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Welcome guys to episode 54 of Behind the Shield Podcast.

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My name is James Gearing.

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And this week I wanted to discuss a topic

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that I've really, really wanted to delve into for a while.

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And this particular guest was the person

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I wanted to talk to about it.

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So the topic is death.

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As far as the end of life in an accident like we see,

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as far as a healthy end of life,

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and then end of life in a hospice or palliative care setting.

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So Dr. BJ Miller, I was first exposed to him,

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listening to him on the Tim Ferriss podcast.

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He also did a TED Talk, which absolutely blew me away.

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And at the time when I listened to the interview,

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he was working with the Zen Hospice Project.

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The premise was that the patients in the hospice

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had a homely environment and every single day

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were given the fullest day of their life,

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even though they were counting down.

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And contrasting that obviously

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to the sterile hospital environment

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that many patients do pass away in.

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So I really want to delve in that side.

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I had nursed my grandfather in hospice.

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I'd seen several fellow firefighters recently

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in hospice care before they passed away.

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So that was an area I wanted to delve in.

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And then also something that we talked about

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because he wasn't exposed too much to what we do,

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is how do you apply palliative care

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in the pre-hospital setting?

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How can we make our patients more comfortable?

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How can we interact with the family after we lose a patient?

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So there were so many areas I want to talk about

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and this was an absolutely fantastic conversation.

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So before we go, as I always say,

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rate us on iTunes, give us those five stars

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and then share these episodes.

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And then let me know, give me feedback.

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Let me know what you think of the show.

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Let me know topics that you want to talk about,

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potential guests.

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I really, really like to have this interactive relationship

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with the people that listen to the show.

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So without further ado, I introduce to you Dr. BJ Miller.

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Enjoy.

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["Spring Day"]

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["Spring Day"]

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Welcome to the show, BJ.

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I just want to preface this whole thing

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by saying that I listened to you on Tim Ferriss' podcast.

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I went and watched your TED Talk

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and I reached out to you guys.

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And I know it was right when you were about

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to take some time and write a book.

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So I think it's been about eight or nine months

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I've been waiting for this interview.

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So I am so excited that we're sitting down

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finally getting to talk.

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Yeah, thanks James.

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It's really nice to be with you

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and I really appreciate your patience.

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I'm glad we're finally here too.

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Fantastic.

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So where are we finding you geographically?

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So I'm sitting right now in my kitchen

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in Mill Valley, California.

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Brilliant, excuse me.

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Is that the Northern California?

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Yeah, it's basically a suburb of San Francisco.

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Just hop, skip and a jump over the Golden Gate Bridge.

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All right, and were you born and raised

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in that part of the country?

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No, I'm very proudly from Chicago.

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My family, we moved around a fair amount

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and I lived many different places

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but Chicago is sort of my home base.

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Okay, and just to kind of set the background.

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So what was your family unit like growing up?

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Well, sort of pretty typical,

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sort of middle-class suburban,

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you know, two parents still together,

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two children, a dog, you know,

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practically a picket fence kind of scene in a lot of ways.

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My dad worked in sort of business management

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and we followed his work around.

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But yeah, mostly a suburban,

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suburban privileged background.

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Okay, and back then were you athletes as well?

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In and out, you know, so when I was younger,

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I was interested in athletics and had some facility for it

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and then I was a very much a late bloomer.

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So it's like all my buddies became men

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while I was back, I was still a little kid.

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And so that kind of changed my athleticism

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for a few years and then late in high school,

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I caught up and rejoined competitive athletics.

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I rode crew in college just before my injuries.

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So athletic-ish.

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Okay, it's funny, I had the same journey.

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I didn't have what they call the growth spur

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until I was 18, so I was like everyone's little brother

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when I hang out with my friends before that.

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Yep, another feeling.

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All right, so well, you just touched on your injuries.

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So I wanna kind of address this right at the beginning

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so that the people listening can paint a picture.

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So I know in your TED Talk, it's a video piece,

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the audience sitting there obviously

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have a pretty good idea of somewhat of your history,

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but for the listeners, can you tell me what happened

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when you were in Princeton and the injuries

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that you suffered there?

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Yeah, so really it was sort of a very much

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an inflection moment for me in my life.

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So I was 19, this was November of 1990,

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coming up, actually November 27th,

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coming up on my 27th anniversary.

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But yeah, we were just back, so sophomore year of college,

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I was at Princeton, as you say,

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and we were just coming back from Thanksgiving holiday

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and a couple of my dear friends and I,

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guys I rode with, we went out on the town at night

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and we're off to go get a late night sandwich

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and we happened upon this commuter train

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that runs across, that runs from Princeton

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to Princeton Junction.

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It's a commuter train for this little bedroom community.

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And anyway, just climbed the train, just parked there,

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just sitting there, we had done far dumber things.

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We just thought we'd be climbing like a tree

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or a jungle gym.

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But I popped up, when I stood up, I had a metal watch on

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and this was a train that runs with the wires overhead.

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And so when I stood up, the electricity,

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I was close enough to the power source,

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the electricity arc to my watch and entered the arm

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and blew down and out my feet.

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So that all resulted in burns, obviously,

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that necessitated amputation of my left arm and both legs.

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Right, and you have prosthesis on all three of those,

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is that right?

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Yeah, yes I do.

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Daily, sort of like you guys,

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you might put your shoes on in the morning,

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I put my legs on in the morning and take them off

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when I get in bed for the most part.

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It's very much akin.

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My arm, the hand is a much more delicate instrument

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than is a foot.

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Foot's kind of just this dumb platform

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and it's pretty easy to replicate,

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synthetically with a prosthesis, but hands are more tricky.

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And I've kind of gotten out of the habit of wearing

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an upper arm, upper limb prosthesis,

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except for when I'm biking.

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So if you saw me now, you would see that I'm not wearing

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an arm and most days I'm not.

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I just use it for ad hoc purposes.

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Right, now when you say biking,

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is that the motorcycle that you talked about?

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Yeah, yeah, so too.

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So I always loved two wheel action, always.

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Grew up on a bicycle, raced BMX, all that good stuff.

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Yeah, and then more recently, last couple years,

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maybe four years now ago maybe,

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so I finally got a motorcycle,

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which I had been dreaming of for a long time.

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So yeah, so I use this arm for both motorcycle

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and mountain biking.

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Yeah, because I heard you talking about

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how they engineered it and you control most of the controls

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with your left arm, is that right?

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I assume it would be your right arm.

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Yeah, my right arm.

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So the left arm is gone.

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So the left arm, I have this specialized prosthesis,

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a guy named Mert Lawill, an old motorcycle,

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motocross racer.

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He happens to live around here and happens to have,

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for whatever reason, begun machining this contraption

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for bicycle use.

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So it looks like a ball and hitch, like a trailer hitch.

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It does a ball fixed in my prosthesis

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that snaps into this cup that's mounted on the handlebar

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and that allows all degrees of rotation.

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So I'm kind of clipped in like you would be

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in like a ski binding.

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So if I wipe out, the arm pops out.

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So I can lean into the bars, but it's passive.

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There's no, I can't, there's nothing I can control

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on the left side.

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So my motorcycle mechanic slash friend slash patient,

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Randy, he figured out a way to splice the brakes

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into one lever and move the turn signals and horn

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and everything else to the right side and build a little box

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so that's within reach of my thumb.

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And we bought a bike, an Aprilia 850 Amana,

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which is essentially a semi-automatic.

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You can put it into fully automatic mode

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so I don't have to worry about a clutch.

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So it works great, frigging a blast, love it.

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Brilliant.

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Now I know when I've seen you on the video so far,

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you look like you're in great shape.

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So do you, what kind of exercise do you use now

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with the challenges of losing some of the limbs?

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Well, I love, so I've always been,

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for whatever competitive sports I've ever done,

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I honestly don't love the competition.

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I'm more intra-personally competitive and it's been fun.

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So I guess I say that, I don't mean to paint a story

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like I used to be some really competitive athlete

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who no longer can do that and miss that.

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I mean, I love solitary sports.

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I just love moving my body.

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So, but these days, and answer to your question, James,

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most of the exercise I do is bicycling.

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I get out, I live in Mill Valley,

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which is sort of a home of mountain biking

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and I can go right out my door.

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And that's what I love, I take my dog out.

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That's my go-to thing.

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When I get my act together and figure out my life soon,

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I wanna get back to the gym.

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There's a trainer I worked with in this last year.

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I used to kind of make fun of the idea of trainers

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and now I totally appreciate what they do.

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And I worked with this woman who kind of set me up

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with all these elastic bands and balls

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and not heavy weight stuff, just smaller core exercises.

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And I've loved it.

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So I need to get back to that.

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I haven't done that in a while.

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So to answer your question though,

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the main thing I do is bicycling.

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Okay, yeah, because I'm seeing a huge shift now in

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the imagination of coaches working with adaptive athletes

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and obviously the mechanics that they come up with

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as far as creating something specific for a sport,

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but even just using what we thought

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were very one-dimensional pieces of equipment in gyms

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and kind of mesh them together to be able to get around

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a missing limb or wheelchair use.

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And I love the inventiveness of some of the gyms

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that you're seeing now.

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Oh, so I totally am with you.

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I think my sense is the US was a little late in doing this,

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but essentially what's happened I think is some folks

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from a more medical background say sort of physical therapy

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have kind of bridged to the world of sort of athletic

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training and have bridged sort of the mechanics of both.

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So in other words, you don't go for rehab to one gym

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and for exercise if you're able-bodied to another gym.

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Like there's a lot to be,

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there's a lot of interplay between the two.

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And my sense is that exercise physiology,

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I know this is part of your background James, you tell me,

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but my sense is the dogma has changed.

260
00:12:42,420 --> 00:12:44,900
Like when I back was in gyms much more often,

261
00:12:44,900 --> 00:12:49,540
it was repetition, hitting weights in a certain way,

262
00:12:49,540 --> 00:12:52,020
isolating muscles in a certain way.

263
00:12:52,020 --> 00:12:55,020
I think what I think has changed,

264
00:12:55,020 --> 00:12:57,260
the little I've seen that's changed so much is around,

265
00:12:57,260 --> 00:12:59,460
basically we're not working, not isolating muscle,

266
00:12:59,460 --> 00:13:02,660
because that's just not a natural way to use our body.

267
00:13:02,660 --> 00:13:07,380
So there's much more, I don't know, you can feel sort of,

268
00:13:08,580 --> 00:13:11,020
it feels like ballet sometimes in the gym,

269
00:13:11,020 --> 00:13:13,540
it feels like yoga sometimes in the gym,

270
00:13:13,540 --> 00:13:16,620
it feels like it's just a much more dynamic world.

271
00:13:16,620 --> 00:13:18,640
And it's way more, it makes way more sense.

272
00:13:18,640 --> 00:13:21,180
I mean, gone are the days of just, you know,

273
00:13:21,180 --> 00:13:25,100
huge comically large biceps at the peril of everything else.

274
00:13:25,100 --> 00:13:28,140
You know, it's pretty awesome.

275
00:13:28,140 --> 00:13:30,500
So Mike, the woman who trained, who I've worked with,

276
00:13:30,500 --> 00:13:32,380
she's not, I mean, she trains everybody.

277
00:13:32,380 --> 00:13:35,180
And it kind of makes the point that

278
00:13:35,180 --> 00:13:37,420
we're all on some spectrum of ability.

279
00:13:37,420 --> 00:13:39,820
You know, it's not like disabled people over there,

280
00:13:39,820 --> 00:13:42,680
able-bodied people over on some other side.

281
00:13:42,680 --> 00:13:45,900
We're all kind of on some spectrum of ability

282
00:13:45,900 --> 00:13:47,860
and adaptation all the time.

283
00:13:47,860 --> 00:13:50,860
And so to your point, it's been really thrilling to see

284
00:13:51,820 --> 00:13:54,700
inventive ways to work a body, love it.

285
00:13:54,700 --> 00:13:56,420
Yeah, no, I'm loving it as well.

286
00:13:56,420 --> 00:14:01,420
And like you said, there was almost stigma towards,

287
00:14:02,140 --> 00:14:04,380
you know, other ways of lifting other than what ended up,

288
00:14:04,380 --> 00:14:07,180
and now we can look at was the bodybuilding mentality.

289
00:14:07,180 --> 00:14:09,660
But now the yoga, the handstands, the gymnastics,

290
00:14:09,660 --> 00:14:12,820
and, you know, again, working around any challenges,

291
00:14:12,820 --> 00:14:13,960
whether it's a permanent one

292
00:14:13,960 --> 00:14:15,160
or whether it's just a temporary one,

293
00:14:15,160 --> 00:14:17,340
you know, you tweaked an ankle or, you know,

294
00:14:17,340 --> 00:14:19,360
you pull your back out, whatever it was.

295
00:14:19,360 --> 00:14:20,880
And now people are realizing that, yeah,

296
00:14:20,880 --> 00:14:22,740
you can keep moving, whether it's a challenge,

297
00:14:22,740 --> 00:14:24,500
that you're gonna have the rest of your life

298
00:14:24,500 --> 00:14:25,820
or whether it's something you're just working through

299
00:14:25,820 --> 00:14:26,660
and injury.

300
00:14:26,660 --> 00:14:29,660
So I think people are understanding the body a lot more

301
00:14:29,660 --> 00:14:31,020
and realizing, just like you said,

302
00:14:31,020 --> 00:14:34,340
if you just trying to look better in the mirror

303
00:14:34,340 --> 00:14:36,860
and that's your only challenge, you know, your only goal,

304
00:14:36,860 --> 00:14:38,540
then yeah, you probably set yourself up

305
00:14:38,540 --> 00:14:40,380
for failure down the road.

306
00:14:40,380 --> 00:14:41,940
Oh yeah, totally.

307
00:14:41,940 --> 00:14:45,260
I mean, it's so funny to think about all the damage

308
00:14:45,260 --> 00:14:48,540
that we probably did in the name of health and exercise.

309
00:14:48,540 --> 00:14:51,220
We see that a lot in medicine, you know,

310
00:14:52,620 --> 00:14:54,420
what we thought was gonna be better for people

311
00:14:54,420 --> 00:14:55,860
ends up being worse, et cetera.

312
00:14:55,860 --> 00:14:58,060
It just seems like part of our reckoning

313
00:14:58,060 --> 00:15:00,700
that actually the body is something we work with,

314
00:15:00,700 --> 00:15:02,680
not something that we commandeer.

315
00:15:02,680 --> 00:15:06,700
That nature is something we sidle up to, not override.

316
00:15:06,700 --> 00:15:07,840
And that's kind of awesome.

317
00:15:07,840 --> 00:15:09,340
Yeah, and I think people realizing

318
00:15:09,340 --> 00:15:11,340
that the body is pretty good at taking care of itself,

319
00:15:11,340 --> 00:15:13,460
you give it the right environment too.

320
00:15:13,460 --> 00:15:14,780
Yep.

321
00:15:14,780 --> 00:15:18,020
Okay, well, I wanna go back just to that train in Princeton

322
00:15:18,020 --> 00:15:20,820
just for a moment, because you made a very,

323
00:15:20,820 --> 00:15:22,660
yeah, just a passing comment

324
00:15:22,660 --> 00:15:24,740
that most people would have even not paid attention to,

325
00:15:24,740 --> 00:15:26,940
but as a first responder, it kind of,

326
00:15:26,940 --> 00:15:29,380
it's an area that I talk about sometimes.

327
00:15:29,380 --> 00:15:32,360
So when you were on the train car,

328
00:15:33,420 --> 00:15:36,860
and I'm not by any means picking on the first responders

329
00:15:36,860 --> 00:15:39,420
that showed up, but when they got there,

330
00:15:39,420 --> 00:15:41,900
the ambulance guys actually refused to get up

331
00:15:41,900 --> 00:15:45,380
onto the carriage to get you, is that correct?

332
00:15:45,380 --> 00:15:47,260
Yeah, yeah.

333
00:15:47,260 --> 00:15:49,940
All right, so I wanted to make an observation about that.

334
00:15:49,940 --> 00:15:52,020
They could be extremely heroic people

335
00:15:52,020 --> 00:15:54,020
that had just seen something that they knew was dangerous,

336
00:15:54,020 --> 00:15:56,860
but we do have an element in our field

337
00:15:56,860 --> 00:15:59,500
where it's like over safety,

338
00:15:59,500 --> 00:16:02,020
where people just won't go into

339
00:16:02,020 --> 00:16:05,020
a partly potentially dangerous area

340
00:16:05,020 --> 00:16:07,340
because they've been taught not to

341
00:16:07,340 --> 00:16:09,460
and just following it dogmatically.

342
00:16:09,460 --> 00:16:11,020
But if your friends were up there,

343
00:16:11,020 --> 00:16:13,380
you were removed from the energy source.

344
00:16:13,380 --> 00:16:15,100
And then I think you said a campus policeman

345
00:16:15,100 --> 00:16:17,900
went up there to help and passed you down in the end.

346
00:16:17,900 --> 00:16:20,020
I was disappointed as a first responder,

347
00:16:20,020 --> 00:16:22,220
understanding that there's potential dangers

348
00:16:22,220 --> 00:16:25,140
that my peers hadn't been the ones

349
00:16:25,140 --> 00:16:27,540
that going up there to get you down.

350
00:16:27,540 --> 00:16:30,700
Yeah, well, thanks for bringing that up, James.

351
00:16:30,700 --> 00:16:32,620
It's something, it's a detail

352
00:16:32,620 --> 00:16:34,660
that I've never really talked about

353
00:16:34,660 --> 00:16:38,260
because I think you may be the first first responder

354
00:16:38,260 --> 00:16:41,540
that I'm having a kind of a more casual conversation with

355
00:16:41,540 --> 00:16:42,980
outside of a trauma scene.

356
00:16:42,980 --> 00:16:46,140
So it's a really interesting point.

357
00:16:46,140 --> 00:16:47,260
Yeah, that is true.

358
00:16:47,260 --> 00:16:50,500
So my buddy, so two of my,

359
00:16:50,500 --> 00:16:54,100
who are still my like best friends, like brothers,

360
00:16:54,100 --> 00:16:57,860
like Jonathan and Pete were with me that night

361
00:16:57,860 --> 00:17:00,100
and Jonathan ran to call 911

362
00:17:00,100 --> 00:17:05,100
and Pete a very burly superhero kind of dude in every way.

