Transcripts For CSPAN2 After Words 20141019 : vimarsana.com

This week, dr. Actual go one day indeed mortal. The awardwinning author argues all the medical science consulted the modern area is still sufficient in aging and dying. This program is about an hour. Well come from something fertile but also the idea that grass is mortal. Grass is temper. Host in the process of writing this book, and tender which i think is triggered by the way, when a few times we can have an honest conversation in a public forum about our mortality and about endoflife issues. Did it strike you, hey, im not going to be ready forever . Maybe i should talk to my patients differently about their goals . What impacted writing this book in doing research for this book have on your own practice . Guest a lot. It was kind of the story of the impact it was having did you start investigating even in my own practice we dont do a very successful job of dealing with mortality. We reached by the end of the 1990s a place where 17 of the population died in home from 83 died in institutions, often hooked up on machines, unaware of what was happening in the world, no chance to say goodbye, no chance to preserve some quality of life as they came to the end. It was clear that this was not what people wanted and i wasnt being successful at it. So what begin interviewing patients, family members, over 200 patients, about their experiences with aging in the endoflife. Or just even with a serious illness. I interviewed scores of geriatricians, how did there patricians, nursing home workers, and i learned along the way. A learned about what some of them do better to successful process of changing caregiving and i began trying that and then my father was diagnosed with a brain tumor in his brain stem and spinal cord, and unexpectedly needed to use some of what i was learning as a son instead of as a doctor. Host was that a tough time for you personally . Guest yeah, it was. Having the chance to understand what people who are more affected, whether as family members or as clinicians, what they do, make it less tough vote. It was very interesting. I think the core thing that came out of the lesson for me was that people have priorities besides just living longer, yet medicine doesnt recognize that. I was never taught to articulate that respect. The second part was that the most reliable method of learning what peoples priorities are used to ask. And i wasnt asking. Also i wasnt asking even my own dad. And so when his condition began to deteriorate, and this is a tumor that is going to make him a quadriplegic as it gradually took his life, and he faced options of surgery, radiation, ma chemotherapy. I started asking questions, you know, so what are your priorities . And one of the tradeoffs you willing to make and not willing to make . Really hard questions to ask, and yet changed every step of his care along the way. Host you describe your grandfather, he lived to be 110 years old. He lived in a village in india. Tell me a little bit about what you learned from his life. Guest he is fascinating to is the kind of old age that we think we want, right . The last 20 years of his life ended 24 hour care basically and it he did not have to check into a nursing home like you would be today here. He was surrounded by family. He would sit at the head of his dinner table at home, still ahead of the family. People came to them for business, advice about who they should marry. He was respected and venerated. And he was able to live as good live as possible all the way to the very end. Now, what made that possible . Why did we lose that . That was a lesson to be taken out of this. As a society, in other words, that was what american in the 19 centric thats what your pet in the 1 19th century. Thats what china, korea and india are leading right now, and why, the breakup of the extended of taking or someone like him is occurring because that works only by enslaving the young. Young women to provide the care, and then on top of it his son, imagine reaching your 80s still waiting to inherit the land. Having the Economic Future still depend on your debt. The economic progress of the world occurs because you give young People Freedom they can work with, live what they want who they want. A move to the cities. They take different lines of work. They often leave the elders behind, and we didnt have a plan in the 19 century for what happens to people left behind to india, china, korea dont either. And what we have decided, medicine will take care but. Host turn it over to the Health Care Field and theyll fix and take care of and treat. Guest my dad is having trouble with memory, or hes having falls in the home. Well, lets take into the dock and the doctor will fix the. What happens . He taken to the doctor and the doctor says we like fixing problems. Weve got a procedure we can do with that, a therapy we can offer. Sometimes you cant fix and we cant make them go away and we throw up our hands and we say, you know, well, i can either try x. Y. Z. Or go see another specialist. Thats the failure of our understanding. There are things to fight for besides just living longer or trying to repair unrepairable problems. Host when we go through school, it seems like, medical schools, Nursing Schools attract good people. Is a type of High School Students who want to be understood remarkable person. The sort of person, they come out in this dilemma, and is it confusion, ill preparedness, the sense of this is out of my league . Where did things go wrong when you get such great people went into a profession and then theyre faced with dealing with the problem that they may feel is out of their league . Guest i think there are a few things that happen. Number one is, i had a geriatrics office, clinic right below my clinic, and for years i walked past it without ever knowing what they did. 97 of medical schools dont teach geriatrics skills. I went down and said let me hang out with