Improving End-of-Life Care
Working with patients at their end-of-life gives me continual pause to think more deeply about life and earn a greater appreciation for it. While growing up, I often heard the expression "We die as we lived." yet little understood what it meant. After years working with serious ill and terminally ill patients and their loved ones, its meaning has become very clear to me. A circle of loving, caring and devoted family and friends isn’t something that people simply fall into in life, but rather something that they build in life. This individual support network is the result of each patient’s past interactions with their loved ones, their friends, and everyone else that they touch in life. Similarly, each patient’s will, determination, gratitude, and kindness do not come to them overnight, but rather are built over time. All of us eventually face the end-of-life journey, sometimes alongside sick or aging loved ones, and inevitably for ourselves. Still, it remains a deeply unfamiliar experience for many, one that finds us unprepared and unsure as to what to do. For me, it is immeasurably fulfilling to be able to help people through this experience.
I am a board member at
Hopewell House, currently the only dedicated end-of-life residence in Portland, Oregon.
Home Palliative Care and Hospice Care
I strongly advocate the need for home palliative care service. There are many patients who prefer to avoid hospital care services if they have adequate help and support at home. While people commonly get sicker, older, or frail, even when they are not yet dying, our healthcare system does not support such populations. We are in desperate need of home palliative care services for those wishing to stay at home under less aggressive care and with improved quality of life, despite that they are not dying 'soon enough' to qualify for Medicare hospice services.
You can learn more about the goals of the Oregon Hospice & Palliative Care Association
here.
Improving the Healthcare System
Guiding patients and their families through serious illness and end-of-life, I developed a broader interest in advocating for improvements in the US healthcare systems. Our current care is fragmented, complicated, and expensive. Improving end-of-life care indeed involves more than just caring for the sick. We all need help as we get sicker and older, and patients' loved ones and care team should be significantly involved. Death, after all, is not the end. The experience of loved ones during a friend of family member's end-of-life care is so strong that it can shape their future experience in medical care. The system which can prepared to do the best in the midst of crisis is the system which will work across all of patient care. Through my various advocacy, outreach, research, practice, and other work toward positive change, I hope to leave the healthcare system better than I found it.
The Official PNHP Website
Improving Communication Skills
As a physician and medical educator, I am also working toward improving communication skills among healthcare professionals, toward providing better patient-centered care, which the Institute of Medicine defines as "Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions." I feel that compassionate and effective communication skills are as much an essential medical skill as basic medical knowledge - for every medical professional. These are acquired skills which can only mature through continual, reflective practice. I am a senior faculty member of
VitalTalk®, an evidenced based communication skills training organization established in 2000, whose curriculum I have been teaching across the nation. I also co-founded
KanwaTalk® of Japan, through which I am involved in teaching medical communication skills to Japanese physicians who practice in Japan and speak Japanese with thier patients. I am also involved in training medical professionals better communication skills, using the Serious Illness Conversation Program, which is offered through
Ariande Lab Serious Illness Care.
Concluding Thoughts
I will continue to work to share the many priceless life lessons that I have learned from my patients and their loved ones as they faced serious illness and end-of-life. Everyone can and should be better prepared for their future. I believe that “dying well” naturally follows if our lives are spent "living well."
Listen and be Curious
For physicians, success comes most of all from listening. Primary care providers serve at the frontline, caring for their patients with a sensitivity to the whole of the patient: concerns, problems, and medical conditions - often in the face of the deep uncertainty. As such, my first and best tools will always be my ears, my eyes, paying attention, and always being curious as to what my patient have to say.
Have Compassion
Another important skill in medicine is being able to put yourself in someone else's shoes. Being honest is the core behavior that makes such empathy possible. It is a quality that everyone should have, and which I believe everyone is capable of. Compassion and honesty follow naturally when I put myself in my patients' shoes. Empathizing with what they are experiencing helps in building a trusting relationship which is the key to joining them effectively in their decision-making process. This is true whether in a family medicine setting, with its long-relationships; or in an in-hospital palliative care setting, where I have just met the patient and their loved ones.
Be Humble
Projecting disease trajectories and prognosticating serious illness are based on general statistics, yet there is always a significant element of uncertainty. Through years of practice, I have learned to be humble and accept this mysteryt of life and nature, since we are often afforded no other option. Disease manifestation can have various unique presentations, depending on the individual. Patients, and those close to them, often have deep knowledge of their body - seeking out this knowledge, with humility and curiosity, is often the key to making a good diagnosis.
Strive for Commitment
Commitment is king. As I work with my patients and their loved ones, I join them in their boat and we sail onward together. We become a team, setting achievable goals, aligning to their preferences and priorities in their current medical situation. As physician, I then navigate them toward with a positive attitude and hope.