363
00:17:05,700 --> 00:17:09,180
He's the first one, he got up on the train

364
00:17:09,180 --> 00:17:10,420
and he was the one who,

365
00:17:11,940 --> 00:17:13,780
he's the one who took the great risk.

366
00:17:13,780 --> 00:17:17,460
He had no training, had no idea what was waiting

367
00:17:17,460 --> 00:17:18,780
for him up there, whether or not,

368
00:17:18,780 --> 00:17:21,180
he couldn't see what had happened.

369
00:17:21,180 --> 00:17:24,660
So he really walked into a burning building, so to speak.

370
00:17:24,660 --> 00:17:28,380
And I love him for it dearly, among other things.

371
00:17:29,620 --> 00:17:32,780
And then he held me down

372
00:17:32,780 --> 00:17:34,300
because apparently at some point when I came to,

373
00:17:34,300 --> 00:17:35,460
I was just flailing around

374
00:17:35,460 --> 00:17:38,300
and I guess it's pretty common in electrical injuries.

375
00:17:38,300 --> 00:17:40,740
You've just got such adrenaline and heat running through you.

376
00:17:40,740 --> 00:17:43,700
You're just, you know, flailing.

377
00:17:43,700 --> 00:17:46,740
I was punching Pete, just thrashing around.

378
00:17:47,820 --> 00:17:51,980
And Pete held me down while the first responders came,

379
00:17:51,980 --> 00:17:53,700
when the paramedics came.

380
00:17:53,700 --> 00:17:55,820
And to your point, they did not get up

381
00:17:55,820 --> 00:17:57,020
on the top of the train,

382
00:17:58,100 --> 00:18:00,100
waited for the police to arrive as well.

383
00:18:00,100 --> 00:18:02,420
I think this was all happening pretty quickly.

384
00:18:02,420 --> 00:18:05,980
And then a man who then went on, who was promoted,

385
00:18:05,980 --> 00:18:09,020
who was part of the town police, not the campus police.

386
00:18:09,020 --> 00:18:10,540
I can't remember his first name,

387
00:18:10,540 --> 00:18:12,540
but his last name was Dawson.

388
00:18:12,540 --> 00:18:14,580
He became Sergeant Dawson at some point,

389
00:18:14,580 --> 00:18:15,620
and maybe beyond that.

390
00:18:15,620 --> 00:18:17,580
But I think he was promoted in part

391
00:18:17,580 --> 00:18:19,580
because of his bravery that day.

392
00:18:19,580 --> 00:18:22,260
And he got up on the train with Pete.

393
00:18:22,260 --> 00:18:25,500
So Sergeant Dawson and Pete were up there.

394
00:18:25,500 --> 00:18:27,580
The paramedics handed them the stretcher.

395
00:18:27,580 --> 00:18:29,660
They put me in the stretcher and handed me down.

396
00:18:29,660 --> 00:18:30,700
And that's how that went.

397
00:18:30,700 --> 00:18:33,180
Right, yeah, like I said, I won't harp on that point,

398
00:18:33,180 --> 00:18:37,420
but to me, if Pete was already up there,

399
00:18:37,420 --> 00:18:40,420
clearly whatever shocked you at the time

400
00:18:40,420 --> 00:18:42,300
was some sort of arc.

401
00:18:42,300 --> 00:18:44,140
That's, you've got to be careful up there,

402
00:18:44,140 --> 00:18:45,540
but you would hope that you would get up there

403
00:18:45,540 --> 00:18:48,220
and get you off as quickly as possible, get away from it.

404
00:18:48,220 --> 00:18:51,740
But I'm Monday morning, Monday morning quarter back in it,

405
00:18:51,740 --> 00:18:54,180
but I think possibly would have done it differently.

406
00:18:54,180 --> 00:18:57,220
But anyway, I don't want to harp on about that.

407
00:18:57,220 --> 00:18:59,340
It was just a first responder observation.

408
00:18:59,340 --> 00:19:01,700
But what I would like to talk about

409
00:19:01,700 --> 00:19:04,260
just before we get away from that night

410
00:19:04,260 --> 00:19:06,900
and start moving forward with what you're doing now.

411
00:19:06,900 --> 00:19:09,220
As a first responder, again, I found it pretty funny.

412
00:19:09,220 --> 00:19:13,380
So can you tell me when you woke up in the hospital

413
00:19:13,380 --> 00:19:17,260
that that incident you had when you needed the bathroom?

414
00:19:17,260 --> 00:19:20,300
Oh yeah, that was quite,

415
00:19:22,540 --> 00:19:23,940
for some reason I love this memory.

416
00:19:23,940 --> 00:19:25,100
I had no idea.

417
00:19:25,100 --> 00:19:26,220
It's a kind of a bleak one.

418
00:19:26,220 --> 00:19:30,220
I don't know why, but it kind of, I think,

419
00:19:30,220 --> 00:19:31,500
well, I'm presaging here,

420
00:19:31,500 --> 00:19:34,900
but I think why I smile when I think of this story

421
00:19:34,900 --> 00:19:37,780
is because sometimes through the fog of it

422
00:19:37,780 --> 00:19:41,180
your brain shutting down, through the medications,

423
00:19:41,180 --> 00:19:43,180
there's so much about those first couple months

424
00:19:43,180 --> 00:19:46,180
in the burn unit that is hazy.

425
00:19:46,180 --> 00:19:47,700
And it's like I wasn't there.

426
00:19:48,660 --> 00:19:50,020
Sometimes when I hear about it,

427
00:19:50,020 --> 00:19:53,060
it's like hearing about someone else.

428
00:19:53,060 --> 00:19:56,580
And this memory that I'm about to share with you,

429
00:19:56,580 --> 00:19:57,420
it cuts through that.

430
00:19:57,420 --> 00:19:59,380
It really reminds me that I was there

431
00:19:59,380 --> 00:20:01,060
and that I actually went through it.

432
00:20:01,060 --> 00:20:04,940
And in a way, there's a, I think part of why I smile,

433
00:20:04,940 --> 00:20:06,620
I think there's a little pride in it

434
00:20:06,620 --> 00:20:10,260
just for, I don't know, I don't know why, but anyway.

435
00:20:11,100 --> 00:20:14,620
So to your point, your question,

436
00:20:14,620 --> 00:20:16,940
the first few days I don't have really any memories.

437
00:20:16,940 --> 00:20:21,940
That night I was taken to a local hospital in Princeton,

438
00:20:21,940 --> 00:20:25,380
a small hospital, and that we're able

439
00:20:25,380 --> 00:20:26,660
to basically cut these things

440
00:20:26,660 --> 00:20:28,540
that you may know, James, called fasciotomies.

441
00:20:28,540 --> 00:20:32,940
They just cut open the skin to let some of the heat expel

442
00:20:32,940 --> 00:20:34,580
because all that electrical current,

443
00:20:34,580 --> 00:20:37,180
you're still, you've insulated a lot of heat

444
00:20:37,180 --> 00:20:38,460
and trapped a lot of heat in your system

445
00:20:38,460 --> 00:20:40,260
and that can still be doing damage.

446
00:20:40,260 --> 00:20:43,100
So the first order of business is to vent you essentially.

447
00:20:43,100 --> 00:20:46,300
So the local guys cut the fasciotomies

448
00:20:46,300 --> 00:20:48,940
and then pretty quickly I was put in a helicopter

449
00:20:48,940 --> 00:20:52,180
and taken to St. Barnabas, which is New Jersey's Birmingham.

450
00:20:53,860 --> 00:20:55,940
And my very first memory was being loaded

451
00:20:55,940 --> 00:20:58,300
into the helicopter and I was almost 6'5".

452
00:20:58,300 --> 00:21:00,360
And I remember the guys, the pilots,

453
00:21:00,360 --> 00:21:02,780
trying to get me in the helicopter and I didn't quite fit.

454
00:21:02,780 --> 00:21:05,120
And it was like this awkward, clumsy moment.

455
00:21:06,020 --> 00:21:09,100
That's my very first memory and that's sort of hazy.

456
00:21:09,100 --> 00:21:11,340
And then it was about five days later,

457
00:21:11,340 --> 00:21:12,900
well, I think five or six days later,

458
00:21:12,900 --> 00:21:15,740
the night before the first amputations.

459
00:21:15,740 --> 00:21:20,740
And you know that feeling where you wake up from a dream,

460
00:21:23,220 --> 00:21:26,620
like a bad dream, and there's a moment

461
00:21:26,620 --> 00:21:28,780
where you're kind of orienting yourself

462
00:21:28,780 --> 00:21:31,140
and you realize that it was just a dream

463
00:21:31,140 --> 00:21:33,980
and this great relief washes over you.

464
00:21:33,980 --> 00:21:34,980
Do you know that?

465
00:21:34,980 --> 00:21:36,020
Yeah.

466
00:21:36,020 --> 00:21:39,420
So somehow I woke up in the burn unit,

467
00:21:39,420 --> 00:21:42,460
which is not in any way a natural environment.

468
00:21:42,460 --> 00:21:44,560
No way I could have confused it with my home,

469
00:21:44,560 --> 00:21:47,500
but whatever the case is, I woke up in the middle of the night,

470
00:21:47,500 --> 00:21:50,740
opened my eyes, looked around, and thought to myself,

471
00:21:50,740 --> 00:21:55,740
oh gosh, this whole burn thing was a bad dream.

472
00:21:55,940 --> 00:21:56,780
Thank God.

473
00:21:56,780 --> 00:21:58,860
I felt this great relief

474
00:21:58,860 --> 00:22:01,180
and I felt the need to go to the bathroom.

475
00:22:01,180 --> 00:22:06,180
So I pull all the central lines out of me,

476
00:22:06,620 --> 00:22:11,620
I unstrap my arm from the bed, I extubate myself,

477
00:22:11,940 --> 00:22:15,520
you know, somehow thinking this was just normal.

478
00:22:15,520 --> 00:22:16,420
I don't know what I thought,

479
00:22:16,420 --> 00:22:19,060
but I'm just on my way to the bathroom.

480
00:22:19,060 --> 00:22:22,220
And I swing my legs out

481
00:22:22,220 --> 00:22:25,420
and I stand up on these like crispy dead feet

482
00:22:25,420 --> 00:22:27,500
and I start shuffling to the door

483
00:22:27,500 --> 00:22:29,300
to go find the bathroom.

484
00:22:31,620 --> 00:22:35,780
But the Foley catheter line that I had in

485
00:22:35,780 --> 00:22:37,500
at some point ran out of slack.

486
00:22:37,500 --> 00:22:41,460
And it was hanging from the bed rails.

487
00:22:41,460 --> 00:22:44,340
And so as I was practically reaching for the door,

488
00:22:44,340 --> 00:22:48,000
I was putting my arm out, that thing ran out of line.

489
00:22:48,000 --> 00:22:50,820
And so there's this great yank on the catheter

490
00:22:50,820 --> 00:22:53,020
with the ball still inflated.

491
00:22:53,020 --> 00:22:56,500
And so the Foley catheter came like part way out,

492
00:22:56,500 --> 00:22:58,220
not all the way out.

493
00:22:58,220 --> 00:23:03,220
And in that moment, like the pain was really intense

494
00:23:04,020 --> 00:23:05,780
and I just fell to the floor

495
00:23:05,780 --> 00:23:08,540
and realized just like had the opposite effect

496
00:23:08,540 --> 00:23:09,540
that I had minutes ago.

497
00:23:09,540 --> 00:23:13,660
I realized that all of this was real and holy shit,

498
00:23:13,660 --> 00:23:17,580
wow, like it all, it was because everything

499
00:23:17,580 --> 00:23:20,540
kind of came into focus in an instant.

500
00:23:20,540 --> 00:23:22,620
And that was hard.

501
00:23:22,620 --> 00:23:25,500
I was trying to like, I was trying to break the line

502
00:23:25,500 --> 00:23:28,660
to somehow relieve the catheter and I couldn't do it.

503
00:23:28,660 --> 00:23:30,620
And finally the alarms were going off

504
00:23:30,620 --> 00:23:33,220
and finally the nurse came in and got me back in bed.

505
00:23:33,220 --> 00:23:34,820
And that was that.

506
00:23:34,820 --> 00:23:38,740
But yeah, that was my first real intense memory.

507
00:23:38,740 --> 00:23:40,460
I think there's two things to be taken for that.

508
00:23:40,460 --> 00:23:41,820
Firstly, the fact that you've extubated,

509
00:23:41,820 --> 00:23:45,020
I'm assuming that the ET tube was still inflated there too.

510
00:23:45,020 --> 00:23:48,380
So you pulled that giant ball through your throat.

511
00:23:48,380 --> 00:23:50,900
But then the second thing that you can walk

512
00:23:50,900 --> 00:23:53,260
on severely burnt feet,

513
00:23:53,260 --> 00:23:55,580
and clearly it wasn't registering with the pain,

514
00:23:55,580 --> 00:23:58,700
but you pull something grape sized through your pee hole.

515
00:23:58,700 --> 00:23:59,540
That's enough to,

516
00:23:59,540 --> 00:24:03,460
that shows you how painful it is when you get a catheter.

517
00:24:03,460 --> 00:24:05,660
Yep, exactly.

518
00:24:05,660 --> 00:24:08,620
Electrical burns doesn't hold a candle

519
00:24:08,620 --> 00:24:10,180
to yanking a Foley catheter.

520
00:24:12,340 --> 00:24:14,020
All right, well, one thing is what you again,

521
00:24:14,020 --> 00:24:15,420
you said in passing and it struck me

522
00:24:15,420 --> 00:24:16,820
and I'm like, I'd never thought of it that way.

523
00:24:16,820 --> 00:24:18,300
And then this will be the last thing

524
00:24:18,300 --> 00:24:19,940
and we'll move on to everything else.

525
00:24:19,940 --> 00:24:22,060
But when one of your interviews I heard,

526
00:24:22,060 --> 00:24:26,660
you said, I used to be about six foot five.

527
00:24:26,660 --> 00:24:27,500
And that struck me.

528
00:24:27,500 --> 00:24:29,060
I'm like, so with your prosthesis,

529
00:24:29,060 --> 00:24:32,180
you're actually a different height than you were.

530
00:24:32,180 --> 00:24:33,020
Yeah.

531
00:24:33,020 --> 00:24:36,860
That's just, I mean, it's nothing amazing about that.

532
00:24:36,860 --> 00:24:38,300
It's just something you never thought about

533
00:24:38,300 --> 00:24:40,860
that what you were used to being eye level with changes

534
00:24:40,860 --> 00:24:43,980
once you start to walk on your prosthesis again.

535
00:24:43,980 --> 00:24:46,060
Yeah, well, so it's so true.

536
00:24:46,060 --> 00:24:47,300
And then one of the,

537
00:24:47,300 --> 00:24:48,660
there are a couple of things to say on that James.

538
00:24:48,660 --> 00:24:52,380
One is, one of the fun, there are upshots.

539
00:24:52,380 --> 00:24:54,620
I would say, I don't know that I've run across anything

540
00:24:54,620 --> 00:24:57,500
in this world that's all bad or all good.

541
00:24:57,500 --> 00:24:59,420
I think it's everything's a mix

542
00:24:59,420 --> 00:25:01,380
and depends how you look at it, et cetera.

543
00:25:01,380 --> 00:25:02,580
But kind of one of the fun,

544
00:25:02,580 --> 00:25:06,220
once you get past some of the annoyances and pains of it,

545
00:25:06,220 --> 00:25:08,980
one of the fun things that you can do as a double leg amp

546
00:25:08,980 --> 00:25:10,980
is you can tweak your height.

547
00:25:10,980 --> 00:25:14,220
So you can make it up.

548
00:25:14,220 --> 00:25:15,940
You get to say.

549
00:25:15,940 --> 00:25:20,940
And so my native height, it was just too tall

550
00:25:21,460 --> 00:25:25,180
because you can't manipulate the knee and the ankle

551
00:25:25,180 --> 00:25:27,980
in the same way you could an able-bodied leg.

552
00:25:27,980 --> 00:25:32,300
So getting in and out of like movie rows and airplane seats

553
00:25:32,300 --> 00:25:36,540
and just the fulcrum being my balance point

554
00:25:37,820 --> 00:25:42,780
to be that tall just made balance that much more tricky.

555
00:25:42,780 --> 00:25:45,660
So I basically have settled into a height roughly,

556
00:25:45,660 --> 00:25:47,740
roughly six foot three.

557
00:25:47,740 --> 00:25:51,540
And that seems to be a good sweet spot for me.

558
00:25:51,540 --> 00:25:55,300
That seems proportionate enough to my body,

559
00:25:55,300 --> 00:25:57,860
but also makes it a little easier to maneuver

560
00:25:57,860 --> 00:25:59,220
in tight areas.

561
00:25:59,220 --> 00:26:00,260
Right.

562
00:26:00,260 --> 00:26:04,660
Okay, so you had the injury and obviously you went through

563
00:26:04,660 --> 00:26:07,500
probably all kinds of horrendous medical interventions

564
00:26:07,500 --> 00:26:09,020
up to that point.

565
00:26:09,020 --> 00:26:12,060
Was it in that healing process that you began

566
00:26:12,060 --> 00:26:16,060
to consider medicine instead of business as a career?

567
00:26:16,060 --> 00:26:20,340
Yeah, so it was, okay, so sophomore year was the injuries.

568
00:26:20,340 --> 00:26:23,540
So I really didn't know what I was gonna do for a living.

569
00:26:23,540 --> 00:26:26,580
I was very much in the liberal arts kind of vein.

570
00:26:26,580 --> 00:26:27,780
I was learning to learn.

571
00:26:27,780 --> 00:26:30,220
You know, I knew I was headed for a major

572
00:26:30,220 --> 00:26:31,260
in East Asian studies.

573
00:26:31,260 --> 00:26:33,740
I was studying Chinese language.

574
00:26:33,740 --> 00:26:36,220
I probably would have just, you know,

575
00:26:36,220 --> 00:26:39,540
by default followed my dad and a lot of Princeton folks

576
00:26:39,540 --> 00:26:42,180
into sort of the business world.

