardy for the patient's life. Like, hey, do you want us to intubate your mom or not? She's she's having a lot of difficulty breathing.

SPEAKER_01 18:18

It's really hard.

SPEAKER_02 18:19

At that moment, where are you gonna say? Right, intubate her.

SPEAKER_01 18:21

Yeah, absolutely. Right.

SPEAKER_02 18:23

Because you are just thinking of seeing her in the in in that despair of uh of trying to grasp air. But when you start having that conversation uh ahead of time and you are able to kind of create a uh plan A, plan B, plan C, plan D, then you can move through the plans uh easier. I like that. So having that conversation, open conversation with the entire influence circle from the family group, and sometimes it's not only family, sometimes it's the pastor, sometimes it's a neighbor, sometimes it's uh it's someone that they know in life that is very significant for them. Bring them in as long as the patient authorizes because we have EPA, of course. Yeah, but I usually tell them bring whoever you want to be uh during the conversation, and we'll sit down and talk. Yeah, I like that. And that helps a lot. I mean, because when that call happens, you feel comfortable, like, no worries. I'll let me call the family, let me let me let them know.

SPEAKER_01 19:21

Because we've already talked about it, we already have a plan. We know how well we're gonna do it.

SPEAKER_02 19:24

It was already a plan. And um it is it is a matter of don't try to see things through your personal lens, try to see things from the patient's lens.

SPEAKER_01 19:37

Yeah, it's not about patients, it's about the it's about the patient.

SPEAKER_00 19:40

Yeah, yeah.

SPEAKER_02 19:41

If you are the patient, how do you want to be treated with respect of what I what I want? Yeah, so so applying that principle, I think makes a huge difference in post-accueare and nursing home. Um, some patients that just want to stop everything, and you are like, hey, that's that's your right. I mean, definitely you can do it.

SPEAKER_00 20:01

Right.

SPEAKER_02 20:01

Um, and uh when they ask, like, is my mom or dad or any family member is gonna live or die? I tell them, like, physicians, we don't determine who lives or who dies. That's God's will.

SPEAKER_00 20:14

Yeah.

SPEAKER_02 20:15

We work toward having the healthiest possible scenario while you're still alive.

SPEAKER_00 20:20

Yeah.

SPEAKER_02 20:21

So while you're alive, we'll be working with you. When God determines and it's time for you to go, there's nothing we can do. When is that gonna happen? We don't know. I had a patient that that um I left on a Friday afternoon, I left I left the facility. She was gasping, which is the process of let's we call it like final breaths, right? Trying to get some air but very slow breathing. Um, family daughter was crying, sister was crying. I took the daughter out of the room, had a conversation with her. She was at ease with what was happening, was even though it was hurting. So she she that it was one of those scenarios in which pain is still gonna be there, but she already knew what to expect. So she was at ease with it. Um when I came back on Monday, I was like, hey, how was it? Um situation on Friday with and they were like, What situation? I was like, when I left, she was in impending death. Yeah. And they were like, no, she's at a dentist appointment today. And I was like, wait, wait, wait, what do you mean that she's an appointment uh in the dentist appointment today? And they were like, Yeah, hours later, we don't know how. The patient woke up and said that she was not gonna die until she's a hot dog. And I was like, You're kidding me! And they were like, Doctor, no. I mean, then after that, the whole weekend she was totally stable, and she's actually at a dentist's appointment. Said and done. She had her dental appointment, she had her hot dog, and a few days later she died. I was like, like, ah so that's that those are experiences that tell you like. They will not die when you think they're gonna die. They will die when it's their time. That's it. Just work with health and let the life or death issue to the above. I mean, like, you don't control that. So, so those are experiences that that helps kind of guide us as physicians. Like, how are we gonna work with each patient and what are we gonna do with them? We have books, we have guidelines. Right. Are you gonna apply everything to every patient? No.

SPEAKER_00 22:30

Yeah.

SPEAKER_02 22:31

I mean, see uh the patient's world, see the patient scenario, adjust the the script to to to that um uh play that you're putting in place and make sure that everybody's engaged and okay with what is gonna happen. So I think that is key.