Guide, Coach, and Recommend
Ultimately, my obligation as a physician is to guide, coach and give my best personalized medical recommendations to each patient and their loved ones. To do this, it is crucial that I listen, with humility and curiosity. No matter how much I can do for any patient, I must foremost be consistently present for them, providing unconditional support and encouragement. My most important professional duties to each patient are guiding, coaching, and providing recommendations - all based on my knowledge and skills, but carefully atuned to their values and priorities.
Family Medicine (Pediatric, Adolescent, Adult, Geriatric, In/Outpatient)
Nursing Home Care
Palliative Medicine (Inpatient)
Hospice Care
American Board of Family Medicine
Hospice and Palliative Medicine
Hospice Medical Director Certification
Certified Medical Director
American Academy of Family Medicine
American Academy of Hospice and Palliative Medicine
Society of Teachers of Family Medicine
American Medical Director Association
Oregon Medical Association
Physicians for a National Health Program
American College of Lifestyle Medicine
Peer-Reviewed Original Research
1. Onishi E, Biagioli FE. Safranek S. FPIN's Clinical Inquiries. Methylphenidate for management of fatigue in the palliative care setting.
American Family Physician. 2014 Jan 15;89(2):124-7. PMID: 24444582.
2. Onishi E, Kobayashi T, Dexter E, Marino M, Maeno T, Deyo RA. Comparison of Opioid Prescribing Patterns in the United States and Japan: Primary Care Physicians' Attitudes and Perceptions.
The Journal American Board of the Family Medicine. 2017 Mar-Apr;30(2):248-254. doi: 10.3122/jabfm.2017.02.160299. PMID: 28379832.
3. Onishi E, Lucas J, Maeno T, Bailey SR. Patient "Catastrophizing" Associated with Expectations of Opioid Prescriptions for Acute Pain Control.
The Journal of the American Board of Family Medicine. 2020 Nov-Dec;33(6):858-870. doi: 10.3122/jabfm.2020.06.200096. PMID: 33219065.
4. Onishi E, Nakagawa S, Uemura T, Shiozawa Y, Yuasa M, Ito K, Kobayashi Y, Ishikawa H, Ouchi K. Physicians' Perceptions and Suggestions for the Adaptation of a US-Based Serious Illness Communication Training in a Non-US Culture: A Qualitative Study.
Journal of Pain and Symptom Management. 2021 Aug;62(2):400-409.e3. doi: 10.1016/j.jpainsymman.2020.11.035. Epub 2020 Dec 5. PMID: 33290856; PMCID: PMC8244824.
5. Onishi E, Uemura T, Nakagawa S, Yuasa M, Ito K, Ouchi K. Bringing VitalTalk to Japan-Assessing Clinicians' Needs in Serious Illness Communication Skills Training and Adaptation.
Igaku kyoiku. 2021 Aug 25; 52(4):345-347. PMID: 34690414
6. Ito K, Uemura T, Yuasa M, Onishi E, Shiozawa Y, Ishikawa H, Ouchi K, Nakagawa S. The Feasibility of Virtual VitalTalk Workshops in Japanese: Can Faculty Members in the US Effectively Teach Communication Skills Virtually to Learners in Japan?
American Journal of Hospice and Palliative Care. 2022 Jul;39(7):785-790. doi: 10.1177/10499091211044477. Epub 2021 Sep 8. PMID: 34493061; PMCID: PMC8901778.
7. Onishi E, Ishikawa H, Ito K, Nakagawa S, Shiozawa Y, Uemura T, Yuasa M, Ouchi K. Culturally Acceptable Emotional Expressions Perceived by Non-U.S. Physicians Undergoing U.S.-Based Serious Illness Communication Skills Training: A Cross-Sectional Study.
American Journal of Hospice and Palliative Medicine. 2022 Dec 27:10499091221148151. doi: 10.1177/10499091221148151. Epub ahead of print. PMID: 36574477.
8. Onishi E, Lucas JA, Maeno T, Bailey SR. Associations Between High Pain Catastrophizing and Opioid-Related Awareness and Beliefs Among Patients in Primary Care.
The Journal of the American Board of Family Medicine.2023 Apr 3;36(2):267-276. doi: 10.3122/jabfm.2022.220311R2. Epub 2023 Mar 22. PMID: 36948540.
9. Uemura T, Ito K, Yuasa M, Shiozawa Y, Ishikawa H, Nakagawa S, Onishi E, Ouchi K. Enduring Positive Impact of a Virtual Communication Skills Workshop of VitalTalk Pedagogy in a Non-U.S. Setting.