you for a date. The geriatricians showed me what he did. Among the things he did was recognize that the most lifethreatening thing for some of those patients over 80 was that they might fall, and if they fell and broke their hip, that they had an average of only six months to survive and they were miserable. More important than getting their mammogram, more important than the colonoscopy was preventing them from falling. He knew how to do that. He knew had examined the feet to look for the way that toenails and the calluses could make someone unsteady, and arrange for a podiatrist to help address those problems. Host he would see they could reach 50, right . Guest yes. Sit back and let them struggle to take off their shoes because they told them something about the abilities and whether there was care they could have at home. He went further and recognized that people who are more than for the drugs are at a much higher risk of falling, and he reduced the drugs so that he was having trouble with dizziness and dehydration. Host he could do the because the drugs were not necessary . Guest they were addressing the priority. So the priority was in survival. The priority was having as good a life as possible for as long as possible. And when you understood it that way, then you are making different choices and tradeoffs. It didnt matter the he was just a pulsing body. It was she was alive to do the things she wanted to do and what she said was her biggest priority was keeping her home. And so if you ask, if i ask you, do you know the four risk factors for someone, for their likelihood of falling . And the three most important things that we can do . We werent taught that. We dont know that. And so we didnt teach people along the way in residency come in medical school before that, what is the science of the aging population and of dying . What are the skills required to help people achieve the best possible outcome . If action is often something that requires the employment of medical technology but its the different goals. I think what has happened is that our medical values, are fundamentally about health, safety and survival, without recognizing that well being is bigger than that. A second force that pushes us is money. Who are the lowest paid people in our profession . Not as insurgents. The geriatricians, the psychiatrists, the palliative the care doctors, primary care physicians. Its because of these professions we take time to talk to people, but having the payment allow people to have the time to talk and get an understanding of what matters in peoples lives and then make the plans accordingly, you know, just doesnt remotely pay off in society. We can do an operation so we can do to operate colonoscopy. Host i didnt even know there was a field of medicine called geriatrics in medical school, did you . Guest no, i didnt. Host if i understand ackre lake pediatrics group, where folks were specialize in Infectious Diseases or primary care, but it did that for older patients. And as i think about these issues youre talking about, i wonder, what is happening to geriatrics today . Guest is in decline at a time when we have more elderly people than ever. We are training few people today in geriatrics that we did a decade ago. In fact, its reached a point where geriatrics profession itself says we are so far behind the eight ball, the country has been ignoring the fact that we dont train geriatricians, dont pay geriatricians, that we have to give up on the idea that will be enough geriatricians for the need out there and we have, theyre saying as geriatricians, we have to train these basic skills to internists, to medical students, residents. They are right. We have to make these basic skills of what are the checklists my last book what are the checklists that have to be executed on that of the most important ones for people who are facing aging and address their particular health risks . Also looking back even higher than that, being able as the key questions and get some skills and a proven along the way and had asked people about their priorities in life effectively while helping them understand you still care. Just because youre talking about the worstcase scenario does not mean that you were saying, you know, im giving up on it. Host medical school seems to be, and i may be overly reducing it, but he seems to be the equivalent of learning so many foreign languages, bill we can memorize everything is to pare things. Diagnosis treatment, diagnosis treatment. Its almost as if we can come up with this reflex. Theres a diagnosis . I know the treatment. Diagnosis and treatment. Whats great about that is you can learn all this knowledge and theres plenty of adopted children, but what is concerning is you can miss out on a sense of whats appropriate, appropriateness. And it really seems to be one of the focuses of the issues around your endoflife as you describe him, that sense of when it is appropriate . Why are we treating high cholesterol in some way has a Life Expectancy of two years when the cholesterol is not going to kill them. Guest and the medication makes them dizzy unlikely to fall. Host and then they confuse it with an important medication. Guest i think it brings up a core point, which is how do we deal with appropriate is . The greater people have, the charge it is a definite, it means its no longer about my choice about what is appropriate. I think what were seeing is an evolution of what it means to be a doctor. In the last halfcentury its change enormous the. 50 years ago it was a prolific doctor knows best. The doctor would tell you what youre going to get, might or might not tell you whats really going on with you, never would go to the options. Yes, doctor, whatever you say. We thought it was our job you dont want to worry peoples original heads about whats going on. We rebelled in the 70s, 80s and 90s about that. About the time you and i were trained were taught to be doctor informative