577
00:26:42,180 --> 00:26:43,020
I don't know.

578
00:26:43,020 --> 00:26:45,500
I really don't know what I would have done.

579
00:26:45,500 --> 00:26:48,380
But when I was in the hospital,

580
00:26:48,380 --> 00:26:51,060
what I did get turned on to was a sort of a new way

581
00:26:51,060 --> 00:26:54,980
of thinking about life and perspective making

582
00:26:54,980 --> 00:26:58,900
and sort of the creative side of being a human being.

583
00:26:58,900 --> 00:27:01,980
And I switched my major to art history.

584
00:27:01,980 --> 00:27:03,660
And that proved to be a really,

585
00:27:03,660 --> 00:27:05,420
that was a very therapeutic and good,

586
00:27:05,420 --> 00:27:06,820
that was a smart decision.

587
00:27:06,820 --> 00:27:08,380
I'm really glad I did that.

588
00:27:08,380 --> 00:27:09,820
We can talk about that in detail.

589
00:27:09,820 --> 00:27:13,780
But to your question, graduation rolled around

590
00:27:13,780 --> 00:27:15,740
and I had been very much in the vein,

591
00:27:17,740 --> 00:27:19,900
not just in a, not so much in a light way,

592
00:27:19,900 --> 00:27:22,180
but in a necessary way of just being in the moment.

593
00:27:22,180 --> 00:27:23,620
I was just, every day was a matter

594
00:27:23,620 --> 00:27:25,180
of getting through the day.

595
00:27:25,180 --> 00:27:27,220
So I wasn't planning a future much.

596
00:27:27,220 --> 00:27:29,140
And then graduation rolls around and I said,

597
00:27:29,140 --> 00:27:32,900
oh, shit, I gotta figure out what I'm gonna do for a living.

598
00:27:34,500 --> 00:27:38,100
And all I knew was I wanted to use my experiences

599
00:27:38,100 --> 00:27:40,460
as a patient, as a disabled person.

600
00:27:40,460 --> 00:27:43,180
The old way of thinking with disability is that something

601
00:27:43,180 --> 00:27:44,780
at best that you overcome

602
00:27:44,780 --> 00:27:47,500
and it's something you put behind you.

603
00:27:47,500 --> 00:27:48,980
Whereas what I learned from my mother

604
00:27:48,980 --> 00:27:51,060
and others in the disability rights movement was,

605
00:27:51,060 --> 00:27:55,340
no, no, no, disability, let it color your worldview.

606
00:27:55,340 --> 00:27:59,500
Don't try to pass, use it, work with it, be proud of it.

607
00:27:59,500 --> 00:28:03,580
It's where it can ignite a sort of adaptive,

608
00:28:03,580 --> 00:28:06,460
creative spark in people, work arounds, et cetera.

609
00:28:06,460 --> 00:28:09,620
So I knew I really wanted to lean into my disability

610
00:28:09,620 --> 00:28:12,260
and work with it and be proud of it.

611
00:28:12,260 --> 00:28:16,060
And I also knew I wanted to be of some amount of,

612
00:28:16,060 --> 00:28:17,220
in a service industry.

613
00:28:17,220 --> 00:28:20,580
I felt like I'd been on the receiving end of amazing care

614
00:28:20,580 --> 00:28:23,700
in the hospital and among my friends and family.

615
00:28:23,700 --> 00:28:27,300
And I had really experienced what it's like to be cared for.

616
00:28:27,300 --> 00:28:29,460
And it was beautiful, it was stunning.

617
00:28:29,460 --> 00:28:33,220
And so I knew I wanted to be in service

618
00:28:33,220 --> 00:28:34,780
and I knew I wanted to use my disability.

619
00:28:34,780 --> 00:28:38,100
And that just on paper pointed me towards medicine,

620
00:28:38,100 --> 00:28:39,540
but I had never studied medicine

621
00:28:39,540 --> 00:28:40,780
and never been interested in.

622
00:28:40,780 --> 00:28:43,900
So I went back and took the pre-meds

623
00:28:43,900 --> 00:28:45,580
and sort of just one foot in front of the other,

624
00:28:45,580 --> 00:28:48,820
went down the road of medicine and kept going.

625
00:28:48,820 --> 00:28:50,580
And where did you go to med school?

626
00:28:52,140 --> 00:28:54,580
University of California, San Francisco, UCSF.

627
00:28:54,580 --> 00:28:57,220
Okay, so that's what took you over to the West Coast?

628
00:28:57,220 --> 00:28:58,180
Yeah, yeah.

629
00:28:58,180 --> 00:28:59,020
Right, so.

630
00:28:59,020 --> 00:29:02,020
Well, I actually moved, yeah, I knew I wanted to go West

631
00:29:02,020 --> 00:29:04,780
and I did the pre-meds here in Oakland.

632
00:29:04,780 --> 00:29:06,260
And that's what really the pre-med

633
00:29:06,260 --> 00:29:08,900
and I was lucky to get into UCSF and stay in the Bay Area.

634
00:29:08,900 --> 00:29:11,180
But yes, that was the Odyssey.

635
00:29:11,180 --> 00:29:13,580
Okay, so when you went through med school

636
00:29:13,580 --> 00:29:16,900
and you came out the other end, how did you,

637
00:29:16,900 --> 00:29:18,300
well, firstly, what was the journey

638
00:29:18,300 --> 00:29:22,180
into the palliative care physician that you are now?

639
00:29:23,940 --> 00:29:26,900
Well, often med school,

640
00:29:26,900 --> 00:29:29,900
again, because I wasn't approaching this

641
00:29:29,900 --> 00:29:31,940
from an interest in medical science per se.

642
00:29:31,940 --> 00:29:33,100
I was approaching this,

643
00:29:33,100 --> 00:29:36,740
I was interested in learning some new skills

644
00:29:36,740 --> 00:29:39,660
and having a bag of tricks to put to use in service.

645
00:29:41,180 --> 00:29:45,220
And so what fueled my interest was not so much

646
00:29:45,220 --> 00:29:48,740
the details of the schooling, physiology, et cetera.

647
00:29:48,740 --> 00:29:49,580
I found it interesting,

648
00:29:49,580 --> 00:29:52,340
but that's not what I was there for.

649
00:29:52,340 --> 00:29:56,380
So all through med school, I was pretty casual about it

650
00:29:56,380 --> 00:30:00,820
because I figured the best place for me to work

651
00:30:00,820 --> 00:30:02,380
would be in rehab medicine,

652
00:30:02,380 --> 00:30:03,980
working with other disabled folks.

653
00:30:03,980 --> 00:30:06,540
And that just seemed like the most obvious choice.

654
00:30:06,540 --> 00:30:08,340
So that's what I just assumed I'd do.

655
00:30:09,820 --> 00:30:10,900
But deep in med school,

656
00:30:10,900 --> 00:30:12,940
I finally did a rotation in rehab medicine

657
00:30:12,940 --> 00:30:14,900
and for a number of reasons,

658
00:30:14,900 --> 00:30:16,460
fell out of love with that idea

659
00:30:17,620 --> 00:30:18,940
and actually was going to,

660
00:30:18,940 --> 00:30:20,420
I was gonna finish medical school.

661
00:30:20,420 --> 00:30:23,180
I was in my senior year, but I was gonna stop.

662
00:30:23,180 --> 00:30:25,540
I mean, I knew from my own coming close to death,

663
00:30:25,540 --> 00:30:29,220
I knew that I was not gonna make my life

664
00:30:29,220 --> 00:30:31,420
an unnecessary sacrifice.

665
00:30:31,420 --> 00:30:32,980
And then I think a lot of folks

666
00:30:32,980 --> 00:30:34,500
who go into medical training,

667
00:30:35,380 --> 00:30:37,260
it takes so much time, so much money.

668
00:30:37,260 --> 00:30:39,060
And then once you're far enough down the road,

669
00:30:39,060 --> 00:30:41,940
the idea of doing something else just seems ridiculous.

670
00:30:41,940 --> 00:30:43,700
So a fair amount of my colleagues,

671
00:30:43,700 --> 00:30:45,380
I think still practice medicine,

672
00:30:45,380 --> 00:30:46,300
not because they love it,

673
00:30:46,300 --> 00:30:50,020
but just because that's all they know how to do

674
00:30:50,020 --> 00:30:52,300
and they had spent too much time training.

675
00:30:52,300 --> 00:30:54,660
So they kind of felt like they had to do it.

676
00:30:54,660 --> 00:30:55,660
I was not gonna do that.

677
00:30:55,660 --> 00:30:57,780
So I was gonna drop out of medicine,

678
00:30:57,780 --> 00:31:01,060
but then did an internship,

679
00:31:01,060 --> 00:31:03,620
the first year residency, my first postdoc year,

680
00:31:03,620 --> 00:31:05,260
just because my Dean said,

681
00:31:05,260 --> 00:31:07,420
you should go do an internship, then stop.

682
00:31:07,420 --> 00:31:08,940
That's just a better stopping point.

683
00:31:08,940 --> 00:31:10,340
You can get your license to practice.

684
00:31:10,340 --> 00:31:12,380
If you wanna jump back in, you can, et cetera.

685
00:31:12,380 --> 00:31:13,740
So I said, okay.

686
00:31:13,740 --> 00:31:15,300
So I went back to my parents,

687
00:31:15,300 --> 00:31:17,740
my family at that point was in Milwaukee.

688
00:31:17,740 --> 00:31:20,820
So I went to Milwaukee to do my internship,

689
00:31:20,820 --> 00:31:23,380
just thinking that I would do that one year and be done.

690
00:31:24,540 --> 00:31:26,540
And then I was probably gonna go into the tea business,

691
00:31:26,540 --> 00:31:27,580
which is another story,

692
00:31:27,580 --> 00:31:30,540
but during that internship,

693
00:31:30,540 --> 00:31:32,460
I got turned on to palliative care.

694
00:31:32,460 --> 00:31:33,940
I did a rotation in it.

695
00:31:33,940 --> 00:31:35,820
And as happens in this field,

696
00:31:35,820 --> 00:31:39,060
I was sort of smitten the very first day,

697
00:31:39,060 --> 00:31:43,020
and then recommitted myself to medicine,

698
00:31:43,020 --> 00:31:45,220
to do palliative medicine specifically.

699
00:31:45,220 --> 00:31:47,220
Okay, so I know that I was really introduced

700
00:31:47,220 --> 00:31:51,180
to that term specifically from hearing you talk before.

701
00:31:51,180 --> 00:31:54,260
So can you give us a definition of palliative care

702
00:31:54,260 --> 00:31:57,700
and then contrast it with hospice?

703
00:31:57,700 --> 00:31:59,140
Yeah, yeah, thank you, James.

704
00:31:59,140 --> 00:32:00,660
It's a really important point to get across.

705
00:32:00,660 --> 00:32:04,260
So yeah, so palliative medicine is,

706
00:32:04,260 --> 00:32:06,940
is palliative care more broadly,

707
00:32:06,940 --> 00:32:11,420
is in a disciplinary pursuit of quality of life.

708
00:32:12,860 --> 00:32:15,860
It's a medical subspecialty now

709
00:32:15,860 --> 00:32:20,180
that focuses on chronic and advanced illness,

710
00:32:20,180 --> 00:32:21,560
so serious illness.

711
00:32:21,560 --> 00:32:24,880
And the idea really, the fulcrum for palliative care

712
00:32:24,880 --> 00:32:28,000
is not so much to combat disease,

713
00:32:28,000 --> 00:32:29,520
but to combat suffering.

714
00:32:30,800 --> 00:32:33,480
And so that's what, so palliative care,

715
00:32:33,480 --> 00:32:35,520
that's palliative care period.

716
00:32:35,520 --> 00:32:37,800
It's doctors, nurses, social workers, chaplains,

717
00:32:37,800 --> 00:32:40,440
and others working together to help you suffer less

718
00:32:40,440 --> 00:32:43,520
and actually feel as good as possible.

719
00:32:44,960 --> 00:32:48,520
So it grew out of hospice,

720
00:32:48,520 --> 00:32:50,920
sort of hospice mentality hit this country

721
00:32:50,920 --> 00:32:54,640
in the mid 70s and grew in the 80s and 90s.

722
00:32:54,640 --> 00:32:56,440
And as you know, hospice really is,

723
00:32:56,440 --> 00:32:58,880
especially since Medicare got in the business in the 80s,

724
00:32:58,880 --> 00:33:01,080
hospice really is meant for the end of life.

725
00:33:01,080 --> 00:33:03,960
It's in the, you qualify for it

726
00:33:03,960 --> 00:33:06,480
when you have six months or less to live.

727
00:33:07,880 --> 00:33:11,880
So it is really meant to be care at the end of life, hospice.

728
00:33:13,280 --> 00:33:15,120
But a lot of people who worked in hospice,

729
00:33:15,120 --> 00:33:19,800
you kind of, you start realizing that, gosh,

730
00:33:19,800 --> 00:33:21,320
people have been through the mill of treatment

731
00:33:21,320 --> 00:33:22,440
and then they enter hospice

732
00:33:22,440 --> 00:33:24,480
and they get this sort of loving embrace

733
00:33:24,480 --> 00:33:26,600
and people rallying around them and supporting them

734
00:33:26,600 --> 00:33:28,720
and not trying to force them to do anything

735
00:33:28,720 --> 00:33:32,440
and they're treating their pain and they're being kind,

736
00:33:32,440 --> 00:33:34,040
and it can be beautiful.

737
00:33:34,040 --> 00:33:36,520
But it's a common moment is for everyone involved

738
00:33:36,520 --> 00:33:39,440
and say, well, why do we wait so long

739
00:33:39,440 --> 00:33:41,320
to provide this kind of care?

740
00:33:41,320 --> 00:33:44,600
Why do you have to be dying to get this kind of care?

741
00:33:44,600 --> 00:33:45,880
And it's that kind of impulse

742
00:33:45,880 --> 00:33:50,880
that gave birth to this wider sphere of palliative care

743
00:33:51,560 --> 00:33:52,400
that I just described.

744
00:33:52,400 --> 00:33:57,400
So the hospice is the mothership,

745
00:33:57,400 --> 00:34:00,120
palliative care grew out of a hospice mentality

746
00:34:00,120 --> 00:34:02,760
and hospice is part of palliative care,

747
00:34:02,760 --> 00:34:04,520
but palliative care is going to be much larger

748
00:34:04,520 --> 00:34:05,360
as I was saying earlier.

749
00:34:05,360 --> 00:34:07,400
You don't have to be dying anytime soon

750
00:34:07,400 --> 00:34:08,760
to get palliative care.

751
00:34:08,760 --> 00:34:10,760
And that's a hugely important fact

752
00:34:10,760 --> 00:34:12,040
for your listeners to absorb

753
00:34:12,040 --> 00:34:15,080
because the common misconception is that palliative care

754
00:34:15,080 --> 00:34:17,440
is hospice, is end of life care,

755
00:34:17,440 --> 00:34:21,200
and therefore you only qualify for it when you're dying.

756
00:34:21,200 --> 00:34:23,440
And so no one wants palliative care

757
00:34:23,440 --> 00:34:25,200
because that usually means they're dying

758
00:34:25,200 --> 00:34:28,320
and that people are suffering unnecessarily

759
00:34:28,320 --> 00:34:29,520
when there's this whole specialty

760
00:34:29,520 --> 00:34:33,120
that can help them feel better anywhere along the way.

761
00:34:33,120 --> 00:34:35,480
So it's a really, really important point

762
00:34:35,480 --> 00:34:37,800
that society has to understand that palliative care,

763
00:34:37,800 --> 00:34:40,760
yes, we do end of life care, but that's not all we do.

764
00:34:40,760 --> 00:34:42,600
Right, and I know for someone who's been in medicine

765
00:34:42,600 --> 00:34:45,960
for almost 15 years now, I wasn't aware of that.

766
00:34:45,960 --> 00:34:50,760
So I guess that needs to get out there a lot more,

767
00:34:50,760 --> 00:34:53,000
especially with the fact, and correct me if I'm wrong,

768
00:34:53,000 --> 00:34:55,440
that once you enter hospice specifically,

769
00:34:55,440 --> 00:34:57,480
you're giving up a lot of your medical treatments as well.

770
00:34:57,480 --> 00:34:58,720
Is that right?

771
00:34:58,720 --> 00:34:59,540
That's right.

772
00:34:59,540 --> 00:35:01,560
So the way, and that may change someday.

773
00:35:01,560 --> 00:35:04,040
There's some demonstration projects out there,

774
00:35:04,040 --> 00:35:08,600
but since 1982 when Medicare defined the hospice benefit

775
00:35:08,600 --> 00:35:12,160
in this country, the way they drew a line around it

776
00:35:12,160 --> 00:35:14,480
was you have to have a doctor tell you

777
00:35:14,480 --> 00:35:16,160
you got six months or less to live,

778
00:35:16,160 --> 00:35:19,360
and you have to give up curative intention.

779
00:35:19,360 --> 00:35:22,160
You have to give up essentially treating the disease.

780
00:35:23,700 --> 00:35:25,360
And that's been a real problem.

781
00:35:25,360 --> 00:35:28,680
I mean, it used to be less of a problem in a way

782
00:35:28,680 --> 00:35:32,920
because once you're in six months or less to live,

783
00:35:32,920 --> 00:35:35,920
oftentimes the treatments are obviously not working.

784
00:35:35,920 --> 00:35:38,040
The treatments are in some ways hurting.

785
00:35:38,040 --> 00:35:40,840
So at one point, giving up treatment

786
00:35:40,840 --> 00:35:43,560
was an emotional and psychological barrier,

787
00:35:43,560 --> 00:35:46,200
but practically speaking, wasn't such a big deal

788
00:35:46,200 --> 00:35:49,160
because you were giving up something that wasn't helping you.

789
00:35:49,160 --> 00:35:51,560
Now, we've gotten better at treating illness

790
00:35:51,560 --> 00:35:56,320
and more savvy at, if not curing it, at least delaying it.

791
00:35:56,320 --> 00:35:59,480
So we're in a pickle now that part of the problem

792
00:35:59,480 --> 00:36:02,180
that faces hospices, as you're pointing out,

793
00:36:02,180 --> 00:36:04,640
we put this really lame fork in the road.