American Journal of Hospice and Palliative Medicine. 2023 May 22:10499091231177863. doi: 10.1177/10499091231177863. Epub ahead of print. PMID: 37216960.
Peer-Reviewed Presentations
1. Joslin T, Yamashita D, Onishi E, Fields S. Conference on Practice and Quality Improvement, Society of Teachers of Family Medicine (STFM): Improving Chronic Pain Management with Data: Comprehensive Approach in the Patient Cantered Medical Home. November 24, 2013. San Diego, CA, USA.
2. Onishi E. The 6th Annual Conference of Japan Primary Care Association: International session presentation: Comparing Opioid Prescribing Patterns in Japan and the US: Examining our Motivations for Prescribing to Control Pain. June 13, 2015. Tsukuba, Ibaraki, Japan.
3. Onishi E, Kobayashi T, Hirano T. The 6th Annual Conference of Japan Primary Care Association: Interest Group: Do opioids have a place in chronic non-cancer pain management? ~A Stateside perspective: what we've learned there and what can be done differently in Japan. June 14, 2015. Tsukuba, Ibaraki, Japan.
4. Chan M, Onishi E. A presentation at Death OK: Crossing the conversation Chasm. October 17, 2015. Portland, OR, USA.
5. Yamada H, Tamai A, Onishi E. The 7th Annual Conference of Japan Primary Care Association: Effect of Japanese Medical student Clerkship in OHSU Family Medicine Department through JADECOM (Japan Association for Development of Community Medicine) program. June 10-11, 2016. Tokyo, Japan.
6. Onishi E, Sato K, Takayashiki A. The 7th Annual Conference of Japan Primary Care Association: Pre-workshop: Let’s start Advance Care Planning now! June 10, 2016. Tokyo, Japan.
7. Onishi E. OHSU Research Week, Oral Presentation: Comparison of Opioid Prescribing Patterns in the United States and Japan: Primary Care Physicians; Attitudes and Perceptions. May 5, 2017. Portland, OR, USA.
8. Onishi E, Lee H. 50th Annual Primary Care Review, Portland, OR, Workshop presentation: Exploration and Discussion of POLST Form Completion: Is It as Simple as It Looks? February 11, 2019. Portland, OR, USA.
9. Onishi E, Uemura T, Sato K. The 10th Annual Conference of Japan Primary Care Association: Workshop: Vitaltalk - Effective Training on Communication with Seriously Ill Patients -Its Demonstration for the First Time Ever in Japan! May 19, 2019. Kyoto, Japan.
10. Onishi E. VitalTalk: Intensive small Group Training-Addressing Goals of Care. Co-presenter in a small group as a facilitator with a senior facilitator. The Annual Assembly, Hospice and Palliative Care, March 18, 2020. San Diego, CA, USA. Canceled due to pandemic lockdown.
11. Uemura T, Onishi E, Nakagawa S, Yuasa M, Ito K, Ouchi K. Report: US-based Communication Skills Training-Implementation in Japanese. The 2nd Annual Conference of Japanese Association for Home Care Medicine@Web, June 27-28, 2020. Virtual Conference.
12. Onishi E, Uemura T, Ito K, Yuasa M, Ouchi K, Nakagawa S, Shiozawa Y, Sato K. The 2nd Annual Local Forum for Japanese Association for Home Care Medicine, Japan: Workshop: VitalTalk Demonstration. October 25, 2020. Virtual Conference.
13. Devarajan S, Onishi E Gallivan E, Krulewitch H, Collins E, Izumi S. 54th Annual Primary Care Review, Portland, OR: Advance Care Planning for All: Serious Illness Conversations in Primary Care. February 9, 2023. Portland, OR, USA.
14. Onishi E, Gallivan E, Krulewitch H, Devarajan S, Collins E, Izumi S. STFM Annul Spring Conference: Implementing an Advance Care Planning Intervention WITH an Age Friendly Model of Geriatric into a Family Medicine Clinic. April 2-May 2023. Tampa, FL, USA.
15. Onishi E, Gallivan E, Krulewitch H, Devarajan S, Collins E, Izumi S. STFM Annual Spring Conference: Advance Care Planning (ACP) Training for Family Residents: Promoting ACP Conversations for All. April 2-May 2023. Tampa, FL, USA.
16. Onishi E, Gallivan E, C Davis-O'Reilly, Krulewitch H, Devarajan S, Collins E, Izumi S. AAHPM Spring Conference, Poster Presentation: Serious Illness Conversation Training for Primary Care Residents: Feasibility, Effectiveness, and Sustainability. March 21-23, 2024. Pheonix, AZ, USA.
