I had a little bit of my training. Having completely missed this part. To what extent when you were investigating issues when you are looking back how could this be missing . All along the way. I am a cancer surgeon, like you like you are a cancer surgeon. You are a pancreatic cancer surgeon, so you are dealing with every patient having to have this discussion. Only some of mine are folks who i am worried they are potentially at the end of life. It would strike me all along the way. One of the first essays i wrote as a resident resident was about a 23 yearold who died from lymphoma and that subsequent times i have written about Family Members with serious illness and the struggles of how we are supposed to cope. I am curious for you reading this book, you break bad news all the time to pancreatic Cancer Patients and have seen a lot of them die. Is this mostly familiar or did you see things that were knew to you that you thought were helpful . I saw things that were knew because you have done a tremendous amount of research and use observations to encourage myself to ask goals as a patient. Just this week, a patient, 81, frail pancreatic surgery needed surgery. Instead i said, needed surgery. Instead i said, what are your goals. He said, i want to spend time with my husband husband, and if we can get another year, i will be happy. It was clear the patient would outlive the cancer and accomplish the goals she wanted to accomplish. The words matter a lot. A lot of time that question is hard for people. When you ask questions, what are your priorities, and a couple of get you there. What are the outcomes you would not find acceptable and what are the outcomes you really hope for here . Another set of words i had not recognized work, what are the goals if your treatment does not work or if your health worsens. Is it harder to ask sometimes the mac. It is eliciting that when things are not going the way you hope you have some understanding, where to help them walk and sometimes make a turn on the pathway. Great points. We will take a a quick break and continue the conversation. On the go after words is available via podcast. Atwul gawande, cdc came out with a report updating life expectancy. On average 83 if you are a man and 86 if you are a woman. Most Health Statistics are better, except better, except one. The suicide rate has gone up by two percentage points. Do you think that depression is one of the underappreciated underrecognized endemic problems . How does it connect to the issues of older people . I do think it is. This is a little counterintuitive. They are likely to have depression, more complex emotion, poignancy. And tell you incarcerate them. I use those words deliberately. Put people into Nursing Homes or housing situations where they do not feel they are at home. What is the most common thing you here from people in Nursing Homes is, when do i get to go home. Those other groups have much lower levels of happiness and and i think that is the crucial finding, it has made it possible to have a great life because we have pensions and Social Security for when you retire, people retire, people are able to sustain themselves, live independently knee replacements and things that keep us going longer. There is no better time to be elderly in history. But when you become dependent and can no longer take care of yourself having trouble with false, your memory goes, that is when it suddenly turns the tide and we are put in to institutions that no longer honor what we get to have in the home which are choices, autonomy, even the small things. In institutions the top goal is health and safety. In fact, they we will tell you, you, we are an incredibly safe place for your parent but we dont talk about can that elderly person simply go to the refrigerator and get what they want to eat whenever they want. Will they be allowed to wake up whenever they want. No. What happens is there is a scheduled time to wake up. There is the pill line. You get dressed at a certain a certain time because it is all on and staff schedule. They look more and more like hospitals. They are all built around the nursing station. In some of these interesting, pioneering stations they build them around the kitchen and move the nurses out into a side area because it is not about the nurses. It is about being in the home. In the kitchen people are allowed to go and get what they want. Do you no how controversial that is . A little bit of autonomy. Because the argument is a diabetic may get a soda. An alzheimers patient might go and get a cookie. It is fascinating. You see the write ups for patients of violating rules and you can get written up by the way, that idea. The most common reason people get written up is because they violated food rules. Alzheimers patients ordering cookies, for example. You know what, let them have the damn cookie. The ability to offer choices 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. They had histories. They were teachers policemen, teachers, policemen, doctors, and they care about the connections to the outside world church, other places they were a part of. And they and they care about being able to live for larger purposes. One of the fascinating experiments i talk about is this pioneer who brought pets into Nursing Homes and had to battle all kinds of regulations to make it possible. When people had pets even ones with dementia dementia, they suddenly had a purpose and a reason to live. And those folks woke up, became active in life needed less medication, even lived longer. Is the autonomy really symbolic for people in that they are given some of their dignity back . Is that really what is part of the happiness when you describe your own motherinlaw, i think it was she would like to wear certain shoes part of her identity. She warned them wore them proudly. The nursing home for safety reasons relegated