794
00:36:04,640 --> 00:36:08,720
So yeah, Mr. Jones, you can come be with us in hospice,

795
00:36:08,720 --> 00:36:11,600
but you have to let go of this idea of treating your disease.

796
00:36:11,600 --> 00:36:14,460
And so it's this really difficult decision

797
00:36:14,460 --> 00:36:16,260
that we make people make.

798
00:36:16,260 --> 00:36:18,700
And it's one of the forces that keeps people

799
00:36:18,700 --> 00:36:21,200
from electing hospice until very, very late in the game.

800
00:36:21,200 --> 00:36:25,340
I mean, commonly people are in hospice for a week or less,

801
00:36:26,400 --> 00:36:29,720
which is a real problem for a number of reasons.

802
00:36:30,640 --> 00:36:32,640
So like I say, there are some efforts

803
00:36:32,640 --> 00:36:35,940
to revisit the hospice benefit and do away with that,

804
00:36:35,940 --> 00:36:39,440
that false distinction there, that false fork.

805
00:36:39,440 --> 00:36:41,680
But meanwhile, it's exactly why Pound of Care

806
00:36:41,680 --> 00:36:44,940
is particularly so important as a field outside of hospice

807
00:36:44,940 --> 00:36:47,640
because you don't, Pound of Care works great.

808
00:36:47,640 --> 00:36:50,680
Like my clinic at UCSF and the cancer center where I work,

809
00:36:51,840 --> 00:36:56,840
I see patients who are full battle mode with their illness

810
00:36:58,080 --> 00:37:01,720
and pushing back on it and maybe even be cured,

811
00:37:01,720 --> 00:37:04,520
but they're still suffering and that's why they see me.

812
00:37:04,520 --> 00:37:07,360
But they're getting aggressive intensive treatments

813
00:37:07,360 --> 00:37:09,580
alongside palliative treatments at the same time.

814
00:37:09,580 --> 00:37:11,180
And that's when it works best.

815
00:37:11,180 --> 00:37:13,440
Okay, now I wanna kind of sidestep for a moment

816
00:37:13,440 --> 00:37:18,440
because I know that we're seeing a much higher incidence

817
00:37:19,080 --> 00:37:21,640
of cancer, especially as we talk before we start recording

818
00:37:21,640 --> 00:37:23,320
in the first responder profession.

819
00:37:23,320 --> 00:37:25,860
I mean, it's been ridiculous.

820
00:37:25,860 --> 00:37:28,240
I've been in so many firefighter funerals last few years

821
00:37:28,240 --> 00:37:31,640
and just went to Memorial yesterday and my brother JP,

822
00:37:31,640 --> 00:37:35,400
who had an autoimmune disease and earlier the year,

823
00:37:35,400 --> 00:37:40,400
we had a gentleman named Shakey who that was cancer.

824
00:37:41,440 --> 00:37:46,440
But again, I can't help but feel there's,

825
00:37:47,280 --> 00:37:48,620
and I'm right away putting it,

826
00:37:48,620 --> 00:37:52,560
I feel like there's more benefit than we are taught

827
00:37:52,560 --> 00:37:54,960
from some of the holistic practices

828
00:37:54,960 --> 00:37:58,180
versus the chemo and the radiation.

829
00:37:58,180 --> 00:38:01,920
Have you being in the West Coast specifically

830
00:38:01,920 --> 00:38:03,220
with the hospice care,

831
00:38:05,600 --> 00:38:08,860
do you see some of these areas outside

832
00:38:08,860 --> 00:38:13,860
of the pharmaceutical applications that we're used to

833
00:38:14,200 --> 00:38:17,200
making a difference in some of these terminally ill patients?

834
00:38:18,600 --> 00:38:21,280
Yes, is the short answer.

835
00:38:21,280 --> 00:38:26,000
So integrative medicine, which is sort of a catchment

836
00:38:26,000 --> 00:38:28,600
for everything that's not traditional medicine

837
00:38:28,600 --> 00:38:29,480
in this country.

838
00:38:29,480 --> 00:38:33,100
So acupuncture, Reiki, energy work, massage therapy,

839
00:38:33,100 --> 00:38:38,100
lymphedema massage, yoga, herbal medicine,

840
00:38:40,220 --> 00:38:42,680
and naturopathy, et cetera.

841
00:38:42,680 --> 00:38:47,680
These all kind of live more or less under this banner

842
00:38:47,720 --> 00:38:49,500
of integrative medicine.

843
00:38:51,020 --> 00:38:53,640
And a place like where I am at UCSF,

844
00:38:53,640 --> 00:38:56,440
there is the Osher Center for Integrative Medicine,

845
00:38:56,440 --> 00:39:00,600
a very well-funded and beautiful program right next to,

846
00:39:00,600 --> 00:39:03,080
it's directly across the street from our cancer center.

847
00:39:03,080 --> 00:39:05,820
So this is not the norm.

848
00:39:05,820 --> 00:39:07,600
The Bay Area in a lot of ways is not the norm,

849
00:39:07,600 --> 00:39:09,280
and UCSF is not the norm.

850
00:39:09,280 --> 00:39:12,220
So we have a pretty good relationship

851
00:39:12,220 --> 00:39:16,520
with the idea of treatments outside of our usual scope.

852
00:39:16,520 --> 00:39:20,800
And over the years, I've noticed there's less bigotry there.

853
00:39:20,800 --> 00:39:22,360
I mean, I think traditionally a lot of folks

854
00:39:22,360 --> 00:39:25,240
who are in the Western American medical model

855
00:39:25,240 --> 00:39:28,520
would have otherwise poo-pooed nutrition,

856
00:39:28,520 --> 00:39:30,300
acupuncture, et cetera.

857
00:39:30,300 --> 00:39:34,800
But this is where the patient population has taught us a lot.

858
00:39:34,800 --> 00:39:37,200
They are, they're going around us

859
00:39:37,200 --> 00:39:39,040
and seeking these other treatments,

860
00:39:39,040 --> 00:39:40,320
and some's working for them

861
00:39:40,320 --> 00:39:41,680
because they spend a lot of money on it

862
00:39:41,680 --> 00:39:42,560
and they keep doing it.

863
00:39:42,560 --> 00:39:45,320
And so finally I think traditional MDs

864
00:39:45,320 --> 00:39:46,720
are starting to open their eyes

865
00:39:46,720 --> 00:39:50,520
that there may be other ways to think about the human body

866
00:39:50,520 --> 00:39:53,280
and other ways to approach helping it.

867
00:39:53,280 --> 00:39:55,920
Now, that said, we've still got long ways to go.

868
00:39:55,920 --> 00:39:59,280
The big pharma and interventional medicine

869
00:39:59,280 --> 00:40:00,800
still rules the day,

870
00:40:00,800 --> 00:40:03,280
and in a lot of ways it deserves to,

871
00:40:04,480 --> 00:40:06,440
but in a lot of ways it doesn't.

872
00:40:07,260 --> 00:40:09,120
So we're not at this,

873
00:40:09,120 --> 00:40:10,880
the healthcare system has all sorts of ills,

874
00:40:10,880 --> 00:40:13,600
including how it treats other approaches

875
00:40:13,600 --> 00:40:14,600
that aren't its own.

876
00:40:14,600 --> 00:40:16,880
So it's still a huge issue.

877
00:40:16,880 --> 00:40:18,800
So, okay, so that's one point, James,

878
00:40:18,800 --> 00:40:19,920
but to answer your question,

879
00:40:19,920 --> 00:40:22,320
yes, I mean, I see a lot of my patients

880
00:40:22,320 --> 00:40:24,640
who then also see an integrative doc,

881
00:40:24,640 --> 00:40:25,800
acupuncturists, et cetera.

882
00:40:25,800 --> 00:40:29,240
So a lot of the patients I see are doing this themselves.

883
00:40:29,240 --> 00:40:30,800
I'm not savvy enough necessarily

884
00:40:30,800 --> 00:40:32,720
to prescribe very other modalities.

885
00:40:32,720 --> 00:40:34,680
I'm savvy enough to be aware of them

886
00:40:34,680 --> 00:40:37,680
and encourage my patients to explore them.

887
00:40:37,680 --> 00:40:40,120
And that happens pretty frequently.

888
00:40:40,120 --> 00:40:41,720
And I'd say the biggest,

889
00:40:43,640 --> 00:40:46,280
so I was gonna cut to nutrition as an example

890
00:40:46,280 --> 00:40:50,720
where people are thinking about food very differently

891
00:40:50,720 --> 00:40:52,560
as we all know,

892
00:40:52,560 --> 00:40:56,120
versus the processed stuff you or I probably grew up on.

893
00:40:56,120 --> 00:40:57,680
And so there's a real revolution

894
00:40:57,680 --> 00:41:02,680
about working with the body rather than upending it,

895
00:41:04,320 --> 00:41:06,320
whether than sort of commandeering

896
00:41:06,320 --> 00:41:09,020
sort of physiology like we do in medicine.

897
00:41:09,020 --> 00:41:11,900
There's all this interest in working with the body

898
00:41:11,900 --> 00:41:14,720
from a more natural or holistic point of view.

899
00:41:14,720 --> 00:41:16,880
And I guess also to your,

900
00:41:16,880 --> 00:41:20,160
so when I feel like that does makes a ton of sense

901
00:41:20,160 --> 00:41:23,240
and it does my patients some good.

902
00:41:23,240 --> 00:41:25,760
Now I can't tell you whether or not

903
00:41:25,760 --> 00:41:28,680
these other interventions are,

904
00:41:28,680 --> 00:41:31,040
I don't have a control group in any one of my patients.

905
00:41:31,040 --> 00:41:32,280
So I don't know if in the end,

906
00:41:32,280 --> 00:41:33,560
does it make a huge difference?

907
00:41:33,560 --> 00:41:35,840
Does any one thing make a big difference

908
00:41:35,840 --> 00:41:38,000
in terms of the longevity?

909
00:41:38,000 --> 00:41:39,600
I don't know.

910
00:41:39,600 --> 00:41:41,880
But what I can say is very commonly

911
00:41:41,880 --> 00:41:44,020
in terms of daily routine, daily life,

912
00:41:44,020 --> 00:41:46,000
in terms of how you're feeling,

913
00:41:46,000 --> 00:41:47,280
nevermind your longevity,

914
00:41:47,280 --> 00:41:49,640
but how you feel in your daily life,

915
00:41:49,640 --> 00:41:52,400
I absolutely believe that a lot of my patients

916
00:41:52,400 --> 00:41:54,480
are benefiting from these other modalities

917
00:41:54,480 --> 00:41:56,400
in ways that I can see and appreciate.

918
00:41:56,400 --> 00:41:59,840
They are, their pain is less, their energy is more,

919
00:41:59,840 --> 00:42:00,920
their nausea is less.

920
00:42:00,920 --> 00:42:02,320
That means they can get outside

921
00:42:02,320 --> 00:42:03,920
and be part of the world more

922
00:42:03,920 --> 00:42:05,320
and they can engage the world more,

923
00:42:05,320 --> 00:42:06,840
which means their attitude is better,

924
00:42:06,840 --> 00:42:08,320
which means their depression is less,

925
00:42:08,320 --> 00:42:10,120
which means they're more functional,

926
00:42:10,120 --> 00:42:11,400
which means they can hang in there

927
00:42:11,400 --> 00:42:12,760
with the more intensive treatments.

928
00:42:12,760 --> 00:42:17,320
So there is the beginning of a virtuous circle there.

929
00:42:17,320 --> 00:42:19,280
I think we got a long ways to go,

930
00:42:19,280 --> 00:42:20,760
but to your point, absolutely.

931
00:42:20,760 --> 00:42:22,160
There's all sorts of good stuff

932
00:42:22,160 --> 00:42:24,960
outside of traditional medicine in this country.

933
00:42:24,960 --> 00:42:27,520
Yeah, I mean, I think that's something

934
00:42:27,520 --> 00:42:28,680
that I personally believe in.

935
00:42:28,680 --> 00:42:29,660
And obviously it's a belief,

936
00:42:29,660 --> 00:42:30,900
everything in life is a belief,

937
00:42:30,900 --> 00:42:35,900
but watching documentaries like Forks Over Knives

938
00:42:35,920 --> 00:42:37,720
and seeing some of the reversals

939
00:42:37,720 --> 00:42:39,920
from the medical scientific point of view,

940
00:42:39,920 --> 00:42:42,200
and then also being a paramedic for,

941
00:42:42,200 --> 00:42:44,680
or riding a rescue for 13 years,

942
00:42:44,680 --> 00:42:48,520
and seeing patients with literally almost like trash bags,

943
00:42:48,520 --> 00:42:51,320
size bags full of pills,

944
00:42:51,320 --> 00:42:54,040
who nothing has changed versus people

945
00:42:54,040 --> 00:42:55,200
that have changed the way they eat

946
00:42:55,200 --> 00:42:57,880
and their exercise routine who reverse disease.

947
00:42:57,880 --> 00:43:00,780
So I don't think you need to take some of these things

948
00:43:00,780 --> 00:43:05,440
to the lab to see that overall removing the anomalies,

949
00:43:05,440 --> 00:43:08,760
generally that seems to have a much better effect.

950
00:43:08,760 --> 00:43:11,040
And like you said, another thing that I've observed

951
00:43:11,040 --> 00:43:14,360
from the people that I've seen that have been very sick

952
00:43:14,360 --> 00:43:16,640
that have gone through these treatments is,

953
00:43:16,640 --> 00:43:19,600
as you just mentioned, the quality of life leading up

954
00:43:19,600 --> 00:43:21,920
to when they pass seems to be a lot worse

955
00:43:21,920 --> 00:43:25,240
than if they had tried other interventions.

956
00:43:25,240 --> 00:43:27,560
And it's to say that it was a foregone conclusion,

957
00:43:27,560 --> 00:43:29,840
the same path.

958
00:43:29,840 --> 00:43:32,560
The quality of life is a lot better leading up to it.

959
00:43:33,960 --> 00:43:35,720
Yeah, I totally agree with that.

960
00:43:35,720 --> 00:43:38,200
And it may be very fascinating.

961
00:43:38,200 --> 00:43:41,000
There may be, I bet it's multiple things.

962
00:43:41,000 --> 00:43:43,320
I'm sure there are direct physiologic effects

963
00:43:43,320 --> 00:43:45,560
from these other kinds of interventions.

964
00:43:45,560 --> 00:43:47,240
And Jesus, it makes so much sense

965
00:43:47,240 --> 00:43:49,760
that food's important and all this, I mean, duh.

966
00:43:49,760 --> 00:43:52,160
I mean, it's just, when I look at my medical training

967
00:43:52,160 --> 00:43:54,280
and how little we got on nutrition,

968
00:43:54,280 --> 00:43:56,040
it's telling and stunning.

969
00:43:56,040 --> 00:43:58,020
And at some point we're gonna just laugh at it

970
00:43:58,020 --> 00:44:01,340
because it feels like a kind of negligence.

971
00:44:02,620 --> 00:44:07,120
But I wonder how much of the salutary benefits

972
00:44:07,120 --> 00:44:12,120
are also when folks engage their own health

973
00:44:14,680 --> 00:44:17,680
and take their role seriously

974
00:44:17,680 --> 00:44:19,400
in terms of what they're putting in their bodies,

975
00:44:19,400 --> 00:44:23,440
their attitudes, et cetera, of course they do better.

976
00:44:23,440 --> 00:44:27,360
It may be much because just because they're engaging

977
00:44:27,360 --> 00:44:30,140
versus they're taking a pound of pills

978
00:44:30,140 --> 00:44:31,360
that their doctor told them to.

979
00:44:31,360 --> 00:44:35,600
And so their engagement is really as a passive vessel

980
00:44:35,600 --> 00:44:37,440
for the doctor's orders.

981
00:44:37,440 --> 00:44:40,560
Whereas the ideal patient that I think you and I

982
00:44:40,560 --> 00:44:43,360
are aware of and see and feel kinship with

983
00:44:43,360 --> 00:44:46,280
is folks who are actually engaging with their own health

984
00:44:46,280 --> 00:44:49,000
and not just handing themselves over to a doctor.

985
00:44:49,000 --> 00:44:50,480
Right, now I couldn't agree more.

986
00:44:50,480 --> 00:44:53,000
Now, just so that I'm not seeming like I'm demonizing

987
00:44:53,000 --> 00:44:55,080
the whole medical industry on that side,

988
00:44:56,520 --> 00:44:58,860
we both agree because you're sitting there talking to me

989
00:44:58,860 --> 00:45:01,840
that trauma medicine seems to be extremely effective.

990
00:45:01,840 --> 00:45:04,320
And I think everyone would agree that a plate of salad

991
00:45:04,320 --> 00:45:06,600
isn't gonna fix a broken femur.

992
00:45:06,600 --> 00:45:08,240
So there's no question about that.

993
00:45:08,240 --> 00:45:13,240
Are there areas of pharmaceuticals in that area of medicine

994
00:45:14,280 --> 00:45:15,960
that you find very beneficial

995
00:45:15,960 --> 00:45:18,300
in the palliative and hospice arena?

996
00:45:19,160 --> 00:45:22,360
Well, so yeah, first point is to totally yes.

997
00:45:22,360 --> 00:45:26,200
I can be very critical of the healthcare system

998
00:45:26,200 --> 00:45:27,440
and there's a lot to criticize,

999
00:45:27,440 --> 00:45:28,880
but I'm also a huge fan of it.

1000
00:45:28,880 --> 00:45:30,560
And I think we just need to use

1001
00:45:30,560 --> 00:45:32,080
all these different modalities

1002
00:45:32,080 --> 00:45:35,760
just thoughtfully and there's a time and a place

1003
00:45:35,760 --> 00:45:36,600
for all of it.

1004
00:45:36,600 --> 00:45:38,800
And to your point, a heap of broccoli

1005
00:45:38,800 --> 00:45:40,920
was not gonna help me that night

1006
00:45:40,920 --> 00:45:42,560
on top of the train, for example.

1007
00:45:44,440 --> 00:45:46,920
So there's all sorts of brilliant things that medicine does

1008
00:45:46,920 --> 00:45:51,920
and public health and there's a lot to love in there too.