17. Onishi E, Gallivan E, C Davis-O'Reilly, Krulewitch H, Devarajan S, Collins E, Izumi S. OHSU Research Week, Poster Presentation: Serious Illness Conversation Training for Primary Care Residents: Feasibility, Effectiveness, and Sustainability. May 6, 2024. Portland, OR, USA.
18. Lee H, Alway A, Pullin K, Wanner K, Halm M, Onishi E. OHSU Research Week Oral Presentation: CPR related Moral Distress: A Descriptive Survey Study of Acute Care Nurses. May 7, 2024. Portland, OR, USA.
19. Onishi, E, Yuasa. M. The 15th Annual Conference of Japan Primary Care Association: On Demand Presentation: Five Years after its First Performance in Japan, "Kanwatalk®", born from the U.S. Communication Training "Vitaltalk®", Outlook in Japan. June 2024. Hamamatsu, Shizuoka, Japan.
Book Chapters
1. Current Status of Women’s Health in the US, The Journal of Therapy, Volume 86 June 2004, Japanese Language, Nanzando, Tokyo, Japan.
2. Family Practice: What to Do After Residency, Chapter in “A Roadmap to American Clinical Medicine”, Third Edition, 2005, Japanese Language, Nanzando; Tokyo, Japan.
3. ACP for Emergency Settings: Approach to Delivering Bad News and Making Important Decisions; Chapter “How to Manage Conflict”, Japanese Language, Igaku-shoin, Tokyo, Japan. 2022.
Web News Organization Citations
1. Why it’s so much easier to get an opioid prescription in the US than in Europe or Japan, Vox, August 8, 2017. https://www.vox.com/policy-and-politics/2017/8/8/16049952/opioid-prescription-us-europe-japan
2. Even More Doctors Are Cutting Back On Opioid Painkillers. BuzzFeed News. May 2, 2018
https://www.buzzfeednews.com/article/danvergano/opioid-prescriptions-survey-sermo
3. How Culture Makes Medicine, by Amos Zeeberg OpenMind, July 7, 2022.
https://www.openmindmag.org/articles/how-culture-makes-medicine
Invited Lectures, Conference Presentations or Professorships
International and National
1. 14th Annual Gender Equality Forum sponsored by Japan Medical Association, invited speaker for the symposium: Report from OHSU, Oregon US; Current status of female physicians in OHSU Family Medicine Residency. May 26, 2018. Kochi-shi, Kochi, Japan.
2. Asian-Pacific American Medical Student Association 2023 National Conference Workshop: Navigating through Cross-Cultural Diversity and Challenges while Caring for Seriously Ill Patients. Co-presenter: Hong Lee, PhD. March 4, 2023. Portland, OR, USA.
Regional and Local
1. Visiting Physician, Bokuto Hospital: Family Practice for Female Physicians. June 2002. Tokyo Japan.
2. Visiting Professor”, General Medicine and Primary Care, University of Tsukuba, School of Medicine: Family Medicine in the United States. May 30, 2007. Tsukuba, Ibaraki, Japan.
3. Visiting Professor, General Internal Medicine, Kobe University: Family Medicine in the United States. September 21, 2009. Kobe, Hyogo, Japan.
4. Visiting Professor; Palliative Care, Osaka University: Hospice in the United States. May 29, 2012. Osaka, Japan.
5. Visiting Professor: A lecture to faculty and students from the Inje University School of Design: Fall Prevention. October 14, 2013. Gimhae, South Korea.
6. Gentiva Hospice West region annual meeting: Update on medications in Palliative care. September 14, 2013. Las Vegas, NV, USA.
7. Visiting Professor; Lectures for residents and attending physicians, Otowa Hospital, October 17, 2013. Kyoto, Japan.
8. Visiting Professor; A presentation to medical students, Special training seminar to learn Comprehensive Medical Care: Family Medicine in the US. February 15, 2014. Tsukuba, Ibaraki, Japan.
9. Symposium “To Think and Learn about Comprehensive Practicing Ability”: How to Communicate Well and How to Make a Good Presentation? What are the Important Factors for Comprehensive Practicing Ability? February 16, 2014. Tsukuba, Ibaraki, Japan.
10. OHSU DFM Grand Rounds: Non-Beneficial Care. Family Medicine Department. August 20, 2014. Portland, OR, USA.
11. Gentiva Hospice West Region annual meeting: Hospice and Palliative Care Update. August 23, 2014. Las Vegas, NV, USA.
12. Cancer Professional Community Medical Care Symposium: Hospice Care in the US. October 24, 2014. Osaka, Japan.
13. Kindred at Home/Gentiva Hospice West Region annual meeting: Prognostication tools, are they useful? August 22, 2015. Las Vegas, NV, USA.