her she was not allowed to where the shoes. Have we taken away dignity for later in life in certain contexts in the United States and places, as you describe, where people are, in are, in essence, incarcerated . Yes. I think their are places getting the idea that this has to change, and the culture of change in Nursing Homes and assisted living and even making Home Healthcare change has become, i think, one of the amazing sources of innovation in the country. We talk about technology innovation. Right now in this country in every state there is a revolution in how this care is provided. The major things are small allowing people to have a lock on their door which means the worker has to knock for permission to enter, respecting privacy, moving from double rooms to single rooms. You know, when in a licensed college we would have had to live with an unknown roommate who might be up all night you know crazy sounds and noises. Yes. Yes. People care about these really fundamental things. The homes that exist understand the people they market to or not the parents. They market to the kids because the kids are often the decisionmakers. Someone i spoke to said safety is what we want for those we love but love, but autonomy is what we want for ourselves. We may go in and ask what is the safety record. We dont ask, how lonely are people. How do you ensure people have purpose in their day how engaged for people able to be with the world and what is important to them. Our people our people even getting to learn and pursue new things in their life. The places that i visit and write about have done that and it has changed his experience. I described meeting a 94 yearold man who was having trouble with his memory, did not have all of his teeth, but he described some of the things he was getting to do. For the first time in my life i i was not afraid of being 94 years old. View nicely. Out how it is both a sense of autonomy and company or companionship that contributes to happiness. Do you think the seeds for loneliness are increasingly starting earlier in life with the Personalized Society that we live in . This is really the first time in civilization where folks leave to go to college and soon after most people live alone and have their personal this and that and phone and devices and personal subscription to movies. It is such a personal, individualized society. Do you think that is why we are seeing an emergence of the shared culture businesses businesses, things like air b b or huber or zip card. The businesses that try say, hey, we are a community, retirement community, trying to create more of a community rather than the facility, more essence of shared activity, participation. It is interesting. Given the pathway that provides the least contact with a human being i dont want to have to connect with a human being if i dont have to. It it has manifest and lots of interesting ways that we have seen. When people got pensions and Social Security the first thing the elderly did was moved out. They would rather live alone that live in the family of their kids and be under their rule. They did not live to five they did not want to live by there son or daughters rules. So we live increasingly with that sociologists call and intimate distance near but not to near. I think we are hungry and do still want a contact, a contact, intimate relations, friendships. Relationships take investment, sometimes involve hard conversations. Retreating to your own space is absolutely necessary. The hard part about aging becomes when you can no longer be independent and hang out and retreat to your own corner because you need human beings to help you be able to manage anything from how to i change that lightbulb to getting to where you want to go. And the frustrations and of having to wait, you no understand my needs and how i navigate and negotiate that world. A crucial part about it is completely assumed that just because you are dependent you dont have a life worth living anymore. What purpose, achievement, their be growth could there be . In fact, there is a huge amount possible. That is reigniting the desire because you can still make contributions along the way. How did Nursing Homes it is an amazing institution that serves a function. Not doing well in terms of giving people institutional life and not the autonomy they may need for happiness or companionship things like the pet program, but but you also. Out, the book despite the title kayseven, you talk about things and it and ways you have been inspired, individuals and changes but i think it is coming from turning upside down the reason we created these places. I thought when i started researching the book the reason Nursing Homes were coming into existence was people were living longer and we were going to come up with a a rational way to take people through the phases of there life. We built a time of hospitals in the 1950s. As a result a result of a law that passed. Thats right. Hospitals suddenly had technological capabilities. And the hospitals filled up with elderly people whose problems cannot be fixed. In the hospital said, what do we do with these folks . As medicare got created there was financing for allowing people to go to a nursing a nursing home for about 60 days. And it was called a nursing home. The idea was to nurse people back to health. The idea was not to acknowledge we might not be able to get people back to health. Safety is important. Many of these places in the 60s were fireds. They were not created out of an understanding that this was about a wellbeing. Nursing people back to health may not happen. The idea that people articulate priorities for the lines we do not cross make me feel like i am at home. Those are the things that we are now discovering. Local incidents baby boomers are reaching the age where they are starting to think about that set of issues, and