Surgeon and prizewinning writer. Everybody who passes away does not do so from some part it is a months long dealing with internal cancer or congestive Heart Failure and so on. We do not have the rituals for how to even talk about what that process is like. All that and more coming up. Welcome to democracy now . The Supreme Court has dealt a major victory for marriage equality. The decision leaves intact Lower Court Rulings that struck down samesex marriage bans in virginia, utah, oklahoma, indiana, and wisconsin. Caseintiff in the indiana celebrated with his husband. We have been together for 27 years. This just kind of makes it official and we can check a few boxes and get some Health Insurance for stephen because he needed Health Insurance. They cannot deny that for me anymore. Our daughter is protected. If something happened to us. Of the ruling, county clerks across the five states begin issuing marriage licenses to samesex couples. The Supreme Court decision will also expand samesex marriage rights to six additional states. That will bring the total number of states where samesex marriage is legal to 30, a majority of the country. Planes are targeting Islamic State militants near the besieged syrian town of kobani along the turkish border. Kurdish forces are struggling to push back the militants after they danced into the town monday, claiming eastern neighborhoods and causing hundreds of civilians to flee. Have so fares failed to halt the militant advance. If the militants capture co ,onnie, they will kobani they will control a large swath of the turkish border. The United States and its allies airstrikes inut iraq, 70 of them in iraq. All of the strikes targeted the Islamic State. Airstrikes had combat positions, training positions, and arms caches. They destroyed or damaged more than 300 vehicles. Also said it has begun flying helicopters in iraq for the first time as part of the campaign. The step could put u. S. Troops at risk for fire from militants on the ground. A new report finds a large percentage of the ammunition used by Islamic State militants in iraq and syria came from the United States. Conflict Armament Research analyzed small caliber ammunition recovered from the militants. The cartridges originated in 21 countries, nearly 20 of them came from the United States. The report states that i s forces appear to have acquired a large part of their current seized from stocks or abandoned by Iraqi Defense and Security Forces the u. S. Gifted much of this material to iraq. Missing00 people are after a boat carrying migrants from syria and Subsaharan Africa sank in the Mediterranean Sea off the coast of libya. Dozens of other migrants were rescued. A report found more than 3000 migrants have died crossing the Mediterranean Sea this year, more than twice the previous high from 2011. Strike has killed six people in northwest pakistan. Unnamed intelligence officials told reuters the target was a suspected militant training cap in the area of south waziristan. Theattack was at least third u. S. Strike in the area and at least three days. The two earlier strikes killed five people each on sunday and monday. Kenyan president kenyatta announced he is temporarily stepping down in order to face charges of crimes against humanity at the International Criminal court. Kenyatta and his deputy ruto stand accused of inciting Ethnic Violence which killed 1200 people after the kenyan election. By turning power over to ruto, kenyatta will avoid becoming the first sitting president to appear before the court. I now take the extraordinary and unprecedented step of invoking article 140 73 of the constitution and i will shortly issue the legal notice necessary to appoint william ruto the deputy present as acting theident while i attend conference at the hague in the netherlands. The u. S. Practice of forcefeeding hunger striking prisoners at Guantanamo Bay is receiving an unprecedented public hearing in civilian court. The case involves a syrian Hunger Striker involved for over a decade. Abu wael dhiab remains a quantum on being cleared for release in 2009. He has been on Hunger Strike periodically for seven years to protest his indefinite detention. His attorneys are challenging forcefeeding practice this is practices. As well as the use of the torture chair where the heads in all four limbs are restrained as a feeding tube is an suited in their nose. The Justice Department tried to keep the hearing secret, but u. S. District court judge Gladys Kessler rejected that request. She ordered videotapes of the forced feeding to be publicly released after they are rejected. Redacted. At quintanasoner most said he guantanamo said retrieve the british hostage was beheaded last month. He was released after the case to against him collapsed. It he he was released, began talks to help secure the release of henning. The bbc he wanted to send a video message he believed to the militants would heed. I can make a video message, deliver it in a language that Islamic State would understand to say that i myself was a former guantanamo prisoner facing execution. He had been a prisoner of the americans. It was a direct statement i wanted to make in the arabic language. Inhe said he spent time syria before the rise of isis and secure the release of other hostages. He said the British Government failed to look at his offer seriously due to its attempt to demonize and criminalize me, he said. To see our interviews, we went to interview him after he was released by authorities, you can go to democracynow. Org. The Mexican Government has sent federal police to take over security and the severance date Southern State of guerrero disappearance of 43 students. Police and unknown gunmen ambushed their buses. 