article. Almost a retail model. You go through all the options, talk about the pros and on and the risks and benefits and make the whole menu of options and then you go, what would you like to do . Which one do you want to . Invariably you find this, right . Basic, well, i dont know. What would you do, doctor . What do we get taught to say . Its not my decision to this is your decision to make. Im not deciding for me. You have to decide. What is evolving is the recognition and begin to see when i followed the geriatricians and the Palliative Care doctors. The political counselor at the counselor says, you are the options but im to ask if you questions to understand you live. Host to give guidance. The one options but they want guidance. Guest the guidance has to come from your distant of what their priorities are in life, and just be good at eliciting a short conversation and theyre good at it. A 20 minute conversation they will ask what your understanding of your help . What are your fears and worries for the future . What are the goals that you have if youre Health Worsens . What are the outcome that would be unacceptable to you . And based on that, oh, well, option a. , that doesnt work. Option b. Doesnt work. Options he might be the way to go. None of them were, we left almost make up a solution here. I a woman who said, she had metastatic ovarian cancer. She said my priority is a wedding i want to get to this weekend on saturday. She was admitted to the emergency room with a bowel obstruction from her tumor making it so she couldnt eat, really sick. What we focus on the how do we cater to that wedding . Use medical technology not to put it in the icu or into surgery, but to cater to that wedding. Thats what, thats when it gets cool again to be doctor, you know . Host thats great. The first time that you break bad news to a patient, do you remember that time, what it was like . Guest i remember it and because as an intern you would be asked, you are probably past, to go in and get the informed consent, or go consent of them. You would invariably be explaining this operation and talking about the risks and benefits, but when youre writing down, you have this risk of death and you have this risk of terrible bleeding edge might have an infection. And invariably they raise their eyebrows and say, that would give anything about that. All, you know, we all have our way of saying it to you learned, you watch. What do they do . They end up saying oh, this is just from these are just forms. Dont worry about it. Just legalese. What do we do . How quick puzzle even know what the complications are like . Host how can we counsel people . Guest the faceting thing is when i met the people were really good at walking through a conversation about whether you want to do a resuscitation order or consent discussion, they treat it, that conversation, the same way that people treated teaching us how to do an operation. They broke it down. They studied what the Component Parts are, and they recognized like there are certain questions that are more effective than others. You need to use questions. For example, one of them explain to me, you need to track yourself, and you should be talking less than 50 of the time that you were in the room with the patient. I was talking 90 plus of the time, the nation the patient would not and you would get you didnt think you understand . Yeah, yeah, i understand. And that was our conversation. Its that set of skills. How do you break bad news to someone . You are good ways and bad ways. The bad what is give all the facts and none of the meeting. Host teach the medical the cabinet. Guest exactly. Heres the data. Heres chances of this, here are the chances of that. Be effective conversation is, heres what i know, and im worried. Im worried about these kinds of complications. Im not worried about these other ones. Im very hopeful about certain things. I wish that, dinner, they talk about i worry, i hope, i wish. I wish it were true that we could cure this. I hope that we will be able to buy you more time. Im worried you may end up back iin the hospital again. And thats saying to people, heres the data, heres your understanding, and im on your side on this. And i admit i have some uncertainty. I am worried is that i am positive. I am positive you are not i am positive. You on eyeball bin folder i tell the story of even my dad. I thought he was towards the very end, that this was it, this was the moment he was gone. You woke up. What are you guys doing . Had three more days of. Host as you say some of those phrases, im concerned. It really reminds me of the importance of the art of language as a doctor. I remember in med school, mentors told me dont ask patients, are you taking your medications . Because they will get defensive, but ask them, a lot of people have a tough time taking their medications as they should, how have you been doing with it . It is amazing. With one set of vocabularies theres almost a huge disconnect or and alienation, and then when you phrase things a certain way, when you talk or endoflife issues as you are, its almost like inviting a conversation. Guest the are two things i think were missing. Words matter. The words matter. And the stories matter. Part of even writing a book like this and doing the kind of investigation i did, it was deliberate a journalistic investigation. I was less interested in taking out the details and the nuances and complexities that make it so, you know, we need a randomized trial you remove all of the detail and look at only everybody has in common. And what we do in a careful case study of a bunch of case studies, is recognize that the stories are really powerful and they tell you a lot about the experiences of the body, the experiences of illness, and in this case the experience of mortality. I think, you know, we are increasingly willing to recognize a medicine that those are just as important contributions to knowledge and our