this generation is not going to put up with simply being wards of a nursing state. [laughter] the subject of endoflife is at tough subject to talk about. It is polarizing. Personal experiences or seeing someone on a ventilator far longer than the person would have ever wanted or vice versa undertreated. Undertreated. You seem to have nicely discussed the difficult issues by also focusing on life, not just a good death, achieving what you want to achieve. What inspired you to take that positive approach. It it has not really evoked the polarized reactions you would normally think. I even talk a little bit about assisted suicide. Here is the fear that people have the discussion is it is all about what you take away. Trying to guide people to give up sooner. What i saw from meeting people and watching what happens is it is really about fighting for a set of goals that are different than what we have understood the goal is not a good death number one death is messy messy, and it is not entirely in our control, but second a tiny moment toward the end about life and living even as you face tremendous constraints, as we all face tremendous constraints. Beginning to recognize that is what people would do is what came out of looking closely at what the field was already discovering. I think it gets us out of the box of this incredibly polarized set of debates. You were talking about death panels. What are death panels so people watching know what you refer to . It is a little unclear, right . On one level it is a specific notion that by allowing for the possibility there would be discussions not allowing, encouraging the possibility that there would be priorities about endoflife, we were looking for ways to hasten peoples and. Rationed care. Rationed care. A poignant thing to understand and alleviates the mistake we have made. , terminal lung patient t5 terminal lung Cancer Patients who had only 11 months to live. Half of them got oncology care and the other half were given oncology care plus having meetings with care specialists who discussed goals and priorities for a person and the remaining time. And the group we will have a discussion about the priorities ended up choosing to stop therapy earlier fewer days in the hospital, less suffering and this is the kicker, lived longer. What does that tell us about what we are doing . Making fundamental mistakes and even our core decisionmaking. Adding that round of chemotherapy or lastditch operation, it is out of an unwillingness to recognize we might be sacrificing quality of life for people. Fighting just to have a good day now instead of more time is ironically is an idea. Ironically it does not shorten the time and often lengthens the time and it is that failure to recognize the truth of that. There are a number of studies. On average they lived equally long or longer. I think it reflects lack of knowledge even in our own profession about what the evidence is showing, lack of understanding about why this might be and that we have not listened to our own patients about what priorities they have and what that might be. Is a positive attitude part of the reason . I actually do not. The pessimists lived less long than optimists . And they dont. They dont. The major difference difference is when you try that lastditch operation of chemotherapy or other kinds of aggressive treatments, putting them on a ventilator, giving people a feeding tube, when you give these approaches hemotherapy or other kinds of aggressive treatments, putting them on a ventilator, giving people a feeding tube, when you give these approaches you get the complications, pain, suffering and often very little benefit to the. That the complications and harm you have done outweigh any potential benefit. People end up doing worse. People get beaten down in other words. By the toxicity of what you have done and it is less about the psychology. We did a study. The week you are most likely to have surgery in your life is the last week of your life. The the day you are most likely is the last day of that week. When we go into surgery begin not know whether things will turn out well or not but when you do it with people facing terminal illness we are often sacrificing not just the quality of your life am of the chance for survival. Often or often or not you are getting it wrong at that last stage. I think it is a wakeup call for medicine and patience your conditions are not willing to recognize your priorities discussing with your family. And make them understand the priorities. Does longevity run in families . I get fears after surgery. To what extent can we explore more the what i tell people, my grandfather died. The genetics, longevity. 90 percent is determined genetically. Identical twins survival they differ by 15 years. People have difference later in life. But wisdom to patients share about accumulating money or time spent with family. There is this great set of studies that has been done by passing people ages 18 to 94 her team will patient periodically and asked them to record what their emotions are experiences, would you rather spend time with your sister or another Family Member or this movie star . They tend to choose one signature. They take options to lead to achieving more, getting more, having more stuff but love the possibility of going to allow bar at 2 00 a. M. In the hopes of yelling to one another in the hopes of conversations in meeting someone knew. And there is an older signature that says there is nothing more of a nightmare than that. People there of the number of people they focus on and want deeper relationships, more connections to the people they love, more focused on being and wanting to make sure they have ways in which they have contributions to the world. The fascination about it is as people age the thought was that our brains are changing to make you more wise that way and then