1009
00:45:52,320 --> 00:45:54,080
So yes, I'm super with you,

1010
00:45:54,080 --> 00:45:56,800
but let's also be naked to the critique

1011
00:45:56,800 --> 00:45:58,720
all in the effort to kind of make it better

1012
00:45:58,720 --> 00:45:59,720
because we love it.

1013
00:45:59,720 --> 00:46:03,760
So that's the first point.

1014
00:46:03,760 --> 00:46:06,660
I mean, for me as a palliative medicine specialist,

1015
00:46:08,480 --> 00:46:10,920
the prescriptions that I write

1016
00:46:10,920 --> 00:46:14,320
are the most important medicines for me

1017
00:46:14,320 --> 00:46:16,400
from a pharmaceutical point of view

1018
00:46:16,400 --> 00:46:18,480
are the symptom management meds

1019
00:46:18,480 --> 00:46:20,280
because that's where the expertise

1020
00:46:20,280 --> 00:46:21,760
of palliative medicine lies

1021
00:46:22,880 --> 00:46:26,240
is really in managing symptoms as optimally as possible.

1022
00:46:26,240 --> 00:46:29,400
So now that means a fair amount of pharmaceutical work.

1023
00:46:29,400 --> 00:46:32,840
I mean, I write a lot of prescriptions for opiates.

1024
00:46:33,680 --> 00:46:35,320
We all know that opiates,

1025
00:46:35,320 --> 00:46:38,200
that's another double-edged sword.

1026
00:46:38,200 --> 00:46:40,120
And especially these days,

1027
00:46:40,120 --> 00:46:41,720
I mean, it's really sad.

1028
00:46:41,720 --> 00:46:43,840
When I was a patient in the early 1990s,

1029
00:46:44,960 --> 00:46:47,500
medicine really was still in the kind of an old fashioned

1030
00:46:47,500 --> 00:46:49,120
view of treating your pain.

1031
00:46:51,120 --> 00:46:53,320
It was an afterthought at best

1032
00:46:53,320 --> 00:46:57,560
and lots of unreasonable concerns around addiction

1033
00:46:57,560 --> 00:47:01,360
and abuse and absolutely like the idea,

1034
00:47:01,360 --> 00:47:02,920
I mean, I've heard it so many times,

1035
00:47:02,920 --> 00:47:05,960
people have been told who are on their deathbed

1036
00:47:05,960 --> 00:47:08,080
that we don't wanna give you too much morphine

1037
00:47:08,080 --> 00:47:09,840
because we don't want you to get you addicted

1038
00:47:09,840 --> 00:47:11,320
and they're literally on their deathbed.

1039
00:47:11,320 --> 00:47:14,760
I mean, there's insanity around it too.

1040
00:47:14,760 --> 00:47:17,840
So what happened in the 90s, we swung,

1041
00:47:17,840 --> 00:47:19,740
we undertreated people's pain,

1042
00:47:19,740 --> 00:47:21,500
we didn't give it serious thought.

1043
00:47:22,640 --> 00:47:24,120
And like when I had phantom limb pain,

1044
00:47:24,120 --> 00:47:27,680
that was still considered a psychological phenomenon.

1045
00:47:27,680 --> 00:47:30,960
And that sucked, having your own pain second guess.

1046
00:47:30,960 --> 00:47:32,520
And then somewhere along the way in the 90s,

1047
00:47:32,520 --> 00:47:34,200
we got hip to the idea that,

1048
00:47:34,200 --> 00:47:36,560
oh gosh, maybe we should take pain seriously

1049
00:47:36,560 --> 00:47:38,480
and maybe that's what our patients want us to do

1050
00:47:38,480 --> 00:47:41,400
and maybe pain sucks and we can,

1051
00:47:41,400 --> 00:47:43,280
so yeah, great, finally.

1052
00:47:43,280 --> 00:47:45,640
And so there was this relatively large swing

1053
00:47:45,640 --> 00:47:48,580
towards opiates and being more liberal with them

1054
00:47:48,580 --> 00:47:50,880
and trying to make sure to be more aggressive

1055
00:47:50,880 --> 00:47:52,440
with pain control.

1056
00:47:52,440 --> 00:47:54,720
And of course, as things go from a systems point of view,

1057
00:47:54,720 --> 00:47:57,860
we swung too far and we made it for some people

1058
00:47:57,860 --> 00:48:00,520
too easy to get these meds and we created new problems.

1059
00:48:00,520 --> 00:48:03,320
And now here we are with the pendulum swinging back.

1060
00:48:03,320 --> 00:48:04,880
So there's a lot to say about that.

1061
00:48:04,880 --> 00:48:06,180
I don't know why I just went off on that,

1062
00:48:06,180 --> 00:48:07,920
but to answer your question,

1063
00:48:09,240 --> 00:48:12,200
a lot of the drugs, the pharmaceuticals that I lean on

1064
00:48:12,200 --> 00:48:16,000
are symptom meds, including stimulants, including opiates,

1065
00:48:16,000 --> 00:48:18,920
including benzodiazepines, all sorts of meds

1066
00:48:18,920 --> 00:48:22,040
that are tricky and serious.

1067
00:48:22,040 --> 00:48:23,320
But very helpful.

1068
00:48:23,320 --> 00:48:25,720
Right, I've actually got two guests lined up.

1069
00:48:25,720 --> 00:48:27,880
Dr. Gregory Smith, who's big in the,

1070
00:48:29,200 --> 00:48:33,880
one of the advocates for anti-opiate over prescription

1071
00:48:33,880 --> 00:48:37,800
and then Sam Quinones who wrote a book, Dreamland,

1072
00:48:37,800 --> 00:48:39,680
they're gonna be coming hopefully the next couple of months

1073
00:48:39,680 --> 00:48:42,000
because that's something that we see

1074
00:48:42,000 --> 00:48:44,920
in an absolute epidemic in the first responder area,

1075
00:48:44,920 --> 00:48:45,920
not only with the patients,

1076
00:48:45,920 --> 00:48:47,760
but within our own people as well

1077
00:48:47,760 --> 00:48:49,520
when they get depression or if they get hurt

1078
00:48:49,520 --> 00:48:50,360
and they get addicted.

1079
00:48:50,360 --> 00:48:52,880
So, and it's sad, like you said,

1080
00:48:52,880 --> 00:48:56,360
because they have a place the same way as the psych meds

1081
00:48:56,360 --> 00:48:59,600
have a place for the people with extreme problems,

1082
00:48:59,600 --> 00:49:01,880
the bipolar and schizophrenia.

1083
00:49:01,880 --> 00:49:03,680
And then they're handing them out like candy

1084
00:49:03,680 --> 00:49:05,080
to everyone that's feeling,

1085
00:49:05,080 --> 00:49:08,240
oh, it's a little bit gloomy today, I need depression meds.

1086
00:49:08,240 --> 00:49:09,880
Absolutely.

1087
00:49:09,880 --> 00:49:13,120
Yeah, I wish for all our sakes we could get beyond

1088
00:49:13,120 --> 00:49:15,840
the, another quick critique here,

1089
00:49:16,800 --> 00:49:19,680
the sort of oversimplified concrete thinking,

1090
00:49:19,680 --> 00:49:22,920
black or white, yes or no, off or on, good or bad.

1091
00:49:24,440 --> 00:49:26,680
We just need to start seeing things on a spectrum

1092
00:49:26,680 --> 00:49:29,560
that matters how we use them.

1093
00:49:29,560 --> 00:49:31,800
We need to be thoughtful, but there's a time and a place

1094
00:49:31,800 --> 00:49:33,760
for a lot of these medicines.

1095
00:49:33,760 --> 00:49:36,400
And I just wish we could get a little bit more sophisticated

1096
00:49:36,400 --> 00:49:37,640
in our reasoning.

1097
00:49:37,640 --> 00:49:38,480
Absolutely.

1098
00:49:39,560 --> 00:49:44,040
Well, going from the medical arena,

1099
00:49:44,040 --> 00:49:49,680
so I have witnessed hospice in different, I guess, age,

1100
00:49:49,680 --> 00:49:52,480
categories now, my friend JP passed away,

1101
00:49:52,480 --> 00:49:54,000
he was in hospice at home.

1102
00:49:54,000 --> 00:49:57,680
I actually nursed my 99 year old granddad a few years ago,

1103
00:49:57,680 --> 00:49:59,000
and he was in hospice at home.

1104
00:49:59,000 --> 00:50:02,800
So these guys were afforded an environment

1105
00:50:02,800 --> 00:50:05,760
that was somewhat familiar and more gentle.

1106
00:50:05,760 --> 00:50:08,360
But as you mentioned in some of your interviews,

1107
00:50:08,360 --> 00:50:11,160
a lot of times the hospice care is in a very clinical,

1108
00:50:11,160 --> 00:50:13,280
sterile hospital environment.

1109
00:50:13,280 --> 00:50:16,160
So what was it when you enter palliative care,

1110
00:50:16,160 --> 00:50:18,920
when did you have that realization that maybe

1111
00:50:18,920 --> 00:50:20,920
that environment wasn't the most,

1112
00:50:22,760 --> 00:50:25,760
the healthiest for the patient in their last days?

1113
00:50:27,160 --> 00:50:29,280
The hospital environment, specifically?

1114
00:50:29,280 --> 00:50:30,120
Yes.

1115
00:50:30,120 --> 00:50:31,840
Yeah, acute care.

1116
00:50:31,840 --> 00:50:36,840
Yeah, to me, it seems like part of approaching

1117
00:50:36,840 --> 00:50:40,680
the end of our lives, especially after long battles

1118
00:50:40,680 --> 00:50:45,680
with illness and dealing with not only the disease,

1119
00:50:45,920 --> 00:50:48,440
but all the side effects of treatments, et cetera,

1120
00:50:49,720 --> 00:50:53,720
that one of the upshots really is you get to,

1121
00:50:53,720 --> 00:50:56,200
at some point, that stuff isn't helping you.

1122
00:50:56,200 --> 00:50:59,800
You get to let go of what can feel like

1123
00:50:59,800 --> 00:51:02,200
such an unnatural and difficult environment,

1124
00:51:02,200 --> 00:51:04,120
the hospital, the acute care mentality,

1125
00:51:04,120 --> 00:51:08,200
et cetera, and that death is,

1126
00:51:09,640 --> 00:51:14,640
everyone we've ever known, anyone who's ever lived dies,

1127
00:51:15,000 --> 00:51:20,000
all of us, it is one of these profound uniting forces

1128
00:51:22,320 --> 00:51:25,480
that affects any living creature.

1129
00:51:25,480 --> 00:51:27,960
And it's hard to think of, it's hard to conceive

1130
00:51:27,960 --> 00:51:31,320
of a more profound moment, perhaps rivaled only

1131
00:51:31,320 --> 00:51:36,320
by birth, and yet, so in an acute care environment,

1132
00:51:37,640 --> 00:51:42,640
all that, the profoundness of it, the beauty of it,

1133
00:51:42,760 --> 00:51:47,760
the stillness of it, the peace that most people seek,

1134
00:51:47,840 --> 00:51:50,640
all that stuff is so inaccessible in an acute care setting

1135
00:51:50,640 --> 00:51:53,040
because an acute care setting is designed,

1136
00:51:53,040 --> 00:51:55,720
explicitly, the death is the enemy.

1137
00:51:55,720 --> 00:51:59,240
And so you're in a setting, in your final stage,

1138
00:51:59,240 --> 00:52:02,240
you're in a setting, in your final moments,

1139
00:52:02,240 --> 00:52:07,240
that is designed exactly for the opposite of you.

1140
00:52:09,520 --> 00:52:12,360
And it does not begin to do justice

1141
00:52:12,360 --> 00:52:16,600
to the profound nature of what's going on.

1142
00:52:16,600 --> 00:52:20,000
So it was pretty easy to spot that.

1143
00:52:20,960 --> 00:52:22,960
And most people don't wanna be in a hospital,

1144
00:52:22,960 --> 00:52:25,160
especially if you're in your final moments,

1145
00:52:25,160 --> 00:52:27,400
why would you want, of all the places to be,

1146
00:52:27,400 --> 00:52:29,160
why would you wanna be there?

1147
00:52:29,160 --> 00:52:32,360
So part of that is a comment on the design and architecture

1148
00:52:32,360 --> 00:52:33,640
and the layout of a hospital

1149
00:52:33,640 --> 00:52:36,280
and the unintuitive nature of it.

1150
00:52:36,280 --> 00:52:38,240
Part of it is a comment on,

1151
00:52:38,240 --> 00:52:40,160
nature has no pride in a hospital.

1152
00:52:40,160 --> 00:52:42,880
There's very few windows and natural light,

1153
00:52:42,880 --> 00:52:45,320
and any ability to touch into the universe

1154
00:52:45,320 --> 00:52:48,240
beyond the hospital is tricky.

1155
00:52:48,240 --> 00:52:50,560
And things like making it hard for your family

1156
00:52:50,560 --> 00:52:53,800
to get in and out, visiting hours, all that stuff.

1157
00:52:53,800 --> 00:52:58,800
So it doesn't need to be that way.

1158
00:52:59,160 --> 00:53:00,680
And most people don't want it that way.

1159
00:53:00,680 --> 00:53:02,440
Most people don't wanna die in a hospital,

1160
00:53:02,440 --> 00:53:04,080
and yet most of us still do.

1161
00:53:05,800 --> 00:53:10,120
So you, well, first educate me,

1162
00:53:10,120 --> 00:53:12,800
were you one of the founding members of Zen Hospice?

1163
00:53:13,920 --> 00:53:16,720
No, no, no, that has been,

1164
00:53:16,720 --> 00:53:21,720
they got started in 1987 in the wake of the HIV crisis

1165
00:53:23,920 --> 00:53:25,120
in San Francisco.

1166
00:53:25,120 --> 00:53:29,000
So no, I was there from 2011 to 2016.

1167
00:53:29,000 --> 00:53:30,720
So I was just there five years.

1168
00:53:33,200 --> 00:53:36,840
But so no, can't take credit for starting that.

1169
00:53:36,840 --> 00:53:39,760
Okay, but so when, let me rephrase it.

1170
00:53:39,760 --> 00:53:43,760
How were you introduced to that amazing project?

1171
00:53:43,760 --> 00:53:46,640
And then can you contrast what you had there

1172
00:53:46,640 --> 00:53:48,040
with the hospital setting?

1173
00:53:49,080 --> 00:53:51,640
Yeah, so in part because,

1174
00:53:56,360 --> 00:53:57,680
in part because, like, you know,

1175
00:53:57,680 --> 00:53:59,160
I'd say again, I majored in art history

1176
00:53:59,160 --> 00:54:01,920
and I was interested in architecture and physical plant

1177
00:54:01,920 --> 00:54:04,560
and space and art and light and aesthetics.

1178
00:54:04,560 --> 00:54:06,760
I was already preloaded for that stuff.

1179
00:54:07,760 --> 00:54:10,600
And I knew early on in my medical training,

1180
00:54:10,600 --> 00:54:13,760
I first heard of Zen Hospice project when I was a med student

1181
00:54:13,760 --> 00:54:16,000
and just, I was like, wow, okay,

1182
00:54:16,000 --> 00:54:18,040
there's this beautiful little Victorian

1183
00:54:18,040 --> 00:54:19,760
with a bunch of human beings who are there

1184
00:54:19,760 --> 00:54:21,760
just because they really care.

1185
00:54:21,760 --> 00:54:23,520
And they're basically helping people die

1186
00:54:23,520 --> 00:54:26,960
in this very sweet and kind and gentle way.

1187
00:54:26,960 --> 00:54:29,880
And it immediately struck me as, wow, gosh,

1188
00:54:29,880 --> 00:54:31,480
what an amazing thing.

1189
00:54:32,320 --> 00:54:34,640
That this doesn't have to be a medical event,

1190
00:54:34,640 --> 00:54:38,320
that this is more, this is a spiritual,

1191
00:54:38,320 --> 00:54:40,280
social, a personal event.

1192
00:54:40,280 --> 00:54:42,920
And here was a teeny little six bedroom house

1193
00:54:42,920 --> 00:54:46,920
in San Francisco espousing this and working from that plane.

1194
00:54:46,920 --> 00:54:49,320
So I was very quickly moved by it

1195
00:54:50,600 --> 00:54:52,640
and didn't think much more of it because I didn't,

1196
00:54:52,640 --> 00:54:54,280
again, I thought I was gonna do a rehab medicine.

1197
00:54:54,280 --> 00:54:57,120
But years later, they had to close their doors,

1198
00:54:57,120 --> 00:55:00,120
they had to deal with some licensing issues.

1199
00:55:00,120 --> 00:55:02,880
And then when they were set to reopen,

1200
00:55:02,880 --> 00:55:05,160
I became very interested in the job

1201
00:55:05,160 --> 00:55:09,840
because one, they had this humanistic,

1202
00:55:09,840 --> 00:55:12,160
sort of spiritual approach to care.

1203
00:55:12,160 --> 00:55:13,880
You're working sort of from the human plane

1204
00:55:13,880 --> 00:55:16,840
rather than the skilled professional plane.

1205
00:55:16,840 --> 00:55:18,960
And the second point I was in love with

1206
00:55:18,960 --> 00:55:21,880
was the infrastructure, that it was a beautiful building,

1207
00:55:21,880 --> 00:55:24,200
a place where you would want to be,

1208
00:55:24,200 --> 00:55:25,920
unlike the acute care hospital.

1209
00:55:25,920 --> 00:55:28,560
And for those two reasons, I took that job

1210
00:55:28,560 --> 00:55:32,200
as the executive director and worked there for five years.

1211
00:55:32,200 --> 00:55:34,320
Okay, so could you tell me some of the things

1212
00:55:34,320 --> 00:55:39,320
that they did at the house to create that feeling of home?

1213
00:55:40,040 --> 00:55:42,040
And I know you mentioned smells

1214
00:55:42,040 --> 00:55:45,440
and some other things that you did

1215
00:55:45,440 --> 00:55:48,320
for the residents before they passed.

1216
00:55:48,320 --> 00:55:52,160
Yeah, so I think a lot of it is not exotic.

1217
00:55:54,640 --> 00:55:56,080
First of all, you start with the building

1218
00:55:56,080 --> 00:55:57,800
that is an old Victorian home.