skills and profession, as the straightforward quantitative one. Host i think of a time i was in the trauma bay and a patient died and i was told the mother is next door. You need to talk to her. I walked in there. The mud is happy unless it means is how is my son doing . And instantly, his massive emotion, mad at myself for not thinking through this ahead of time, what should i tell her, and mad all of it at my training for having me be completely missed this part. To what extent when you researching the issues with endoflife care did you look back and feel like, how could this be missing . Guest i mean, all along the way. You are a pancreatic are you dealing with every patient having to have this kind of discussion. Only some of mine are folks with whom i am worried that their potential at the end of life. And it was striking to me all along, one of the first essays i wrote even as a resident was about a 23 yearold who died from lymphoma, and ive had subsequent times ive written about family members who have really serious illness and the struggles of just how are we supposed to cope in these situations. Im curious where you, like reading this book, you break bad news all the time, pancreatic cancer patient vicki seen a lot of them died. Was this mostly familiar or did you feel like you so things that were new to you that were helpful . Guest . Host youve done it commits on research and used a lot of observations. To really encourage myself to ask him what are your goals as a patient . Just this last week by the patient who was 81, frail, and needed at increased surgery in order to remove the pan chris but instead i stopped and said wait a minute, what are your goals . Tell me about what are the affects . They said i want to spend time with my husband here, and if we get another year, ill be happy. It was clear to me that she will outlive this cancer and accomplish the goals she wanted to accomplish. Guest one of the things i do think that the words matter a lot, and asked people about what are the goals but a lot of times that question is hard for people. They dont necessarily have clear goals. But when you ask questions that you want your priorities, and a couple of them get you there, one is what are the outcomes that you wouldnt, that you would find unacceptable . One of the outcomes you really hope for . Or another set of words that i havent really recognized is, you know, one of the goals if your treatment doesnt work, or if youre Health Worsens . These are harder to ask sometimes. Another one is just what are your fears and worries in the future . Its the listening, guidance, so that when things arent going the way you hoped, youve got some understanding about where to help them walk, sometimes make a turn on the pathway to. Host great point. We will take a quick break and continue the conversation. Host the cdc cannot with a report just this month updating the numbers on Life Expectancy. And now the Life Expectancy is up to 79, and if you make at age 65, on average, you will live to 83 if youre a man, and 86 if youre a woman. As a matter of fact, most of the Health Statistics are better except for one. The suicide rate has gone up by two percentage points. Do you think that depression is one of the underappreciated underrecognized endemic problems, and how does it connect to the issues of older people . Guest i do think it is, and what you see is very interesting, which is that as people age they actually, they are happier as they get older. This is a little counterintuitive. People in all these studies, you can for a 30 yearold and a 70 year old and a 70 year old is more happy. Theyre likely to have lower rates of depression, have more complex emotions. Making a poignancy which is this idea of negative and positive emotion at the same time, until you incarcerate them. I use those words deliberately. Put people into Nursing Homes are into housing situations where they dont feel they are at home. Whats the most common thing here sometimes and people in Nursing Homes. They say when do i get to go home . Posada groups who have much lower levels of happiness, and i think thats the crucial finding is that, weve become a society that has made it really possible to have a great life because we have pensions and Social Security for when you retire. People are able to sustain themselves. They can live independently. We get new replacements at that thanks to keep us going for longer. There is no better time to be elderly in history, but when you become dependent, when you know longer can take care of yourself, when youre having trouble with false and your memory is going and you need help, that is when it suddenly turns the tide and we are put into institutions that no longer honor what we did you have in the home, which are choices, autonomy. Host even with small things. Guest even small things. Institutions, their top goal is health and safety. They will tell you, we are an incredible safe place for your parents. But well talk about whether, you know, can the parents go, can be elderly person sibley go to the refrigerator and get what they want to eat whenever they wont . Will they be allowed to wake up whenever they want . No. What happens is theres a scheduled time to wake up. Theres a pill line to get ready for and you get dressed at a certain time because all on the staffs scheduled record. They look more and more like hospitals, and in the hospitals they are all built around a nursing station. In some of these interesting hiding places, they have built them around the kitchen, and moved the nurses out into the site area because its not about the nurses. Its about being in a home, in the kitchen to people are allowed to open the door and get what they want. You know how controversial that is . Host just a little bit of autonomy like that. Guest a diabetic make it a soda out of the picture but its not safe. An alzheimers patient is supposed the eating only a pureed diet might go and get a