14. Visiting Professor, A presentation at Tokushima University, School of Medicine: Medical system in the US, a career path as a physician in the US. October 24, 2015. Tokushima, Tokushima, Japan.
15. The 20th Pennington Lecture, OHSU, Department of Family Medicine: Differentiating the Dementias and Making It Matters. September 16, 2016. Portland, OR, USA.
16. Asian-Pacific American Medical Student Association 2019 Regional Conference Workshop: Care and Cultural Diversity at the End of Life. March 16, 2019. Portland, OR, USA.
17. A Pancreatic Cancer Roadman: Guidance for Patient and Families 1st conference sponsored by Brenden-Colson Center for Pancreatic Care: Working with Your Primary Care Provider. September 14, 2019. Portland, OR, USA.
18. Asian-Pacific American Medical Student Association Regional Conference, Region VI+VIII: Care and Cultural Diversity at the End of Life. October 24, 2020. Virtual presentation.
19. Salem Marion County, Oregon Adult Behavioral Health Advance Care Planning Presentation; Co-panelist: Advance Directives and More. June 16th, 2022: Virtual presentation.
20. Continuing Professional Development-Primary Care Educational Series through Salem Health Hospitals & Clinics: Advance Care Planning - Let’s start in the Primary Care Setting. November 1, 2022. Salem, OR, USA.
21. Clackamas Community College, Gerontology Class. Invited as an Advance Directive Advisory Committee (ADAC) member: Let’s Learn About Oregon Advance Directive and POLST! May 16, 2023: Virtual presentation.
22. Oregon Gerontology Association Seminar. Invited as an Advance Directive Advisory Committee (ADAC) member: Advance Health Care Planning 2023, The Oregon Advance Directive and POLST. May 30, 2023: Virtual presentation.
23. Post-Acute Care Partnership in Oregon Presentation. “How Can We Better Guide Our Patients on Their Post-Acute Care Journey?” June 22, 2023: Virtual presentation.
24. Professional Development Conference, Salem Health. “CPR related Moral Distress: A Descriptive Survey Study of Acute Care Nurses Name” August 3, 2023: Salem, OR, USA.
25. Oregon Hospice and Palliative Care Association Educational Webinar. “What Hospices Need to Know About the Update to the Oregon Advance Directive and the POLST” September 7, 2023: Virtual presentation
26. Oregon Hospice and Palliative Care Association Educational Webinar. “Updates on Oregon’s Advance Directive and the Oregon POLST” November 11, December 12, 2023: Virtual presentation
27. Providence Center for Health Care Ethics, Lunch and Learn Event. “CPR-Related Moral Distress: A Descriptive Survey Study of Acute Care Nurses” December 14, 2023: Portland OR, USA: Virtual presentation.
28. Ambulatory Nursing Conference 2024, Oregon Health and Science University “Empowering Nurses to Partner in Advance Care Planning” February 24, 2024: Portland, OR, USA.Virtual presentation.
29. Institute of Continued Learning, Willamette University, class session. “Let’s Start Your Advance Care Planning Exploring the Oregon Advance Directive, the Oregon POLST, and More~” April 4, 2024: Salem OR, USA.
30. 2024 Annual Conference Oregon Academy of Family Physicians. “Let’s Learn More about Oregon POLST and AD” April 12, 2024: Portland OR, USA.
31. 2024 Annual Conference Oregon Academy of Family Physicians. “Primary Care Beyond Clinic Walls-Second Cohort Pannel Discussions and Presentations” April 12, 2024: Portland OR, USA.
32. 2024 Spring Intensive: Regulatory Update, Oregon Hospice & Palliative Care Association and Washington State Hospice & Palliative Care Organization. “How Do We Coach Them to Not Say That? An Implicit Bias Panel” Panelist. May 2, 2024: Portland OR, USA.
33. 2024 Spring Intensive: Regulatory Update, Oregon Hospice & Palliative Care Association and Washington State Hospice & Palliative Care Organization. “Opportunities in Community Advance Care Planning Conversations” May 2, 2024: Portland OR, USA.
34. 2024 Spring Intensive: Regulatory Update, Oregon Hospice & Palliative Care Association and Washington State Hospice & Palliative Care Organization. “Relatedness & Coverage Challenges” Panelist. May 3, 2024: Portland OR, USA.
35. Oregon Academy of Family Physician Lunch and Learn (CME provided). “Let’s Learn about Oregon POLST and Advance Directive” June 18, 2024: Virtual presentation