1219
00:55:57,800 --> 00:56:00,760
So it is a home, and it feels like it's designed

1220
00:56:00,760 --> 00:56:03,080
to be a home, and it feels that way.

1221
00:56:03,080 --> 00:56:05,240
So the second you walk in the door,

1222
00:56:05,240 --> 00:56:08,480
just the structure itself has already said a lot to you

1223
00:56:08,480 --> 00:56:10,360
and makes you feel a certain way.

1224
00:56:10,360 --> 00:56:13,560
But beyond that, you have to give the training

1225
00:56:13,560 --> 00:56:14,400
a lot of credit.

1226
00:56:14,400 --> 00:56:17,280
So it was like a lot of older hospices in this country,

1227
00:56:17,280 --> 00:56:18,960
it was largely volunteer-led.

1228
00:56:20,360 --> 00:56:22,280
And then you layer on nursing and medicine

1229
00:56:22,280 --> 00:56:25,320
and other skilled stuff on top of that.

1230
00:56:25,320 --> 00:56:28,440
But the heart of that place was the volunteer training.

1231
00:56:28,440 --> 00:56:32,640
So you're met by human beings who aren't in some costume

1232
00:56:32,640 --> 00:56:37,640
or in some way making you feel like they're an expert

1233
00:56:37,640 --> 00:56:38,480
and you're not.

1234
00:56:38,480 --> 00:56:40,680
You walk into a hospital, you're pretty quickly aware

1235
00:56:40,680 --> 00:56:42,760
of your vulnerability as a patient.

1236
00:56:42,760 --> 00:56:44,680
You walk into a place like Zen Hospice Project

1237
00:56:44,680 --> 00:56:46,520
and you're pretty quickly aware

1238
00:56:46,520 --> 00:56:48,680
that you're among fellow human beings.

1239
00:56:48,680 --> 00:56:51,520
And that is not just the architecture doing that,

1240
00:56:51,520 --> 00:56:52,760
that's a lot of the training

1241
00:56:52,760 --> 00:56:55,320
that goes into the volunteer work.

1242
00:56:55,320 --> 00:56:58,520
So the way you're met by people is different.

1243
00:56:58,520 --> 00:57:02,400
And then we also, and I can't take credit for this,

1244
00:57:02,400 --> 00:57:03,480
they were doing this already,

1245
00:57:03,480 --> 00:57:06,400
but we really put a lot of effort into the kitchen

1246
00:57:06,400 --> 00:57:11,400
because another thing that just makes you feel proud

1247
00:57:11,400 --> 00:57:15,160
or glad to be alive in the moment are the life of the senses.

1248
00:57:15,160 --> 00:57:18,680
So if you're met by the smell of classically cookies baking

1249
00:57:18,680 --> 00:57:19,920
in the Zen Hospice kitchen,

1250
00:57:19,920 --> 00:57:22,200
and you open the door and you're met with a waft

1251
00:57:22,200 --> 00:57:26,440
of cookie dough instead of Clorox cleaning product

1252
00:57:26,440 --> 00:57:28,960
or something else that you'd smell in a hospital,

1253
00:57:28,960 --> 00:57:31,400
it's just, again, an immediately different experience.

1254
00:57:31,400 --> 00:57:34,000
It just sets you up to, you want to be there.

1255
00:57:34,000 --> 00:57:36,520
And as we both know, there's something primal

1256
00:57:36,520 --> 00:57:37,360
about the sense of smell.

1257
00:57:37,360 --> 00:57:39,800
It can bring you back to your childhood

1258
00:57:39,800 --> 00:57:42,720
or it can transport you just about anywhere.

1259
00:57:42,720 --> 00:57:45,680
So a lot of the effort was put into the environment

1260
00:57:45,680 --> 00:57:48,200
in that way and setting an aesthetic tone.

1261
00:57:48,200 --> 00:57:51,720
Again, the design prompt is like create an environment

1262
00:57:51,720 --> 00:57:53,640
where you'd really want to be.

1263
00:57:53,640 --> 00:57:55,440
And that's basically what it is.

1264
00:57:55,440 --> 00:57:56,720
Yeah, and I love that.

1265
00:57:56,720 --> 00:57:59,280
I mean, when I was nursing my granddad, I was lucky.

1266
00:57:59,280 --> 00:58:00,480
I flew over back to England

1267
00:58:00,480 --> 00:58:04,120
and had about three days with him before he actually passed.

1268
00:58:04,120 --> 00:58:08,000
And it struck me when you talked about some patients going,

1269
00:58:08,000 --> 00:58:09,640
you know, or at peace and some fighting,

1270
00:58:09,640 --> 00:58:11,400
because, oh my God, he was like Muhammad Ali

1271
00:58:11,400 --> 00:58:12,880
right to the last breath.

1272
00:58:12,880 --> 00:58:14,520
He did not want to go.

1273
00:58:14,520 --> 00:58:16,160
And it was heart wrenching in one way,

1274
00:58:16,160 --> 00:58:18,440
but it showed that his lust for life,

1275
00:58:18,440 --> 00:58:22,720
but he was able to stay in his home with his wife,

1276
00:58:22,720 --> 00:58:24,480
be in his same bedroom that he'd always been in,

1277
00:58:24,480 --> 00:58:25,600
you know, be around family.

1278
00:58:25,600 --> 00:58:29,640
And so even though the disease, which was cancer,

1279
00:58:29,640 --> 00:58:32,360
was ravaging his body and he was jaundiced to the point

1280
00:58:32,360 --> 00:58:35,360
he looked like a Simpsons character when he passed,

1281
00:58:35,360 --> 00:58:37,160
he, you know, he was able to be there.

1282
00:58:37,160 --> 00:58:40,880
And I have to say kudos to the British healthcare system.

1283
00:58:40,880 --> 00:58:43,560
I know they're kind of painted in a slightly different light

1284
00:58:43,560 --> 00:58:47,240
when you're in America, but the National Health,

1285
00:58:47,240 --> 00:58:49,480
they had such amazing care.

1286
00:58:49,480 --> 00:58:51,600
They had home hospice, they had doctor's visits,

1287
00:58:51,600 --> 00:58:53,000
they set his bed up.

1288
00:58:53,000 --> 00:58:55,480
They visited my grandmother for about two weeks

1289
00:58:55,480 --> 00:58:56,800
after he passed.

1290
00:58:56,800 --> 00:58:57,640
It was incredible.

1291
00:58:57,640 --> 00:59:00,640
So I don't know how it compares

1292
00:59:00,640 --> 00:59:02,200
with the British healthcare system,

1293
00:59:02,200 --> 00:59:05,160
but I know the sheer acts of him being able to stay

1294
00:59:05,160 --> 00:59:08,920
in his home, you know, was probably monumental

1295
00:59:08,920 --> 00:59:11,680
versus him being in some sterile hospital environment

1296
00:59:11,680 --> 00:59:12,880
for the last few days.

1297
00:59:13,760 --> 00:59:15,240
Oh, amen to that.

1298
00:59:15,240 --> 00:59:18,400
And I mean, there's a couple of things to say.

1299
00:59:19,520 --> 00:59:23,720
One is to just kudos to the NHS and to the UK.

1300
00:59:23,720 --> 00:59:25,560
I mean, this is the modern hospice movement

1301
00:59:25,560 --> 00:59:28,360
came out of London, Sicily Saunders

1302
00:59:28,360 --> 00:59:31,800
built St. Christopher's in 1967.

1303
00:59:31,800 --> 00:59:34,320
So we owe a great deal of gratitude to Great Britain

1304
00:59:34,320 --> 00:59:37,720
for developing and furthering this.

1305
00:59:37,720 --> 00:59:43,360
And a second point is, as you mentioned

1306
00:59:43,360 --> 00:59:44,200
about your grandfather,

1307
00:59:44,200 --> 00:59:45,400
this is really important to get across.

1308
00:59:45,400 --> 00:59:49,160
I think where I and others in my field sort of talk

1309
00:59:49,160 --> 00:59:53,000
about wanting us as a culture to acknowledge

1310
00:59:53,000 --> 00:59:56,440
and even accept the fact, the plain fact,

1311
00:59:56,440 --> 00:59:59,160
the reality that we have to die at some point.

1312
01:00:00,120 --> 01:00:02,600
We're only demanding that we just fold that

1313
01:00:02,600 --> 01:00:06,440
into our worldview because it's a reality

1314
01:00:06,440 --> 01:00:09,640
that we ignore at our own peril.

1315
01:00:10,720 --> 01:00:12,720
But that doesn't mean, that shouldn't mean

1316
01:00:12,720 --> 01:00:17,720
that we're mandating or advocating a certain way to die.

1317
01:00:17,720 --> 01:00:20,280
So many people want to be at peace at the end

1318
01:00:20,280 --> 01:00:22,120
and just want to have their comfort tended to

1319
01:00:22,120 --> 01:00:24,440
and want to say goodbyes and want to kind of tie it up

1320
01:00:24,440 --> 01:00:27,400
with the bow and that can be beautiful.

1321
01:00:27,400 --> 01:00:31,160
But to be clear, it's not like that's the right way to die

1322
01:00:31,160 --> 01:00:33,240
and some other ways the wrong way to die.

1323
01:00:33,240 --> 01:00:35,320
The last thing we want to do is make anyone feel

1324
01:00:35,320 --> 01:00:38,760
like they're failing at dying, like they're dying wrong.

1325
01:00:38,760 --> 01:00:43,240
So it's really important to call out

1326
01:00:43,240 --> 01:00:45,400
like you did with your grandfather.

1327
01:00:45,400 --> 01:00:48,440
He could be on hospice getting all this great kind of care,

1328
01:00:48,440 --> 01:00:50,680
but that doesn't mean he's got to pretend to be happy

1329
01:00:50,680 --> 01:00:52,840
to be dying or at peace with the idea.

1330
01:00:52,840 --> 01:00:57,840
I mean, my job is to help people kind of,

1331
01:00:58,920 --> 01:01:02,200
I'm like an usher, I kind of link people to the care

1332
01:01:02,200 --> 01:01:07,200
that's going to help achieve their goals.

1333
01:01:07,200 --> 01:01:09,160
So if my patient, if I have a long conversation

1334
01:01:09,160 --> 01:01:10,840
with the patient, their eyes are wide open,

1335
01:01:10,840 --> 01:01:13,560
they know they're dying, but they want to keep staying

1336
01:01:13,560 --> 01:01:15,960
really aggressive even if that next chemo dose

1337
01:01:15,960 --> 01:01:18,520
isn't likely to help them, but they want to go down swinging

1338
01:01:18,520 --> 01:01:22,200
as it were, my job is to help them go down swinging.

1339
01:01:22,200 --> 01:01:24,360
My job really is just to make sure their eyes are wide open

1340
01:01:24,360 --> 01:01:26,960
and they're not just falling out in some default pathway,

1341
01:01:26,960 --> 01:01:28,280
but that they're getting the kind of care

1342
01:01:28,280 --> 01:01:31,040
that registers as best for them.

1343
01:01:31,040 --> 01:01:34,240
So amen to your grandfather for kicking and screaming

1344
01:01:34,240 --> 01:01:35,080
on the way out.

1345
01:01:35,080 --> 01:01:37,120
I mean, that's beautiful.

1346
01:01:38,360 --> 01:01:39,640
So that's another point.

1347
01:01:39,640 --> 01:01:43,040
And then, well, I had a third point,

1348
01:01:43,040 --> 01:01:44,640
can't remember where I was going.

1349
01:01:44,640 --> 01:01:48,640
I thought we were talking about NHS kicking and screaming

1350
01:01:50,040 --> 01:01:52,920
and then versus the hospital environment, but.

1351
01:01:52,920 --> 01:01:55,160
Oh, well, I guess that's also to call it,

1352
01:01:55,160 --> 01:01:57,240
yeah, I want to also call out that the hospice

1353
01:01:57,240 --> 01:02:01,360
in this country has, year over year,

1354
01:02:01,360 --> 01:02:03,920
more and more people who die do so on hospice.

1355
01:02:03,920 --> 01:02:08,920
So we're around like 42, 44% of people who die every year

1356
01:02:09,400 --> 01:02:11,560
are on hospice.

1357
01:02:11,560 --> 01:02:12,800
So that's pretty great.

1358
01:02:12,800 --> 01:02:16,760
And that's, a lot of development,

1359
01:02:16,760 --> 01:02:18,360
a lot of effort has gone into that

1360
01:02:18,360 --> 01:02:21,000
and we're heading in the right direction.

1361
01:02:21,000 --> 01:02:24,920
So, and fewer than 50% of people are dying in hospitals.

1362
01:02:24,920 --> 01:02:27,480
Still bulk of people are dying in institutional settings

1363
01:02:27,480 --> 01:02:29,640
when you throw in nursing homes, et cetera.

1364
01:02:29,640 --> 01:02:31,640
But we're heading in the right direction

1365
01:02:31,640 --> 01:02:35,000
in the ways that the UK has paved for us.

1366
01:02:35,000 --> 01:02:38,960
So home hospice is remarkably accessible now.

1367
01:02:38,960 --> 01:02:41,320
You just have to dare to request it

1368
01:02:41,320 --> 01:02:43,520
and you have to have a doctor who dares to point it out

1369
01:02:43,520 --> 01:02:46,560
to you when the time is right.

1370
01:02:46,560 --> 01:02:49,400
But dying at home is not the difficult exotic thing

1371
01:02:49,400 --> 01:02:51,840
it was 15 years ago.

1372
01:02:51,840 --> 01:02:53,280
Well, that's great to hear.

1373
01:02:53,280 --> 01:02:54,960
Now that transitions pretty well though

1374
01:02:54,960 --> 01:02:57,800
to one topic that we touched on before we start recording

1375
01:02:57,800 --> 01:03:00,360
as well that I wanted to talk about.

1376
01:03:00,360 --> 01:03:05,360
So the medics and EMTs and anyone that's in the ER field

1377
01:03:07,040 --> 01:03:08,720
is gonna be able to relate to this.

1378
01:03:08,720 --> 01:03:13,720
In our field, usually, sadly, when we have death,

1379
01:03:14,400 --> 01:03:17,520
we're going to a car accident, going to a cardiac arrest,

1380
01:03:17,520 --> 01:03:20,120
whatever it is, we're wheeling them into a hospital

1381
01:03:21,040 --> 01:03:24,120
and then we see very much of that sterility

1382
01:03:24,120 --> 01:03:25,640
and this is by no mean a blame.

1383
01:03:25,640 --> 01:03:28,280
It is what it is in the emergency setting,

1384
01:03:28,280 --> 01:03:31,000
but we'll bring in a patient, they'll go to bed one,

1385
01:03:31,000 --> 01:03:34,360
for example, and then you clear to your report

1386
01:03:34,360 --> 01:03:36,080
and then come back and then before you know it,

1387
01:03:36,080 --> 01:03:38,360
bed one's made up again and it's available

1388
01:03:38,360 --> 01:03:39,280
for your next patient.

1389
01:03:39,280 --> 01:03:44,280
So we don't get so much of the palliative side,

1390
01:03:44,720 --> 01:03:46,920
but what we are not taught to deal with,

1391
01:03:46,920 --> 01:03:51,400
which is very interesting, is death in itself,

1392
01:03:51,400 --> 01:03:54,720
but really the family that's left behind.

1393
01:03:54,720 --> 01:03:57,200
I remember very specifically a 29-year-old man

1394
01:03:57,200 --> 01:03:59,760
that I had drop dead in one of our businesses

1395
01:03:59,760 --> 01:04:04,000
on the Disney side and totally unexpected.

1396
01:04:04,000 --> 01:04:08,040
The guy was just dropping off a dog for a kennel

1397
01:04:08,040 --> 01:04:10,760
and then I literally was finishing my report

1398
01:04:10,760 --> 01:04:12,760
in the hospital about eight feet from these people

1399
01:04:12,760 --> 01:04:15,480
where the grieving room was, that's where they put us.

1400
01:04:17,480 --> 01:04:20,400
And they knew I was the medic that was leading that code

1401
01:04:20,400 --> 01:04:22,800
and there was nothing we could do.

1402
01:04:22,800 --> 01:04:27,640
So from your perspective, I know you're dealing

1403
01:04:27,640 --> 01:04:32,640
in a different speed of the demise of the patient,

1404
01:04:34,640 --> 01:04:37,280
what would you say if you were in with a bunch

1405
01:04:37,280 --> 01:04:41,720
of paramedic students on what to say to parents,

1406
01:04:41,720 --> 01:04:44,760
excuse me, to family after they've lost someone like that?

1407
01:04:45,760 --> 01:04:50,760
Yeah, so you just said something that's really important

1408
01:04:52,680 --> 01:04:53,720
a couple of things.

1409
01:04:53,720 --> 01:04:58,720
And one is, it's just to be clear on why we do what we do.

1410
01:05:01,720 --> 01:05:05,520
So all of us should be clear on that and think about that,

1411
01:05:05,520 --> 01:05:08,360
but we should also think about that on institutional lines

1412
01:05:08,360 --> 01:05:10,480
too, so for example, healthcare.

1413
01:05:11,360 --> 01:05:14,680
Is healthcare really just about combating disease

1414
01:05:14,680 --> 01:05:17,720
or is it about supporting human beings?

1415
01:05:18,800 --> 01:05:21,040
Cause if it's just about combating disease,

1416
01:05:21,040 --> 01:05:22,880
then there really is a moment where, sorry,

1417
01:05:22,880 --> 01:05:24,360
there's nothing more we can do.

1418
01:05:24,360 --> 01:05:27,200
We tried our best, good luck out there.

1419
01:05:27,200 --> 01:05:30,120
And that beyond the cure that there's nothing much

1420
01:05:30,120 --> 01:05:31,840
for us to offer.

1421
01:05:31,840 --> 01:05:33,600
And I think that's what the train that you and I

1422
01:05:33,600 --> 01:05:37,400
have absorbed is that kind of mentality.

1423
01:05:37,400 --> 01:05:40,720
I would say we're right for a kind of a mission redo.

1424
01:05:40,720 --> 01:05:43,120
So I think all of us have to, like, are we,

1425
01:05:45,040 --> 01:05:48,080
does our job end when someone's not curable?

1426
01:05:48,080 --> 01:05:49,400
I don't think so.