22 Police Officers have been detained. The mayor and police chief appear to have fled. The police have been accused of collaborating with a drug gang. The mexican president vowed to bring the perpetrators to justice. I particularly regret the violence that has occurred and above all else that they are mostly young students. Mexican society, the families of the young people, are rightly demand and clarification on the incident and that justice be done and that those found be brought to justice and that there is no impunity in the case. The families have continued to them protest to the government. The mother of a missing student said authorities would do more if it was their child missing. Andhey will move heaven earth to find them. This is what we are going to do. We are going to do whatever it takes to find them and we will not rest until we find them. Womens Health Providers and taxes have in texas have asked to block sweeping legislation that would block choice. They would shatter all but eight abortion facilities in texas where there were previously more than 40. The only two remaining clinics in the Rio Grande Valley were forced to close. Abortion patients who arrived on friday were told that the nearest legal Abortion Facility was now about four hours north. Have filed ans emergency application asking the high court to intervene, saying we are being forced to turn women away from safe compassion and health care simply because of our politicians ideological agenda. Immigrant women in prison in south texas have accused guards of sexually assaulting them. County Detention Center opened in august and is run by the private company they geo group. It holds more than 500 mothers and children who are seeking asylum after fleeing violence and persecution in central america. Guards are promising women help with immigration cases in return for sexual favors and removing them from their cells at night to sexually abuse them. With more on the Detention Center and on the crisis of on wednesdayss, when we broadcast live from san antonio. Members of the Ohio Student Association have occupied the Police Station in the town of beaver creek to protest the Fatal Police Shooting of john crawford. A 22yearold africanamerican, crawford was killed inside a walmart in august and a 911 call or falsely accused him of pointing a gun at customers. He had picked up an unloaded bb air rifle, which was on sale at the store. A grand jury declined to indict the officer who fatally shot him. 20 students slept in the lobby of the beaver creek police department. They are demanding the firing of the officer who shot crawford and criminal charges against the 911 caller whose account was contradict it by surveillance footage. Ruled policege has and ferguson, missouri violated the constitution when responding to protests over the Fatal Shooting of michael brown. The case concerned the Police Practice of forcing protesters to remain in constant motion, telling them they were not allowed to stand still or that they were walking to slowly. The activist professor and writer Betty Reid Mandell has died in massachusetts at the age of 89. Known locally as the fairy godmother of the welfare office, she distributed survival tips to help Homeless People obtain aid and published frequent articles challenging what seesaw she saw as a war against the poor. Those are some of the headlines. This is democracy now im amy goodman. Welcome to our listeners and viewers around the country and around the world. Leone is pleading for more International Help despite the Ebola Outbreak in west africa. Recorded 120 deaths on saturday in one of the single deadliest days since the disease appeared more than four months ago. The president spoke on monday. We should be this, mindful that ebola is still around. We need more Treatment Centers. We need 1000 Treatment Centers in the whole country. What we are doing is our responsibility. As a government, it is our responsibility to do it. But we need the partners who want to help us to come as fast as possible. We need them yesterday. If it until today they are not here, they should not wait for another day. At least 678 people have died in sierra leone. Says at least 3404 have died of a cola in west africa. The actual title is believed to be higher. President obama said his administration is working on fortional protocols screening airplane passengers to identify people who might have ebola. Without a travel ban on africa. Protocols to do additional pass through at the source and in the United States. All of these things because confident that the chances of an outbreak in the United States are extraordinarily low. The first patient diagnosed on u. S. Soil, thomas eric duncan, remains in Critical Condition at a dallas hospital. He was diagnosed after flying in from liberia. Duncan is now receiving an experimental therapy initially intended for other viral diseases. The handling of his case has raised questions about how u. S. Hospitals are prepared to handle and Ebola Outbreak. At texas Treatment Health presbyterian after he began feeling ill. Despite telling a nurse he had just returned from liberia, he was initially discharged with antibiotics. He returned to the same hospital by ambulance after vomiting outside the apartment complex where he was staying. He was then diagnosed with ebola. In madrid hasrse become the first person to contract the disease outside of west africa. She treated a priest who returned to spain from sierra leone. , one have dr. Atul gawande of the most Influential Health policy writers in the country. Surgeon inwande is a boston, a professor at Harvard Medical School. He is a staff writer at the new yorker. Author offfer of several books. His most recent book has been published. Being mortal. We will talk about the new book in