cookie. Its fascinating. You see the writeups of patients for violating rules, and you can get written up, like that idea even to the most common reason people if they violated food world. You will see alzheimers patients hoarding cookies, for example. You know what . Let them have the damn cookie. The bill to offer choices in ways that not only its important the cookie, what we have sacrificed is the idea that these are people who live for something more than bingo and safety and just being alive today. These are people who have histories. They were teachers. They were policemen. They were doctors. And they care about the connections to the outside world, to the church, to other places that they were part of comment and they care about being able to live for larger purposes. One of the fascinating experiences i talk about experiments as a pie in a who brought pets into Nursing Homes and about all kinds of precautions to make it possible. But when people and pets can even people with dimension, they something is something you care for in the world. They had a purpose an and a rean to live. Those folks woke up. They became active in life. They ended up needing less medications than they even lived longer. Host is the autonomy really symbolic of people in that they are given some of their dignity back . Isnt really what is a part of happiness when you to scribe your own motherinlaw, i think it was . She liked to wear certain shoes. That was part of her identity, and she wore them proudly. The nursing home, for safety reasons, they relegated her to guest she was allowed to wear the shoes. Host have we taken away dignity later in life in certain contexts in the united states, in places that you describe where people are in a sense been incarcerated . Guest yes. I think ther there are places tt are there are places that it didnt i do this has to change, and that the culture of change in Nursing Homes and in assisted living and even in making Home Health Care change has become i think one of the most amazing sources of innovation in the country. We talk about the technology innovation. Right now in this country and every state theres a revolution and now this kind of care is provided. And the major things are small. Its a line people to have a lock on their door, which means that the workers have to knock on the door to have permission to come in. Its respecting privacy. You know, moving from double rooms the single rooms. Went in our life since college where weve had to live with an unknown roommate who might be up all night, you know . Crazy host sounds and noises, disrespectful. Guest people care about these fundamental things. Why does this happen . The homes that exist, they understand the people who they market to are not the parents. They market to the kids because the kids are often the decisionmaker. Someone i spoke to said, this is a great quote, they said, safety is what we want for those we love, but autonomy is what we want for ourselves. We may go in and ask whats the Safety Record . We dont ask how lonely our people . How do you ensure people have purpose in their days . How engaged you are people able to be with the world and with what is important to them . Are people even getting to learn and pursue new things in their life . The places that ive visited and write about have done that. It is changed the experience. I described would meeting and 94 yearold man who was having some trouble with his memory. He didnt have all of his teeth, but then he describes some the things he was getting to do. And for the first time in my life i was not afraid to be 94 years old. Host unites the point out how its both a sense of autonomy and company, or companionship, that contributes to happiness. You think this seeds though for loneliness are increasingly starting earlier in life with a Personalized Society that we live in . This is really the first time in civilization where folks lea lee to go to college and they may live with some folks are live alone, and soon after when they graduate from college most people that love and i have the personal this and that in phone and devices and personal subscription to movies. Its such a personal, individualized society. Do you think thats why we are seeing an emergence of the shared culture businesses . Things like airbnb or hoover uber or zipcar, the businesses that try to say, hey, we are a community, a Retirement Community trying to create more of a team unity rather than a facility, trying to great more of a sense of shared activity, shared participation . Guest its interesting because given the choice many people which is the pathway that would provide Police Contact with the human being. I dont want to have to connect with the human being if i dont have to. Its manifest and lots of different ways that weve seen over the last century that when people got pensions and Social Security, the first thing the elderly did was they moved out. It would rather live alone and live in the family of the kids. And be under the rules in the house but they didnt want to live by their son or daughters role. The son and daughter dont want to live by their rules and live in the house, and so we live increase i am what sociologists call an intimate distance. Near one another but not too near. And i think where we are hungry though is that we do still want to contact, you know, the intimate relationship and friendship. Relationships over time take investment, sometimes involve hard conversation and people dont always get along. The freedom to retreat into your own space is actually necessary in order to navigate this kind of for you. The hard part of an aging comes when you can no longer be independent and just hang out in your own, retreat to your own corner because you need human beings to help you be able to manage anything from how do we change the lightbulb to getting to where you want to go. And the frustration of having to wait, you know, understand my needs and how do i