1427
01:05:49,400 --> 01:05:51,640
So part of the answer to your question is for us

1428
01:05:51,640 --> 01:05:55,160
to kind of revisit our ethos and our training

1429
01:05:56,320 --> 01:05:59,760
to cut a wider, to include a fuller breadth

1430
01:05:59,760 --> 01:06:03,320
of the human experience on our way to death.

1431
01:06:03,320 --> 01:06:05,640
So that's one point.

1432
01:06:05,640 --> 01:06:07,560
Second point, and answer your question more narrowly,

1433
01:06:07,560 --> 01:06:10,520
like, you know, one of the things that I learned

1434
01:06:10,520 --> 01:06:12,840
from the volunteer training at Zen Hostess Project,

1435
01:06:12,840 --> 01:06:15,280
and just also from being a patient,

1436
01:06:15,280 --> 01:06:18,640
is the power when someone, the power of someone

1437
01:06:18,640 --> 01:06:22,160
just not running away is profound.

1438
01:06:22,160 --> 01:06:25,800
So when we're at our ugliest, smelliest, worst,

1439
01:06:25,800 --> 01:06:29,080
most painful, most miserable, that's oftentimes

1440
01:06:29,080 --> 01:06:30,840
where society just kind of disappears.

1441
01:06:30,840 --> 01:06:33,160
Cause it's, you know, you talk yourself out of it,

1442
01:06:33,160 --> 01:06:35,440
you think that the person wouldn't want you there,

1443
01:06:35,440 --> 01:06:36,280
whatever we do.

1444
01:06:36,280 --> 01:06:38,320
And so we end up isolating people

1445
01:06:38,320 --> 01:06:41,040
who are in these very difficult situations.

1446
01:06:41,040 --> 01:06:42,320
And we do it in the hospitals too.

1447
01:06:42,320 --> 01:06:46,520
We abandon people either literally or sort of psychologically.

1448
01:06:46,520 --> 01:06:48,240
And so part of the answer to your question is

1449
01:06:48,240 --> 01:06:51,120
we all have to get better at exercising the muscle

1450
01:06:51,120 --> 01:06:53,480
of just sitting with someone who's suffering

1451
01:06:53,480 --> 01:06:56,240
in ways that we can't fix.

1452
01:06:56,240 --> 01:07:00,080
So that, if you can kind of embody that

1453
01:07:00,080 --> 01:07:02,240
and have that kind of vibe about yourself

1454
01:07:02,240 --> 01:07:05,440
and be still and comfortable when someone's world

1455
01:07:05,440 --> 01:07:09,000
is falling apart and not run away and be there with them,

1456
01:07:09,000 --> 01:07:10,680
you don't necessarily even have to say anything.

1457
01:07:10,680 --> 01:07:12,160
It's almost like a vibe.

1458
01:07:13,680 --> 01:07:17,920
So that's a second point I would sort of get us all

1459
01:07:17,920 --> 01:07:19,600
trying to think about.

1460
01:07:19,600 --> 01:07:22,920
And then finally, you know, there are,

1461
01:07:24,640 --> 01:07:27,360
there aren't any particular Pat things to say

1462
01:07:27,360 --> 01:07:30,240
because there's so many cultural and personal overlays.

1463
01:07:30,240 --> 01:07:33,960
So what might be nice to hear according to one patient,

1464
01:07:33,960 --> 01:07:36,840
maybe downright offensive to another.

1465
01:07:36,840 --> 01:07:41,040
So you can think about various lines to have in your pocket,

1466
01:07:41,040 --> 01:07:43,880
but what I really think works best

1467
01:07:43,880 --> 01:07:46,040
is just being authentic and real.

1468
01:07:46,040 --> 01:07:49,560
So that may mean sitting there saying to the family,

1469
01:07:52,160 --> 01:07:54,400
I don't know what to say right now,

1470
01:07:54,400 --> 01:07:55,520
but I'm here with you.

1471
01:07:55,520 --> 01:07:56,520
I'm here for you.

1472
01:07:56,520 --> 01:07:59,160
I wish it could have been otherwise.

1473
01:07:59,160 --> 01:08:02,040
Or, you know, even just kind of fumbling your way,

1474
01:08:02,040 --> 01:08:06,560
but being obviously emotionally honest and moved.

1475
01:08:06,560 --> 01:08:08,520
That's where I think most of the healing comes

1476
01:08:08,520 --> 01:08:12,160
for the family, much more than just saying the perfect thing.

1477
01:08:13,280 --> 01:08:15,880
So I think we all have to kind of get comfortable

1478
01:08:15,880 --> 01:08:17,960
with discomfort in a way.

1479
01:08:17,960 --> 01:08:20,960
That I think is where so much of the healing happens.

1480
01:08:20,960 --> 01:08:25,400
And very often it can be in the form of a hug,

1481
01:08:25,400 --> 01:08:27,880
physical touch, obviously have to be thoughtful and careful,

1482
01:08:27,880 --> 01:08:31,520
but physical touch can be so profound.

1483
01:08:31,520 --> 01:08:35,760
A hug from a stranger in an ER lobby

1484
01:08:35,760 --> 01:08:38,160
can be really, really moving.

1485
01:08:38,160 --> 01:08:40,880
And I think related, and this is my last comment on this,

1486
01:08:40,880 --> 01:08:44,560
would be, you know, dare to show your emotions.

1487
01:08:45,680 --> 01:08:47,960
In medical school, we're trained to, you know,

1488
01:08:47,960 --> 01:08:51,560
be dispassionate and a little bit removed, you know,

1489
01:08:51,560 --> 01:08:55,200
so as to not eclipse the patient's emotional experience.

1490
01:08:55,200 --> 01:08:56,320
But we take it too far.

1491
01:08:56,320 --> 01:08:58,760
We end up just being numb or cold.

1492
01:08:58,760 --> 01:09:01,000
Some of the most profound moments I've had with patients

1493
01:09:01,000 --> 01:09:03,800
are when I am just overcome myself.

1494
01:09:03,800 --> 01:09:05,840
I don't know what to say, I'm fumbling for words,

1495
01:09:05,840 --> 01:09:07,560
but I don't run away and I just sit,

1496
01:09:07,560 --> 01:09:09,680
I stay there with the person.

1497
01:09:09,680 --> 01:09:14,680
And even like my boss, Steve McPhee, a mentor of mine,

1498
01:09:15,480 --> 01:09:18,120
he was famous for, he would cry with his patients.

1499
01:09:18,120 --> 01:09:21,280
He didn't try, he was a crier, they came.

1500
01:09:21,280 --> 01:09:23,880
And traditional training would say that's not a good idea,

1501
01:09:23,880 --> 01:09:25,560
that that's overreach.

1502
01:09:25,560 --> 01:09:29,600
But for Steve, and I watched, it was magical,

1503
01:09:29,600 --> 01:09:32,680
that was profound for families, to see that their life,

1504
01:09:32,680 --> 01:09:35,400
that their loved one's life moved their doctor,

1505
01:09:36,880 --> 01:09:38,400
was itself healing.

1506
01:09:38,400 --> 01:09:40,480
So that may feel like a mistake traditionally,

1507
01:09:40,480 --> 01:09:42,080
like, oh my gosh, he doesn't know what to say

1508
01:09:42,080 --> 01:09:43,640
and he's crying, oh my God.

1509
01:09:43,640 --> 01:09:46,560
In a way, that's ideal when it's authentic.

1510
01:09:46,560 --> 01:09:48,920
And so I guess the bottom line is just find a way

1511
01:09:48,920 --> 01:09:50,800
to stay real and not run away.

1512
01:09:50,800 --> 01:09:53,600
And it doesn't need to be anything more magic than that.

1513
01:09:53,600 --> 01:09:56,000
Yeah, I know when we talked before as well

1514
01:09:56,000 --> 01:09:58,080
about bridging the palliative care

1515
01:09:58,080 --> 01:10:01,440
with the pre-hospital emergencies,

1516
01:10:01,440 --> 01:10:03,080
something that's kind of ringing

1517
01:10:03,080 --> 01:10:05,520
while you were talking about that was,

1518
01:10:05,520 --> 01:10:08,400
there's this phrase called a show code that we have

1519
01:10:08,400 --> 01:10:12,240
in the pre-hospital arena where we know

1520
01:10:12,240 --> 01:10:14,320
that the patient is gone.

1521
01:10:14,320 --> 01:10:15,920
There's no way in hell you're gonna save him.

1522
01:10:15,920 --> 01:10:17,840
They fall within certain parameters.

1523
01:10:17,840 --> 01:10:21,520
But people kind of get uncomfortable with calling it there.

1524
01:10:21,520 --> 01:10:25,120
So they start working, especially if it's a child.

1525
01:10:25,120 --> 01:10:28,720
But this is way past any form of viability whatsoever.

1526
01:10:28,720 --> 01:10:31,600
And I think that's an area that we fail in

1527
01:10:31,600 --> 01:10:34,800
because it's a bitter pill to swallow

1528
01:10:34,800 --> 01:10:36,480
and it's something that's very uncomfortable.

1529
01:10:36,480 --> 01:10:39,120
But to let that child be at rest

1530
01:10:39,120 --> 01:10:42,680
and just cover them in a sheet or just lay them in the bed,

1531
01:10:42,680 --> 01:10:45,680
whatever it is that the environment that they're in,

1532
01:10:45,680 --> 01:10:47,400
I think is a lot better for the family

1533
01:10:47,400 --> 01:10:49,120
than then start drilling their shin bones

1534
01:10:49,120 --> 01:10:50,680
and sticking tubes in their ass.

1535
01:10:50,680 --> 01:10:53,200
And then knowing damn well, let's have the same conclusion.

1536
01:10:53,200 --> 01:10:55,640
Now they've got to go see their child lying,

1537
01:10:55,640 --> 01:10:56,960
deceased in a hospital bed.

1538
01:10:56,960 --> 01:10:59,760
So I think when you said about us bridging the gap,

1539
01:10:59,760 --> 01:11:03,200
I think there are many areas where we as first responders

1540
01:11:03,200 --> 01:11:07,000
can start thinking about maybe not even palliative care,

1541
01:11:07,000 --> 01:11:09,120
but just the human side again,

1542
01:11:09,120 --> 01:11:12,600
and get away from the temptation,

1543
01:11:12,600 --> 01:11:15,960
which is that this is just patient 1075,

1544
01:11:15,960 --> 01:11:18,600
the deceased and we lose that human side.

1545
01:11:18,600 --> 01:11:21,000
And lose that compassion towards the patient.

1546
01:11:21,000 --> 01:11:23,440
Right. Well, there's so much to say.

1547
01:11:23,440 --> 01:11:25,960
I think there's this hopefully a beginning conversation,

1548
01:11:25,960 --> 01:11:27,360
James, over time,

1549
01:11:27,360 --> 01:11:29,840
because I think there's so much for our fields

1550
01:11:29,840 --> 01:11:31,360
to learn from each other.

1551
01:11:31,360 --> 01:11:33,960
And I would say, by the way, I mean, you know,

1552
01:11:33,960 --> 01:11:37,280
there's now a subspecialty of hospice and palliative medicine,

1553
01:11:37,280 --> 01:11:40,040
you know, and there's expertise around it.

1554
01:11:40,040 --> 01:11:42,960
But so much of the rudiments and the fundamentals of it

1555
01:11:42,960 --> 01:11:46,160
are basically, they are just good medicine.

1556
01:11:46,160 --> 01:11:49,760
So I would encourage your folks in your field

1557
01:11:49,760 --> 01:11:53,840
to feel part of the palliative care family

1558
01:11:53,840 --> 01:11:55,960
if you believe that your job

1559
01:11:55,960 --> 01:11:58,560
includes tending to someone suffering.

1560
01:11:58,560 --> 01:12:00,600
If you see your job is narrowly defined

1561
01:12:00,600 --> 01:12:02,160
around disease management,

1562
01:12:02,160 --> 01:12:04,560
and then, you know,

1563
01:12:04,560 --> 01:12:06,920
then you really aren't in a palliative care mode.

1564
01:12:06,920 --> 01:12:09,240
But if you as a person, as a professional,

1565
01:12:09,240 --> 01:12:13,160
feel that you have an extended duty and interest

1566
01:12:13,160 --> 01:12:16,160
to tending to suffering, then I would say,

1567
01:12:16,160 --> 01:12:17,160
welcome to the family.

1568
01:12:17,160 --> 01:12:19,600
You're part of the palliative care world.

1569
01:12:19,600 --> 01:12:23,160
And let your work flow from there.

1570
01:12:23,160 --> 01:12:26,560
And to your point, I think one of the very concrete ways

1571
01:12:26,560 --> 01:12:28,280
that our fields can inform each other

1572
01:12:28,280 --> 01:12:30,440
is exactly what you just described,

1573
01:12:30,440 --> 01:12:33,560
this sort of theatrical code that happens

1574
01:12:33,560 --> 01:12:36,160
that is itself, for the most part,

1575
01:12:36,160 --> 01:12:38,360
a kind of trauma for the family.

1576
01:12:38,360 --> 01:12:40,760
I've heard from many people who,

1577
01:12:40,760 --> 01:12:43,360
their loved one died at home just as planned,

1578
01:12:43,360 --> 01:12:45,680
but they weren't on hospice, so they called 911,

1579
01:12:45,680 --> 01:12:48,160
and paramedics came, and the death was beautiful,

1580
01:12:48,160 --> 01:12:49,360
and they knew it was coming.

1581
01:12:49,360 --> 01:12:52,360
And then all of a sudden, in rushes this gang

1582
01:12:52,360 --> 01:12:53,960
who starts stomping on the chest, et cetera,

1583
01:12:53,960 --> 01:12:56,560
and doing all this stuff, which feels brutal,

1584
01:12:56,560 --> 01:12:58,960
absolutely brutal, and ends up being traumatic

1585
01:12:58,960 --> 01:13:01,160
for that family to watch that.

1586
01:13:01,160 --> 01:13:04,560
So, and it's completely unnecessary, as you point out.

1587
01:13:04,560 --> 01:13:06,760
So that's a good case in point where I think

1588
01:13:06,760 --> 01:13:09,160
we could all benefit from other protocols,

1589
01:13:09,160 --> 01:13:11,760
around how to treat a deceased body

1590
01:13:11,760 --> 01:13:14,560
that is clearly no longer viable.

1591
01:13:14,560 --> 01:13:17,760
And I'm sure that for most of the public,

1592
01:13:17,760 --> 01:13:20,760
the soft code or the theatrical code,

1593
01:13:20,760 --> 01:13:22,560
I can't remember the phrase you used,

1594
01:13:22,560 --> 01:13:23,760
is-

1595
01:13:23,760 --> 01:13:24,760
A show code.

1596
01:13:24,760 --> 01:13:27,560
A show code, is actually hurtful.

1597
01:13:29,560 --> 01:13:32,160
And in fact, the better thing for you to do in that setting

1598
01:13:32,160 --> 01:13:36,560
is pull up a chair with a family member or spouse,

1599
01:13:36,560 --> 01:13:38,360
hand them a tip, and then you can go

1600
01:13:38,360 --> 01:13:41,960
and hand them a tissue, offer to be there with them,

1601
01:13:41,960 --> 01:13:47,360
offer a hug, maybe even put your arm on that child's shoulder

1602
01:13:47,360 --> 01:13:48,960
and say your own goodbye to that.

1603
01:13:48,960 --> 01:13:52,560
And just pay the body respect rather than intervening.

1604
01:13:53,760 --> 01:13:56,560
Because those final moments for the family,

1605
01:13:56,560 --> 01:13:57,960
you guys probably know this,

1606
01:13:57,960 --> 01:14:00,760
but people will live with whatever your work was,

1607
01:14:00,760 --> 01:14:04,960
whatever you guys do, it's seared in the memories of families.

1608
01:14:04,960 --> 01:14:10,360
And so you set folks up for the rest of their lives

1609
01:14:10,360 --> 01:14:12,360
with imagery in those final moments.

1610
01:14:12,360 --> 01:14:14,360
And that can either be brutal imagery,

1611
01:14:14,360 --> 01:14:16,160
which will complicate their grieving period,

1612
01:14:16,160 --> 01:14:18,960
or it can be much more kind and tender

1613
01:14:18,960 --> 01:14:22,160
and help someone in their grief.

1614
01:14:22,160 --> 01:14:25,560
Yeah, because I know our protocols where I work now,

1615
01:14:25,560 --> 01:14:27,560
many of them lean towards,

1616
01:14:27,560 --> 01:14:30,960
and even if it is an actual code, to try on it,

1617
01:14:30,960 --> 01:14:37,160
but if it's not working, if you get a 20-minute period to work a code,

1618
01:14:37,160 --> 01:14:41,360
if it's certain cardiac rhythm, you can call it then.

1619
01:14:41,360 --> 01:14:45,960
So even then, the family are left with their loved one,

1620
01:14:45,960 --> 01:14:50,760
hopefully in their home, where they can then start to process it.

1621
01:14:50,760 --> 01:14:54,360
But I know a lot of places, and certainly where I work,

1622
01:14:54,360 --> 01:14:57,560
there's an old-school mentality of, you know,

1623
01:14:57,560 --> 01:14:59,360
get them out of here, really.

1624
01:14:59,360 --> 01:15:01,160
I mean, there's no other way of putting it.

1625
01:15:01,160 --> 01:15:06,160
Which again, is the initial, I think, goal behind that

1626
01:15:06,160 --> 01:15:08,760
was better customer service overall.

1627
01:15:08,760 --> 01:15:10,760
But I think, as we just talked about,

1628
01:15:10,760 --> 01:15:14,560
it's the actual opposite, that it's much worse for the family

1629
01:15:14,560 --> 01:15:16,960
if they're whisked away and then they find themselves

1630
01:15:16,960 --> 01:15:20,360
in not only in a hospital, but let's talk logistics too,

1631
01:15:20,360 --> 01:15:22,160
with a huge medical bill at the end

1632
01:15:22,160 --> 01:15:24,760
for working the code that was never going to work in the beginning.

1633
01:15:24,760 --> 01:15:26,160
Absolutely.

1634
01:15:26,160 --> 01:15:31,160
And absolutely, we've just muddied this very hard reality for somebody.