the coming segments. We are going to start off with ebola. A welcome to democracy now lets talk for a moment about the piece you just wrote on mr. Duncan and what happened in the hospital. Weit showed some of the gaps have that i have been writing for a long time. We know the checklist for what needs to be done when people come in with potentially infectious disease. They deployed the checklist at this hospital about asking about somebody who has a fever and a travel history. The nurse captured he did not tell them liberia. He was more vague. He said africa. She recognized that this might be an ebola case. She entered it into the records. There is a communication breakdowns. The doctor did not pick it up. This kind of breakdown likely happens all over the country all the time. This was not a special event. It has forced our hospitals to realize that they have to download the checklist and then learn how to use them. The most common failure is a communication breakdown like this. A failure to pass on information that is critically important. I wanted to go back to the checklist manifesto. You were making about a surgeon being in surgery and what it means just to a knowledge the people, the nurses and the others, who are with him to assist him. Talk about that whole scenario. This is almost a philosophical issue in our profession. Do we follow the known procedures that exist or do we just kind of go with our judgment every time . In the operating room, the known way to make it more safely is there are a few things you do around infection practices, there are a few things you do around communication. You make sure nurses can speak their concerns. You make sure the anesthesiologist has reviewed the medical history. The surgeon reviews the Major Concerns and plans the operation. You would think we would do this every time. It is like getting in an airplane. We had not. , weound that making that can lower the death rate. Knowing the nurses names can decrease the death rate . It is like a Football Team having the huddle before they go to the line. If they did not have the huddle, people would not necessarily know, they just assume you know where the ball is going. The same thing happens on ebola. In an operating room, we are seeing reduction in death when people use these kinds of basic tools. The netherlands implemented this across the country and they lowered the death rate 47 compared to the control group. It is hard to pull off because of the cultural barrier. That is the barrier we saw in the texas hospital that is happening all over the country. 2 Million People come into hospitals and they pick up infections in the hospital that they did not come in with because people were not wearing the counts properly, putting on the gloves properly, washing hands properly. Rightw how to do the thing, but we do not always systematically walk our way through it. You talk about simple verbal comp formation confirmation. The most common breakdown in the safety of a hospital is that people do not communicate the critical information. Just because you put it in the computer does not mean anyone will know it or use it. In high risk other industries, you communicate verbally to somebody else the critical information and make sure they received it and understood it. It could be electronically confirming they got the information or facetoface. If you are concerned you have someone with ebola, you do not put it in the computer. You tell them and you hear that it has been fed back. That is where it broke down. This goes to the whole issue of digital medical records. Having spent time visiting people in hospitals, seeing the frustration with nurses and doctors spending more time facing the computer screen trying to figure out how to categorize particular things, when they want to just convey impressions that they have. Dos windows the phase of american computerization. There is no question that it has made life incredibly safer for patients. Information you would otherwise not have, prescriptions are not eligible and hard to read. Nowhe same time, we are spending our lives facing the computer screen instead of the patient. Surveys have looked at theralization and find that computers are themselves causing tremendous demoralization. We have all become data entry morers, spending more and time entering data and not doing what is really the work of taking good care of patients. The design of the system is what has to change. , maked that userfriendly it easier to be inexpert. I dont think the computer industry is waking up to that yet. Go larger than mr. Duncan in the texas hospital. Talk about the ebola crisis. Thousands of people are now dead. The president of sierra leone is desperately reaching out for help. What is going wrong here . Why isnt this being contained . What are the implications for Public Health . The epidemic in west africa is severe and getting worse fast. Ist people dont understand that this outbreak started last december, starting at march 31, Doctors Without Borders said that the hospitals in guinea and liberia are overwhelmed and they were crying for help. As late as september 2, they were telling the u. N. And others that the help being provided is a shamble of assistance against a disease that is doubling in the number of cases every three weeks. Our response was pathetic. We simply mounted no substantial response. It might have been the best thing that has happened that the first case to leave the african continent came to america because it brought our mobilization to relies what happens there matters to us here. Suddenly, we are now mobilizing thousands of people to go. The cdc has mounted the Largest Global operation for Public Health in u. S. Government history. It is going to be working district by