navigate and negotiate that world . The crucial part about it is that weve completely assume that just because you are dependent, you dont have a life worth living anymore. Junior, what purpose, what achievement, what growth could there be . And, in fact, theres a huge amount that is possible. That is reigniting the desire for connection into the world, because you can still make contributions along the way, or just have some joys of connection to people you love are close to. Host how did we get Nursing Homes . Its an amazing institution today in america in terms of the function be to point out what theyre not doing well in terms of giving people sort of institutionalized and not giving them the a ton of me they may need for happiness or companionship for things like the pet program. But you also point out, i mean, the book despite the title being mortal has a lot of positive things in it. You have been a spy but what you see out there, individuals and changes in the way things are done. Guest i do think its coming from turning upside down the reason we created these places. You wouldve thought, i found when i started researching it, the book, the recent Nursing Homes wouldve come into existence was because people were living longer and were going to come up with a really rational way that makes sense for how do we take people through the different phases of their lives . No. We built a ton of hospitals in the 1950s. Host as a result of a law that passed around that time. Guest thats right. Hospitals some have technological ability to allow a lack of the commit build a hospital in finance the hospital. The hospitals filled up with elderly people whose problems could not be fixed. And the hospitals that can what do we do with these folks . As medicare got created, there was financing for allowing people to go to a nursing home for about 60 days. And it was called a nursing home. The idea was you would be nursing people back to health. We were not creating these places to acknowledge you might not be able to get back to health. So they were built around the prairies of health and safety. Safety is an important. Many of these places in the 60s were firetrap. It would die in them. People were neglected. Theres some basic level it has to be there, but they were created out of an understanding that this is really about a well being home. Nursing people back to health may not happen. Nursing people to well being can happen regardless of what prevails we face, and the idea that people would articulate priorities for what were the lines that you do not cross that make me feel like im at home. I think those are the things that we are now discovering. Its no quintessential the baby boomers are hitting the age where theyre starting to think about that set of issues. We have parents who are starting to think about those sets of issues. This generation is not going to put up with being simply wards of a nursing state. Host the subject of endoflife is a tough subject to talk about. For one reason, because its polarizing to folks. That is, people have had individual expenses or they have seen somebody on a ventilator far longer than the person wouldve ever wanted, or vice versa, undertreated. You seem to nicely discuss the difficult issues in endoflife care, by also focusing on life not just a good death, focusing on achieving what you want to achieve during the endoflife. What inspired you to take a positive approach to what otherwise is a very polarizing subject, which from i understand, is not really a vote the polarized reactions you would normally think from this book . Guest i even taught a little bit about assisted suicide. Talk about. A discussion of whats going to happen, its going to be all about what you take away. Its just trying to guide people to give up sooner because youre not giving up soon enough. What i saw from meeting people and watching what happens is its really about fighting for a set of goals that are different than what weve understood. I realize the goal is not a good death. That is not, number one, death is messy. Is not entirely in our control. But second, that is just the tiny moment towards the end, and it is about life and living, even as you face tremendous constraints, as we all face tremendous constraints. And beginning to recognize that that was what people were doing is really what came out of looking closely at what we were already discovering. I do think also gets us out of the box this incredibly polarized set of debates about i really talk about death panels host of what our death panels just so people know what youre referring to. Guest is a little bit unclear, right . On one level its a very specific notion that we, by allowing for the possibility that there would be discussions, not just allowing, encouraging that there be discussions about peoples priorities at the endoflife, that we were really looking for ways to just hasten peoples and. Host rationed care. Guest rationed care. Heres the important thing to understand. The fundamental mistake weve made, a number of studies show this but one powerful one looked at terminal lung Cancer Patients who have 11 months to live on average. At the time the study was done. Half of them got usual oncology care, the other half were given oncology care plus having meetings with the Palliative Care specialists who discussed goals and priorities for a persons remaining time. And the group of the discussions about their priorities ended up in choosing to stop chemotherapy earlier. Earlier. They had fewer days in hospital, less likely to die in the icu, started Hospice Center, less suffering at the endoflife. They lived, and this is the kick, they lived 25 longer. Host even though they got less chemotherapy but what does that tell us about what were doing . Guest it indicates that we are making really fundamental mistakes even in our core decisionmaking, that when we are adding a fourth or fifth round of chemotherapy or trying that last