As Dr. Ellen Brown begins her house calls, there is a distinct lack of the impersonal formalities one might normally associate with a doctor's visit. Instead, there is familiarity and good cheer in her rapport.
Brown, a medical director at the nonprofit home health care provider Pathways, specializes in offering comfort to her patients in their final months of life. The specialty is known as hospice and palliative care, and Brown visits up to four such patients across the Bay Area per day. Recently, the Palo Alto resident was selected as 2011's Home Care Physician of the Year by the California Association for Health Services at Home (CAHSAH).
"People have lots of questions when they begin reaching the end of their lives," Brown said. "And a lot of the time, patients just need somebody to listen."
Hospice care is mostly about ensuring a good quality of care, she said, and paying attention to what patients want to achieve in the time they have left.
"We want to make sure we can get them to reach those goals, whether they include traveling, or something as simple as going to their grandchild's graduation ceremony," she said.
Evelyn Landes, a Midpeninsula patient of Brown's, suffers from heart and lung disease. She faces considerable difficulty breathing and spends much of the day connected to an oxygen feed. Her condition makes it tricky for her to enjoy even the simplest pleasures, such as venturing out into the garden, and her energy varies day to day.
Brown checks in on Landes' condition and ensuring that her medication is in order. But Brown's concern also lies in assessing her patient's feelings and answering any questions Landes and her husband, Nate, have.
On a recent Thursday, Brown checked to see if the swelling on Landes' feet is causing pain, tested her breathing to see whether her discomforting wheezing has subsided, and asked her whether she is enjoying her meals -- not just eating them.
Though she will often only see patients a handful of times, her relationship with them and their families is like that of a trusted friend, and this is more than reflected in the warm welcome she receives from the Landeses.
"Coming out of high school, I knew I wanted to be a physician," Brown said. She completed her residency at Rhode Island Hospital after graduating from Brown University. Interested in becoming a primary-care provider, the New York native then moved to the Bay Area to pursue a 10-year fellowship in geriatric care and internal medicine at Stanford University Medical Center.
She joined Pathways more than 15 years ago and says that despite the sad circumstances, she finds her work incredibly fulfilling.
"Home visits are my favorite part of it," she said. "There is a huge dynamic shift from when a patient is visiting your office, dressed in a hospital gown, and when you are a guest in their home."
Visiting patients offers the opportunity not only to assess what medication and treatment her patients should receive but to make sure that their support systems -- their families and loved ones -- are there and aren't facing any problems.
"You can learn an incredible amount about a person by making a house call," Brown said. "The medication may be prescribed, but do they have a way of getting it? Is there a system in place? And is there someone close by to help them?"
Some of her visits are to the families of children with just a number of months left. Child hospice care is often a neglected field, she said, and she attends as many conferences on the subject as possible, as well as speaks to pediatricians on a regular basis.
"Our goal is to make sure that we can get children out of the hospital in their final months and help their parents provide the care that they need."
It really helps their peace of mind to know that there are teams of people -- nurses, volunteers, social workers -- that are able to help them, 24 hours a day, she said.
Along with internal medicine, Brown is certified for palliative care medicine, one of the fastest growing specializations in the industry.
Extending to those with life expectancies greater than the six-month requirement of hospice, Brown says that palliative treatment gives patients more opportunities to seek and properly establish the goals of their treatment.
"People with serious illnesses deserve to have people around to help them to determine or reorient their goals, as well as manage their comfort," she said.
"Most people ask me, 'Don't you find it depressing?'," Brown said. "Of course it's emotionally challenging, and some stories affect you more than others, but the way I look at it is this: I truly believe I am helping people and that they really feel better because of the work my team does.
"Yes, they are dying. But dying people still have hope."