district to create emergency treatment units and isolate the sources. The second part of this is that this is a disease that is eminently stoppable with basic Public Health measures. The most basic Infection Control measures that we generally follow, should be following in our own hospitals. It is highlighted in the fact that it is in the places where the Health Systems are broken down. You have people being turned away from hospitals because the beds are overwhelmed. There are calls for closing borders. What is your take . It is a real danger to do that. In order to stem the tide, one of the things that the model shows that if you just try to shut it down with a travel ban, healthcare workers cannot get in. The disease explodes within the combined area. It spreads even more widely. You have only delayed it coming abroad by a few weeks. The reality is that we will see a few cases over the next months that may come here. We know how to contain it. We know what the checklist is for taking care of it. It will my become an epidemic here. The general public is not at risk. This is a hard virus to spread. It is harder than the common cold. It spreads because if you have contact with the vomit, the ofod, the stool, the saliva someone who was actively sick and infected, you are going to run the risk. Those are caregivers. That is why the people who are getting the virus or healthcare workers and family members. End up containing it and containing it very quickly. Doesnt this also go to the issue of public versus Corporate Health . With epidemics like these, it is not in the interest of corporations to have developed cures. They do not have a large profit margin. The World Health Organization had their budget gutted at a time when it seems we need this more than ever. The vaccine for ebola had been in development for more than a couple of years. The interest and it was never going to come from a Forprofit Corporation because you could not bank on there being this kind of epidemic to drive it. Instead, you need Public Investment in Public Health and in this kind of research. It sat fallow. Now there is tremendous interest. Now you have the nih and the pharmaceutical Companies Gearing backup this drug that was on the shelf for a couple of years. We are talking with dr. Atul gawande. He is the author of a number of books. The checklist manifesto. His most recent book is being mortal medicine and what matters in the end. We will talk about that in a minute. [music break] here on democracy now im every good amy goodman. We turn now to a new book that calls for a radical transformation in how we approach the end of life. That al gawande argues rigid focus on prolonging life can undermine what is best for a dying patient. Has renderedce obsolete centuries of experience, tradition, and language about mortality. We increase the harm we inflict on people and deny people the basic comforts they most need. The book is called being normal being mortal. It is by dr. Atul gawande. Book. S his fourth thethers include checklist manifesto. I wanted to go to the first line of your introduction. I learned about a lot of coal things things in medical school, but mortality is not one of them. We teach doctors how to try to save people. We teach very little about how we manage the realities of what we cannot fix. The place we have ended up in is a Health System that not only has the basic Public Health failures we previously described, but this other failure, which is the ability to manage mortality. I have been a surgeon for more than a decade in cancer surgery. I could see that my own skills were inadequate for helping people navigate what is normal. Denial, anxiety, the desire to have everything thrown at you. There have been a series of studies about how badly this is going. They took lung cancer patients, half of them got usable oncology care and the other got usual careplus a palliative about what happens if and when things dont work out. They went on to hospice sooner and had less suffering at the end of their lives and they lived 25 longer. We are making bad decisions because we are unwilling as a profession and his families to begin earlier the discussions and planning for how we deal with endoflife or just the aging process. You profile many cases where patients suffer because of inability to reckon with death. Im wondering if you can profile sarah thomas maloney. That broughtne home to me. She was a 34yearold woman who was diagnosed in her eighth month of pregnancy with lung cancer. This is as hard as you possibly can get. She knew it was not curable. You want treatments that can extend the time you have. She got her infant baby and wanted to spend as much time as she could with her new daughter. She knew the end would come. We had a plan that this would not end with having no quality of life in the end. And yet the train still went down the track. I was part of that team. What i found was that we had an inability to recognize and even ask questions about the fact that people had priorities beside just living life. ,riorities include things like i really care about whether my brain works as time goes on. Whether im suffering from daily pain or not. The power that comes from the fact that we can have discussions was reflected to me in my own fathers case where he had a brain cancer in his brainstem. We had the conversations that i learned from Palliative Care physicians. Palliative care is a specialty that has evolved for how to make preservedellbeing is in the course of their life, especially with chronic illness or terminal illness. Palliative care is often paired with hospice, where if you reach the stage where youre at the last six months of your life, you can be eligible to move into care that is really about having your