ditch operation, it is out of an unwillingness to recognize we might be sacrificing quality of life for people that, in fact, fighting just to have a good day now instead of more time is an ironically zen the idea. Just find have a good day now and not worried about how much time there might be, ironically does not shorten the time, and it often lengthens the time. I think its that failure to recognize the truth and the. There have been a number of studies. People who start on Hospice Center dont end up living shorter. On average they lived equally long or longer. So i think it just reflects lack of knowledge, even her own profession, about what the evidence is shown. A lack of understanding about why this might be, and we havent listened to her own patients about what priorities they have and why that might be. Host is a positive attitude part of the reason you think people may have lived longer in the arm of patients in the study that got less chemotherapy but get better traffic actually dont think so. There have been studies, the pessimists live less long than optimists . Defied his live longer . And to do. I think the major difference is when you try that last ditch operation, or chemotherapy or other kinds of aggressive treatments, putting them on the ventilator, giving people the feeding tube, you would think a feeding tube if people cant eat, when you give these approaches you could all of the complications, the pain, the suffering. And often very little benefit to the point that the complications and the harm youve done as you begun to do, outweigh any potential benefit there. And so people end up doing worse. Host people get beaten down, in other words, country yes, beaten down by the taxi of what you done and its less about psychology. Its more we did a study. The week you are most likely to have surgery in the light is the last week of your life, and the date youre most likely to have surgery is the last day of that week. When they go into surgery come we dont know whether things will turn out well in the end or not, but when youre doing it with people were facing terminal illness, this is your last ditch effort, having discussed her become were often sacrificing not just the quality of their life, their chance of survival. Were often than not were getting it wrong at the very last stage. I think its a wakeup call for us in medicine, and for our patients who, you know, if your clinicians arent willing to recognize your priorities, discussing with your family and pushing clinicians to make them understand what your priorities are besides living longer, what are the things you do not want to sacrifice as part of your care. I think its important we communicate that. Host does longevity run in families . You will hear patients say, you know, i get fevers after search but theres no infection. My mom has that and her mother had the. What extent can we explore more the aspect genetics. What i tell people, my grandfather died at 110, you are so lucky. You might live longer. And i said that my grandmother died at 30 and it was from malay. Well, that doesnt count. There are innocent studies about the contribution of genetics to longevity and the contribution is very weak. How tall you are. 90 of it is determined genetically and we know that by comparing the heights of identical twins, but the average difference in the length of time, length of survival for identical twins is 15 years. That there is on average, they differ by 15 years and how long they lived. Host people have a lot of wisdom later in life. Older patients can disclose thanks to the doctor they wouldnt even tell their own spouse, or they will let you put a knife to the skin within minutes of meeting them, just because you are there searching. What wisdom to patients share . What have they shared with you about a Community Mining or about time spent with family . Guest there is, i think youre referring to this great set of Research Done by stanford psychologist named laura carstensen. And she has been studying by asking people aged 1894 in this study does not going on for two decades. Her team will page then periodically and ask them to record what their emotions are, what their experiences are. She also spent studies with asking if you have an hour of time would you rather spend it with your sister or another family member, or his movie star . And the young tend to choose one signature, which is that they want to take options that lead to achieving more, to getting more, accumulation more, having more stuff, that they want to meet more people, that they love the possibility of going to a loud bar at 2 a. M. In hopes of yelling to one another in conversation, the hope you might meet someone new. Theres an older signature that says theres nothing more of a nightmare than that. I would rather spend time with my sister. People near the number of people they focus on and want deeper relationships. They want more connections to the people they love. They are more focused on beans, and wanting to make sure they have some ways in which they have some contributions. They could be anonymous and small, but some contributions in the world. The fascination about it is that as people age, the thought was that our brains are changing to make you more wise that way. And then she discovered, this is laura carstensen, discovered that some of the folks she was following had a terminal illness. Especially, this was done on the west coast in the early days of hivaids, and the hiv aids patients would suddenly shift, even though they were young, to having the older signature. And then she did a study during 9 11. And then when the world became uncertain and fragile and you werent sure about what was happening, everybody moved to a signature of saying, you know what . I would rather be with family. I want to be connected to those i love. I want to make sure im making a difference for them. And that was the revision thing. As time goes on when we are unaware