SPEAKER_01 22:48

Yeah, no, I I think sometimes the most compassionate thing we can do is like to let go and like um follow what the patient wants and help the family come to the same conclusion. And there's no, I really enjoyed our conversation today. I'm glad I've enjoyed it. Yeah, it's a hard topic, but it's like really important. And comes, and I think can be some of the most defining moments of being a provider.

SPEAKER_02 23:12

And as clinicians, yeah, when you are able to, I mean, you don't master these dynamics. Yeah, I mean, every experience is different, and you gotta have done it thousands of times. Every patient is different, and I'm I tell the patients, I'm the kind of doctor that I cry with them. So I tell them later, you see me crying, I mean, expect that to happen because I have the problem crying. Yeah, uh, and um, but it's also trying to feel what they feel. Um back, I want to say, well, let me not say the amount of years because I'm gonna date myself, but um, my mom passed when I was 26. Sorry. So uh, and it was years later, I was working on the hospital, and this was this patient, female lady, of course, female lady. I need more coffee, but um, a female that that was terminal illness, her kids were kind of around my age, and they were all around super supportive family. Every time you walk into the room, all of them were just seated there quiet, looking at her, being there with her, and not knowing what to do. And um I was like, are you guys aware of where are we right now? What is happening? I was like, we have an idea. I was like, okay, this is the condition your mom is at right now. Um there's not much we can do at this point. My recommendation is be the be here with her, make sure that she knows you're here and just enjoy every single moment that you still have with her.

SPEAKER_00 24:49

Yeah.

SPEAKER_02 24:50

And I told them I went through this experience, it was like maybe one year or two years after my mom passed. Um, I told them, like, I went through this. I cannot tell you what you're gonna feel because every person feels something in a different way. Um, but I told them, but one thing I don't regret until uh like ever, and I will never forget, is every single moment I was able to spend with my mom on her end of life process. Um, and I we had to take decisions in my with my mom that were her wishes, not mine. And I had to take the decision and sign at that time.

SPEAKER_00 25:26

Right.

SPEAKER_02 25:27

Um, and I was like, but I know that that was what she would have asked for. Uh and I told them, like, keep this in mind, be here, be with her, enjoy every moment, and you'll see. Patient died a few months later. Uh I was at a grocery store, and uh the cashier was like, Hey, how are you? And I was like, Good. Uh yeah, I was like, nice cashier, right? Yeah, um, and he would she was like, Do you remember me? And I was like, it's like the scariest question to get. I know. Yeah, I was like, um, yeah, from where? Yeah. And she was like, You were with us when my mom was passing.

SPEAKER_00 26:08

Yeah.

SPEAKER_02 26:08

And we are all very grateful for you being there.

SPEAKER_00 26:12

Yeah.

SPEAKER_02 26:12

And I was like, I mean, that that breaks your heart, but at the same time, it gives you satisfaction.

SPEAKER_00 26:18

Right.

SPEAKER_02 26:19

I did the human aspect of medicine rather than the clinical aspect of medicine.

SPEAKER_00 26:25

Yeah.

SPEAKER_02 26:26

I was just there with them.

SPEAKER_00 26:27

Yeah.

SPEAKER_02 26:27

And they were like, I like that. Whoa. So so I think that keeping that balance of we are not only clinicians, we're always still gonna be humans. And letting that human part also interact with your patients and your and your family members are gonna give you the tools that are necessary to deal with situations like this one.

SPEAKER_01 26:48

That's great. Thank you so much. I really enjoyed our conversation. We'll have to have you on. I'm glad maybe a different topic, but this is really important. So yeah, discussion. Definitely always at your service and appreciate your friends, Dr. Gonzalez. Okay. Well, thank you. We'll see you next time. See you. Before we conclude, huge thanks to our sponsor, Vital Care Connect. Whether you're burning the midnight oil or just trying to survive another 2 a.m. call, Vitalcare Connect provides on-call medical director support whenever you need it. Nights, weekends, and holidays. With coverage nationwide, they're leading the way in post-acute care, elevating quality, expanding access, and supporting well-being for all. Learn more at Vitalcare.org. Thank you for joining us for this episode of Sniff This. Share this show with your favorite CNA or anyone who's survived an all staff meeting fueled by cold coffee. Until next time, I'm Chance in Skilled Nursing. If you sniff something, say something.