best possible day today instead of sec or facing your time for the sake of the future. Sacrificing your time for the sake of the future. Palliative care asks basic questions like, tell me what your understanding of the condition is, tell me what your fears and your worries are about the future, tell me your goals, tell me what outcomes are unacceptable for you. That is what we failed to ask sarah. When we asked to them for my father going through his brain cancer, that gave us the direction where we understood what really mattered to him. He was a social person. He was a very active person. He went through surgery to preserve that capability. When chemotherapy started to take that away, that is when we stopped. Talk about your grandfather. That goes to the issue of how cultures honor aging or marginalize people. My grandfather had the kind of old age that i think we are nostalgic for. Village in a rural until the age of 110 in india, 13 children, he was surrounded by family all the way to the end. If he was in america, he would have been in a nursing home for the last years of his life. Instead, he was supported by family, at the head of the dinner table every night, often consulted on Business Decisions and marriages right to the end. It was a way that we wish we all could have. The reason it worked is because it in slave young people. It was often young women whose futures were tied to his future. The progress of countries, whether with us in the 19th century or india and korea today is giving young people to freedom to work and live where they want and marry whom they want. It in slave young people. He had sons in their 80s still wondering when they would inherit land so they could have a living in the future. We moved to a place of freedom. Moving to freedom meant that young people went to the city. They became more prosperous. , whether the plan 19th century or 21st century, for what happens with the elderly who are left behind. The answer became, medicine will take care of them. Medicine has proved to be an extraordinarily expensive way to take care of them. Great when we have treatments that can repair problems, replace an arthritic knee. Thathen it is a problem has only mounting difficulties, my fathers brain cancer, simply the old age of my grandfather, putting people in the hospital and expecting that that is going to fix things does not work. What is your main critique of the nursing home system . The main difficulty is that by putting medical values into the place that take care of us while we face the realities of mortality extend well before the end of life. You simply cannot get around it anymore. You move into a nursing home and health and safety and survival are their top values. The result is that you lose what matters to your life, which includes euro and freedom. Your own freedom. I discussed the case of my wifes own grandmother. Her experience was she could not wear the shoes she wanted because they were not safe, the heels were too high. She had no privacy because no one cared for no one focused on that because that is not a matter of safety or survival. She cannot eat the food she wanted because that could be, some of it could be you will see the biggest complaint with all summers patients is that they will not stick to just eating the pureed food they are supposed to eat. Alzheimers patients will hoard cookies. Give them the dam cookies. [laughter] let them have something more to live for then just safety and survival. Pioneers, group of some of them call themselves nursing home abolitionists, who were marie making how senior care works. We are reexcited about technology, but to me the most exciting innovation is how people are redesigning the places we care for the elderly, so that they can make choices and have lives they want to live. Of the problem that they are segregated . There is no the longer that intergenerational atmosphere around them . This remarkable film of a social worker called alive inside who goes into a nursing home and puts earphones on older people who have been and have not contacted in the world. Suddenly, they come alive. What they are doing now is kids are coming in after school with their Favorite Music and playing it for older people. It might not even just be the music. A retirement home with nursing home facilities that is also attached to a school. The elderly go in and teach classes. Just because you are in a wheelchair does not mean you cant contribute anymore. They teach and tutor in the library and vice versa. The students take care of the elderly with exceptional needs. I tell the story of a young man who cares for an elderly man who died after severe dementia and had him give the eulogy at the funeral. There is this possibility. In every experiments state in the country that have created places like this. That wejust a mentality need to have. I was deeply moved in your book about the geriatric ward floor that you never even bothered to walk into, you said. Talk about the experience of sitting there with a lead geriatrician and his patients. Howhis brought home to me we are utterly failing to teach basic skills the geriatricians understand. What is the geriatrician . They take care of the elderly people number or dominantly over the age of 75 or 80. Say to mom, lets go see a geriatrician today . Patients, heis would be willing to take the time to deal with a high blood pressure, the bad knees, the lung cancer. They have a lot of issues. What he recognized was, howd do you cut through that to recognize what the most threatening concerns are for a person . Tell us the story. It is astonishing what you thought was important and what the doctor thought was important. He nodules seen on her lung film that might be a possible cancer. What the doctor