of our mortality, which are most of our lives, then the focus on getting, having, a cheating. When we are nearer, we would become aware of the finiteness, the limitation because of our health, because of the uncertainty of a political atmosphere, for any bride of reasons, it could be ebola, we seldom want to focus in on people with a close with and be connected to others. And i think that that wisdom is really just a manifestation of adding some perspective on where we are in life. Host its interesting to ive had patients tell me they wished they wouldve spent more time with her family, but ive never heard anybody say i wish i wouldve spent more time at work. Guest well, i had to get going to college and if they said that to me right now and they said, i do want to focus on work out i just want to be found, i would say you, im not sure its a good idea. Host its a perspective issue. Guest if they think of 20 years or so, we behave as if we are immortal and that means were willing to sacrifice some time now for the sake of future achievements. So we are willing to delay gratification. That makes no sense when you become more aware of there being a finiteness of type x. I think it really is just a matter of perspective, and th that wisdoms that the proper perspective for where you are in your place and time. Host its great to see it again. Congratulations on the book, being mortal. I loved it and look forward to continued the conversation. Guest and thank you. That was afte after words, booktv sensing chip program in which authors of the latest nonfiction books are interviewed by journalists, public policymakers and others familiar with the material. After words airs every weekend on booktv at 10 p. M. On saturday, 12 and 9 p. M. On sunday, and 12 a. M. On monday. You can also watch after words online. Click on after words in the booktv series and topics list on the upper right side of the page. During booktvs recent visit to green bay, wisconsin, we visited the readers loft bookstore to talk about the competitive business of independent bookstores. Bookstores in green bay over the years has kind of come and gone and have been of a variety of all of these. And, of course, every independent bookstore is different from every other one. The readers loft was first opened 21 years ago by the owner, virginia crest. Then a barnes noble moved into town and theres going to be a major road project that was going to close a street for six month. It became apparent should do something else. So she looked for the kind of commercial space that she was looking for, and she didnt find it so she bought this land and she built this building from an essential into the commercial property business. So right at the center of this building which has for other rentable spaces, is the readers loft. It is the largest of the spaces here, and that move probably made it possible for us to continue to exist. Throughout the socalled recession, we continued to have higher sales and better profits each year come and have continued to do that. We are kind of known for literary fiction. We sell a ton of mysteries. We have the largest poetry selection in northeastern wisconsin, i can assure you. Even the barnes noble has, their poetry section is pretty flimsy and has really only the popular stuff. And what we are basically known for is getting the books that you want. The owner has said, try as hard as possible not to say no to anybody. We can almost always find a copy of the book, thanks to the internet. That didnt used to be so. Be used be a very sort of medieval process, but then when book dealers began to list their inventory on any number of variety of sites, 40 or 50 different sites on the internet, where book dealers lose their inventories, and there are a couple of meta Search Engines that will search all of those sites at the same time. So within about 20 or 30 seconds i can have access to the inventories of about 40,000 book dealers worldwide. And i can usually have an answer for a customer while theyre still on the phone. Because india but booksellers curate their own collections, you will find a different selection in each different story. Barnes noble stores, and other Big Box Stores are curated by someone at the head office, and they have their own warehousing system. And if you walk into a barnes noble in green bay or st. Louis or San Francisco or new york for that matter, you will find largely the same collection of books. So thats the truth between us and the Big Box Stores. The difference between us and amazon is that amazon has everything and all i have is 30,000 books here are but we have that will we have that amazon doesnt his life human beings, and we have opinions and we have books that we like in our, evangelist for, as they say. Weekend to recognize, to recommend to our regular customers whose tastes we get to know books we think they will like. And thats, theres a lot of difference between that, believe me, and an algorithm. Amazon really complicated the Book Business a lot more, and it will still be interesting to see how that works out, their recent dispute with passionate has brought to public consciousness some of the aspects of this unwillingness of the Book Business. And the conglomeration of the industry, most recently, probably the really big thing thats happened is the merger of penguin and random house, which were the two largest publishers to start out with, and now they are one publisher. We will see how that works out. In general, it appears to me that the conglomeration of imprints and the publishing houses thats taken place over the past probably 15 years has really opened the doors for smaller independent publishers, of which there are a lot more now than there were 10 or 15 years ago. I continually learn more about the business. For more information on the recent visit to green bay, wisconsin and in many other cities visited a local content vehicles, go to cspan. Org local content. New yorku