said was the geriatrician recognized the most significant danger to the woman was that she was going to fall. She knew how to examine the feet. We dont even teach that. He said, take off your shoes. Every patient had to be examined with their shoes and socks off. He would watch how they took them off. To see if they could reach down to care for their own nails. What the condition of the toenails were. It matters because if you have painful feet, they make you unstable. He recognized that the woman was on multiple medications, some of them were were dehydrating her and making her dizzy. That issue of medication. There is an interesting role he had which has to do with having more than four meds. This is not just his role. This is Research Evidence that most doctors do not even know. Patients on more than four drugs isnt much higher risk of having a fall. Is at much higher risk of having falls. For this woman, the biggest danger to her of losing her way of life is that you would fall and break her hip and a 50 chance of death six months later. He changed her medications. He simplified them. He worked on having her see a podiatrist and he changed her nutrition. A year later, she was still living her apartment on her own and doing remarkably well and maintained her weight. We dont teach geriatrics to 97 of her medical students. The geriatrics profession has fewer people who are being trained in it today than a decade ago, even though our numbers of people who do you skills are exploding. This has been our failure to value the skills that absolutely matter most to our future. What i will care about. System forngle payer the government was at the cost, we had far more faulty for cash people that if we had a system where cost mattered and actual human conditions mattered . Thehere are many things singlepayer system may be able to make better. But we have a singlepayer system for the elderly and it has not served its needs. Medicare. Some of it is for political reasons. One of therd lowest paid professions in the country is being a geriatrician. We have had this political sure physicians are paid for the time to have conversations about the needs of people as they face the end of life or face their mortal problems. It was accused of being a death panel. I think we are beyond that now. Part of the reason to write this book is that we have been able to move beyond the idea that this is about death panel. This is about assuring people not that they have a good death. That is not the goal. The goal is as good a life as possible all the way to the very end. We are talking to dr. Atul gawande. Writer for the new yorker and is just out with his new book being mortal. We will continue our discussion in a minute. [music break] this is democracy now . Ur guest is dr. Atul gawande the author of a number of books including the checklist manifesto. And being mortal. In the book, you talk about a choice that patients are faced with in terms of choosing hospice care, which is translated to giving up, or choosing dangerous invasive procedures which is perceived as the best choice. I found i would pose options to people and it would always be about, do you want to fight order you want to give up . I knew that was not the right way to think about it but i did not know how we might want to think about a better. What are we fighting for . The people i saw in hospice, what was amazing to me as i watched the work they did, they were fighting, too. They were fighting to give people a good day. The idea of what our goals are, it boils down to medicine ordinarily says we will sacrifice your time now for the sake of time in the future. But we have to be open to the may wantople a to have my best possible day today and use the medical capability to accomplish that. That does not only have to happen in hospice. That has been a huge mistake. If we orient ourselves to the concept that we need to communicate to our doctors if they are not asking the questions, communicate to them what our best possible day is, what the life that is worth , tell people is are fears and anxieties, tell them our goals for what happens if our Health Worsens and what outcomes are an acceptable, then we can have a Health System that drives toward what we are trying to achieve. That it is lower costs and helps people to live longer. Study thatished a found that hospitals make a lot more profit when an insured surgical patient develops complications than if it comes off without a hitch. I did. I was looking at the perversity in our system that we will pay more and more for procedures. If there is a complication, it turns out that the profit margin goes up for hospitals. What is the incentive to invest in keeping people out of the hospital, making sure the care is appropriate and not inappropriate, and making it as safe as possible . No hospital is trying to profit by increase complications and deaths. The main issue is that you simply just dont invest in it. In my office, we will higher a whole phalanx of people to check insurance numbers and it always pays to hire one more to triple check the insurance referral number. But hire one more nurse who could contact the patient earlier and keep them out of the hospital by catching problems after they have left from the operations i do, you have to fight for it because there is no margin and being able to pay for that. I wanted to ask you about the issue of assisted suicide. It 29yearold woman was diagnosed with an aggressive form of brain cancer. Dr. Is advocating for assisted suicide. She moved to oregon so she could benefit from the death with dignity law. This is the next from a video she appears in. I dont wake up every day and look at it. [laughter] it is in a safe spot. I know that it is there when i need it. I plan to be surrounded by my husband and myy mother and my stepfather and my best friend, who is also a physician, and probably not much more people. I will die upstairs in my bedroom that i share with my husband, with my mother and my husband by my side and pass peacefully with music that i like in the background. That is britney maynard. She has chosen to die on november 1 so she can celebrate her husbands birthday with him the previous day. Your take on this issue. I think that if we are unwilling to recognize that when people have unbearable suffering that we can do nothing about that they need to be allowed to have an option where they can relieve that suffering. If i had the chance to vote for a safe i would allow approach like they have been taking in oregon and washington, i would be in favor. However, i am worried about the goal that a good death is our aim. As goal is as good a life possible all the way to the very end. The fear and concern that britney has is that they will not be allowed that possibility, that they will just have suffering toward the end. Of patients in washington and oregon choose this. Medication, less than half of them end up using it. It just relieves them to know that they have the option if it needs to be there. The critical parts are that we have the capability to relieve pain, to relieve nausea, to relieve many of the terrible symptoms people have. We have the capacity to help them recognize and achieve goals that they might have to the end, everything from being able to say goodbye to people. I tell the story of my daughter upon piano teacher who was suffering in tremendous pain. When it finally got in control, she said, i want to teach my students again. My daughter got four lessons with her before her last weeks of life and a final recital. What that woman was able to pass not even dream was possible. She might have chosen assisted suicide in that moment of pain when no one was doing anything. I just wanted to read to you what if you were just wrote in. A life as good as possible right to the end should include a far cheaper attendant care at home for people who dont need Nursing Homes, but gets sent there anyway because the system rewards Nursing Homes. Medicare does not pay for home care attendants, which is much cheaper. The listener is right. Want is themost ability to be at home. There is two ways in which we mean that. We are able to provide services for far less that can sustain people longer in the home. We are not doing an adequately. Point thatach the you cannot be in the home, we put people in Nursing Homes that feel much more like hospitals. There isve no control redesigned of many of these places to make sure they are smaller, just a dozen people and it is not organized around a nursing station but a kitchen. The elderly are allowed to go in and opened up the kitchen door and have what they want. This is regarded as unsafe. That is why people want to be in their homes as long as possible. Movement called the villages movement. These are the very crises that can drive you into a nursing home and it does not take that in mexico, they have the day of the dead. We are a culture that is violent, but does not deal with death and any approachable way. Whyd you think our society is aware verse to death. There is an interesting statistic that is happening right now that we dont recognize. In 1960, the majority of americans died in their home. I the end of the 1990, it with 17 . In the last five years, the number of people choosing hospice has grown to almost 50 people are shifting and having that experience in bringing or in the Hospice Center outside of hospital and nursing home institutions. That is a remarkable change. We are all starting to have that experience that death is terrible, but death is normal. You in most shocked writing this . You are at the top of the hierarchy as a surgeon. He see geriatricians are at the bottom. What most shocked you and what is most important to change . What most shocked me was how temple simple the change turns out to be. Recognizing the people have priorities besides living longer and the most powerful thing we can do is ask people what the priorities are. We dont. We dont do it as family. We dont make it a priority in the home where we take care of folks. We dont do it in hospitals. Cost. S driving tremendous more importantly, it is driving suffering. There is this full idea that is surprising to me that there is the possibility of still achieving a potential in your life even in your last weeks of life. There are Amazing Things that can happen, like the story of my daughters piano teacher. That to me shows a picture of the future we can have. Dr. Atul gawande, we want to thank you for being with us and for writing this book and others. He is a surgeon at the brigham and Womens Hospital and a staff writer at the new yorker. He is a professor at Harvard Medical School and the author of a number of books. s most recent is being mortal. That does it for todays broadcast. If you would like a copy of todays show, you can go to our website at democracynow. Org. I will be speaking at Trinity University tonight at 7 00. On thursday, i will be at university of michigan flint and friday in santa fe, new mexico. Check our website, democracynow. Org. Special thanks. Special thanks. Special thanks. narrator toward the end of the first millennium b. C. , a complex society sprang to life in mesoamerica imaginative, literate, philosophicallyinclined and sophisticated. This eevol ctu cit out of the primordial forest and sunk its roots into the soil. Today, we know the region by its countries mexico, honduras, el salvador, belize, and guatemala. But long ago, it was the world of the maya. Not an empire, nor a country, the classic maya culture