1635
01:15:31,160 --> 01:15:32,560
And one of the kindest things you can do,

1636
01:15:32,560 --> 01:15:36,760
even if the family is yelling at you and just in their grief,

1637
01:15:36,760 --> 01:15:38,960
someone taking responsibility and saying,

1638
01:15:38,960 --> 01:15:41,560
this person is gone, this person is dead,

1639
01:15:41,560 --> 01:15:45,160
there's no coming back, that's a hard thing to transmit,

1640
01:15:45,160 --> 01:15:47,560
but it is, in the end, a very kind thing to transmit,

1641
01:15:47,560 --> 01:15:50,960
especially if you do it with love.

1642
01:15:50,960 --> 01:15:55,160
So, yeah, yeah, I feel I'm so with you on this, James.

1643
01:15:55,160 --> 01:15:58,560
It's a huge subject and it's where your field could do

1644
01:15:58,560 --> 01:16:00,160
even more good than you already do,

1645
01:16:00,160 --> 01:16:03,160
if we could loop this into your training somehow.

1646
01:16:03,160 --> 01:16:05,160
Yeah, I agree 100%.

1647
01:16:05,160 --> 01:16:08,560
So, well, talking of death, and we're going to transition back to,

1648
01:16:08,560 --> 01:16:13,560
I mean, obviously, you've seen thousands of people pass away now.

1649
01:16:13,560 --> 01:16:16,160
I just want to touch on one thing before we do some wrap-up questions

1650
01:16:16,160 --> 01:16:17,160
and let you get on with the day,

1651
01:16:17,160 --> 01:16:19,360
because you've been extremely generous with your time,

1652
01:16:19,360 --> 01:16:23,960
but I heard you talk about this before and I kind of want to visit it.

1653
01:16:23,960 --> 01:16:27,960
Of all the patients that you've had at the end of their life,

1654
01:16:27,960 --> 01:16:32,960
have you seen common denominators as far as regrets

1655
01:16:32,960 --> 01:16:36,560
and common denominators as far as feelings of fulfillment

1656
01:16:36,560 --> 01:16:40,360
from the patients that you've seen before they passed away?

1657
01:16:40,360 --> 01:16:44,560
Yeah, I mean, so, you know,

1658
01:16:44,560 --> 01:16:47,360
there's a sort of what I think most of us kind of assume.

1659
01:16:47,360 --> 01:16:50,360
There are sometimes communicating regrets around, like,

1660
01:16:50,360 --> 01:16:54,560
gosh, why did I work so hard or should have spent more time with my family

1661
01:16:54,560 --> 01:16:57,560
or should have done this, taken this trip or, you know,

1662
01:16:57,560 --> 01:17:01,560
there's sort of the stereotypical regrets that usually come from someone

1663
01:17:01,560 --> 01:17:06,560
who's basically never conceived of the limitations of their life

1664
01:17:06,560 --> 01:17:10,160
and always, you know, basically absorbed and perpetuated an idea

1665
01:17:10,160 --> 01:17:14,760
that death was kind of optional and wasn't kind of really going to happen to them.

1666
01:17:14,760 --> 01:17:18,160
And if they did, they'd have a lot of time to reckon with it, et cetera.

1667
01:17:18,160 --> 01:17:20,560
Of course, that's just not the way death plays out.

1668
01:17:20,560 --> 01:17:23,960
And this is why another reason why I think it's so important for us all to be talking about it

1669
01:17:23,960 --> 01:17:27,160
so that we can live our lives a little bit differently

1670
01:17:27,160 --> 01:17:29,560
so that regret isn't such a problem.

1671
01:17:29,560 --> 01:17:32,760
I mean, I can, we can help with symptoms and pain and the suffering

1672
01:17:32,760 --> 01:17:36,360
that a lot of people can, that are worried about that dying portends.

1673
01:17:36,360 --> 01:17:40,760
You don't have to suffer in death necessarily.

1674
01:17:40,760 --> 01:17:44,160
But it's impossible. I can't do much with regret.

1675
01:17:44,160 --> 01:17:47,760
You know, those are something that we compile over a lifetime.

1676
01:17:47,760 --> 01:17:54,960
So where things that go really well are for people who have roped this fact into their lives

1677
01:17:54,960 --> 01:17:58,960
and lived a life in a certain way that they didn't stoppile regrets.

1678
01:17:58,960 --> 01:18:07,160
And if they had any regrets, they either came to terms with them or, you know, rework their lives.

1679
01:18:07,160 --> 01:18:12,560
So anyway, but to your question, yeah, it's pretty common for people

1680
01:18:12,560 --> 01:18:15,160
to kind of transmit basic regrets like that.

1681
01:18:15,160 --> 01:18:18,960
But I must say it actually doesn't happen all that often.

1682
01:18:18,960 --> 01:18:22,360
By the time most people are done with all the medical treatments,

1683
01:18:22,360 --> 01:18:25,560
and I see people with chronic illness, so they're not dying suddenly.

1684
01:18:25,560 --> 01:18:28,760
They've known the end is coming on some level for a while.

1685
01:18:28,760 --> 01:18:31,960
And most of folks don't have a lot of unfinished business.

1686
01:18:31,960 --> 01:18:34,960
They're just really, it's just deep sorrow.

1687
01:18:34,960 --> 01:18:39,160
And, you know, I feel like we've done our job right if someone, if a family

1688
01:18:39,160 --> 01:18:44,160
and a patient are just sad at the end of life because there's plenty to be sad about.

1689
01:18:44,160 --> 01:18:48,160
But it gets troubling when you have sadness plus regret plus guilt

1690
01:18:48,160 --> 01:18:50,960
plus all these other complicating variables.

1691
01:18:50,960 --> 01:18:53,360
So sadness, beautiful.

1692
01:18:53,360 --> 01:18:56,560
Everyone, there's sweetness and love and sadness.

1693
01:18:56,560 --> 01:19:01,360
Where it gets tricky is if you put off thinking about the importance of your time

1694
01:19:01,360 --> 01:19:04,760
and your life too long and then are surprised by your death.

1695
01:19:04,760 --> 01:19:07,760
But for the most part, most people I ever work with or meet,

1696
01:19:07,760 --> 01:19:10,360
they're, you know, when the push comes to shove, they may be sad,

1697
01:19:10,360 --> 01:19:12,760
but they're often really ready to go.

1698
01:19:12,760 --> 01:19:17,560
The harder part is the family left with, gosh, I wish I had said this or said that.

1699
01:19:17,560 --> 01:19:19,760
I wish we had done this or done that.

1700
01:19:19,760 --> 01:19:21,160
Why was I so selfish?

1701
01:19:21,160 --> 01:19:22,760
Why was I, blah, blah, blah?

1702
01:19:22,760 --> 01:19:25,160
We don't grieve very well in society.

1703
01:19:25,160 --> 01:19:27,760
And that's another thing I think we should all learn to do a little bit better.

1704
01:19:27,760 --> 01:19:29,560
There's a lot of beauty and grief.

1705
01:19:29,560 --> 01:19:34,760
And also if we grieve well, then when it's our turn, we do it a little differently.

1706
01:19:34,760 --> 01:19:35,960
We die a little differently.

1707
01:19:35,960 --> 01:19:42,560
People who have known loss and dealt with it, they die better, I must say.

1708
01:19:42,560 --> 01:19:45,960
Right. And then flipping that on its head.

1709
01:19:45,960 --> 01:19:48,560
So what advice would you give to people just, you know,

1710
01:19:48,560 --> 01:19:52,360
obviously collectively from all the wisdom of all these, you know,

1711
01:19:52,360 --> 01:19:56,360
men and women that have passed through your doors as to, you know,

1712
01:19:56,360 --> 01:20:03,760
the key points of living a fulfilling happy life before you get to that point?

1713
01:20:03,760 --> 01:20:12,360
So, you know, I would say that I think the people who do best

1714
01:20:12,360 --> 01:20:18,360
have found a way to see life beyond themselves.

1715
01:20:18,360 --> 01:20:23,360
One way or another, they have a diffuse ego.

1716
01:20:23,360 --> 01:20:26,160
Because the ego, that is the part that dies.

1717
01:20:26,160 --> 01:20:29,960
But you're going to live on in people whose lives you've touched.

1718
01:20:29,960 --> 01:20:31,360
You know, there is an immortality.

1719
01:20:31,360 --> 01:20:32,960
It's just not in this body.

1720
01:20:32,960 --> 01:20:36,160
Like it's the effect you've had on people, et cetera.

1721
01:20:36,160 --> 01:20:40,160
And so things like, you know, the fundamentals of kindness,

1722
01:20:40,160 --> 01:20:44,360
of seeing, of being concerned with life beyond your own.

1723
01:20:44,360 --> 01:20:46,960
These are things that feel good in real time,

1724
01:20:46,960 --> 01:20:50,160
set you up to learn good things, but also will help you die.

1725
01:20:50,160 --> 01:20:54,960
Because you haven't confused life at the macro with the life of,

1726
01:20:54,960 --> 01:20:56,160
like with your own life.

1727
01:20:56,160 --> 01:21:00,160
You're not, you've not put yourself at the center of the universe.

1728
01:21:00,160 --> 01:21:03,360
And so therefore, you're not as freaked out

1729
01:21:03,360 --> 01:21:06,560
when that center of the universe starts to crumble.

1730
01:21:06,560 --> 01:21:10,960
So, and again, also think of all the people you've met

1731
01:21:10,960 --> 01:21:12,560
who would qualify as wise.

1732
01:21:12,560 --> 01:21:16,160
I don't think there are not a lot of arrogant,

1733
01:21:16,160 --> 01:21:18,960
self-centered, wise people in the world.

1734
01:21:18,960 --> 01:21:21,360
So one is to see the world outside of yourself,

1735
01:21:21,360 --> 01:21:24,160
and to feel part of that world, because that world keeps going.

1736
01:21:24,160 --> 01:21:26,560
You'll always be part of that world.

1737
01:21:26,560 --> 01:21:32,360
You feel nice and small and proportionate and like you belong.

1738
01:21:32,360 --> 01:21:36,760
So that's a huge piece that will really, really protect you.

1739
01:21:36,760 --> 01:21:39,760
And I think basic kindness, never, you know,

1740
01:21:39,760 --> 01:21:42,560
thinking about moments for their own sake,

1741
01:21:42,560 --> 01:21:46,760
not looking at life so strategically or transactionally.

1742
01:21:46,760 --> 01:21:48,760
That allows you to stop and smell the roses

1743
01:21:48,760 --> 01:21:53,760
and appreciate what you have while you have it, which is so key.

1744
01:21:53,760 --> 01:21:57,760
But also allows you to slow down and just be kind just for its own sake.

1745
01:21:57,760 --> 01:22:00,160
I mean, I think of how many times my day has been salvaged

1746
01:22:00,160 --> 01:22:03,760
by just a kindness of a stranger holding the door open a certain way,

1747
01:22:03,760 --> 01:22:04,960
or whatever it is.

1748
01:22:04,960 --> 01:22:07,960
It's very basic stuff and in real time.

1749
01:22:07,960 --> 01:22:11,160
But you do, you kind of organize a life around that.

1750
01:22:11,160 --> 01:22:17,160
And I can't guarantee you, but you're much more likely to die better too.

1751
01:22:17,160 --> 01:22:19,360
Okay, I almost feel from all the interviews I've had

1752
01:22:19,360 --> 01:22:22,560
and all the experiences I've had in my life so far,

1753
01:22:22,560 --> 01:22:27,360
that a universal religious doctrine would just have two pages.

1754
01:22:27,360 --> 01:22:30,160
One would say kindness and one would say gratitude.

1755
01:22:30,160 --> 01:22:30,560
Yeah.

1756
01:22:30,560 --> 01:22:31,960
That's it.

1757
01:22:31,960 --> 01:22:35,960
Because that seems to be, you know, the common denominator from everyone you talk to is,

1758
01:22:35,960 --> 01:22:39,360
if you have those two things, your life's going to be probably pretty kick-ass.

1759
01:22:39,360 --> 01:22:42,360
Yeah, I think that's right.

1760
01:22:42,360 --> 01:22:47,560
And pieces of that is also like having an attitude like,

1761
01:22:47,560 --> 01:22:51,560
you know, the folks who are stuck with why me when they get sick

1762
01:22:51,560 --> 01:22:54,360
and are dying and are wracked with questions of why me,

1763
01:22:54,360 --> 01:22:59,760
but that's, it's sad, but it's also telling that they didn't reconcile the limitations of a life

1764
01:22:59,760 --> 01:23:02,560
before they were losing their life.

1765
01:23:02,560 --> 01:23:07,160
They, you know, sort of a why not me mentality,

1766
01:23:07,160 --> 01:23:09,560
like knowing that this body is going to die someday,

1767
01:23:09,560 --> 01:23:14,160
it'll freeze you up to work with it and play with it and use it while you have it.

1768
01:23:14,160 --> 01:23:17,960
And that cuts back to gratitude at least too.

1769
01:23:17,960 --> 01:23:18,560
But I'm with you.

1770
01:23:18,560 --> 01:23:23,360
I would sign those two pages wholeheartedly as a total way of life.

1771
01:23:23,360 --> 01:23:24,560
Yeah, I couldn't agree more.

1772
01:23:24,560 --> 01:23:30,360
Well, that segues very well to one of the last few questions.

1773
01:23:30,360 --> 01:23:35,360
So you, the reason why we didn't do this interview earlier is you were on high as kind of,

1774
01:23:35,360 --> 01:23:37,560
as far as writing a book.

1775
01:23:37,560 --> 01:23:40,160
So are you able to talk about that book yet?

1776
01:23:40,160 --> 01:23:40,960
Yeah, yeah.

1777
01:23:40,960 --> 01:23:45,360
So we're in the editing phase.

1778
01:23:45,360 --> 01:23:48,760
It's my, I have a co-author by the name of Shoshana Berger.

1779
01:23:48,760 --> 01:23:52,760
She's a journalist and instructional design person.

1780
01:23:52,760 --> 01:24:00,760
And so we have teamed up to write this book that is tentatively called How to Die,

1781
01:24:00,760 --> 01:24:02,560
a Field Guide.

1782
01:24:02,560 --> 01:24:08,360
And it's meant to be, this is very practical to the point in plain language,

1783
01:24:08,360 --> 01:24:11,160
preparing yourself for the inevitable.

1784
01:24:11,160 --> 01:24:15,960
So there's, you know, much of what we've talked about will be in the book in terms of explaining hospice

1785
01:24:15,960 --> 01:24:19,760
and palliative medicine, how to talk with your doctors,

1786
01:24:19,760 --> 01:24:23,160
how to protect yourself against fear at the end of life.

1787
01:24:23,160 --> 01:24:26,360
And Shoshana's parts will be much more like around advanced care,

1788
01:24:26,360 --> 01:24:31,760
advanced care planning, how to write an obituary, planning a memorial, etc.

1789
01:24:31,760 --> 01:24:35,760
So it is meant to be for a very general audience and cover the waterfront of issues

1790
01:24:35,760 --> 01:24:38,360
that arise around the end of life.

1791
01:24:38,360 --> 01:24:40,360
Simon Schuster's publishing it.

1792
01:24:40,360 --> 01:24:41,760
We're not quite done with it.

1793
01:24:41,760 --> 01:24:45,960
And it'll probably be on shelves about a year from now.

1794
01:24:45,960 --> 01:24:51,560
Okay, well, when you get ready, I will put it on all my areas because not only would that be a great resource

1795
01:24:51,560 --> 01:24:56,160
for anyone who deals with death in their profession, obviously, as human beings,

1796
01:24:56,160 --> 01:24:58,360
I'm pretty sure we're all going to deal with it at some point too.

1797
01:24:58,360 --> 01:25:00,760
So, yep.

1798
01:25:00,760 --> 01:25:04,760
Now, what about outside of your own book?

1799
01:25:04,760 --> 01:25:09,560
Is there a book that you recommend to people, one of your favorite books?

1800
01:25:09,560 --> 01:25:10,560
Huh.

1801
01:25:10,560 --> 01:25:11,960
You know, it's funny.

1802
01:25:11,960 --> 01:25:17,360
I am, whenever I have time, I'm not a huge reader.

1803
01:25:17,360 --> 01:25:25,960
But a book that was given to me not too long ago and that is just has been very touching for me in a lot of ways is a book just,

1804
01:25:25,960 --> 01:25:29,160
I think the book is just called Wabi Sabi.

1805
01:25:29,160 --> 01:25:33,960
It's a short pamphlet book around the sort of Japanese aesthetic around,

1806
01:25:33,960 --> 01:25:40,960
around delighting in imperfections and loving things that are broken because that's a natural state.

1807
01:25:40,960 --> 01:25:45,160
And I believe the book is just simply called Wabi Sabi.

1808
01:25:45,160 --> 01:25:49,360
And it's like practically a religion in a few pages as far as I'm concerned.

1809
01:25:49,360 --> 01:25:49,960
Fantastic.

1810
01:25:49,960 --> 01:25:59,160
It reminds me of a picture I saw floating around the internet and it was a pot that had been broken and been repaired with gold,

1811
01:25:59,160 --> 01:26:00,160
like gold glue.

1812
01:26:00,160 --> 01:26:07,760
And there was some quote saying that the Japanese repair in gold so that they relish in the fact that it was imperfect.

1813
01:26:07,760 --> 01:26:08,560
Yeah.

1814
01:26:08,560 --> 01:26:09,160
Well, there you go.

1815
01:26:09,160 --> 01:26:11,360
That is that's Wabi Sabi ism right there.

1816
01:26:11,360 --> 01:26:13,360
And it's practically a way of life.

1817
01:26:13,360 --> 01:26:17,960
Unless you find a way to define perfect and stay perfect your whole life.

1818
01:26:17,960 --> 01:26:21,760
It's much more efficient for us to somehow get into our imperfections.

1819
01:26:21,760 --> 01:26:25,260
I much more realistic way to go and much more beautiful way to go.

1820
01:26:25,260 --> 01:26:26,060
Yes.

1821
01:26:26,060 --> 01:26:27,160
Yeah, absolutely.

1822
01:26:27,160 --> 01:26:27,560
All right.

1823
01:26:27,560 --> 01:26:32,260
What about a movie and or documentary?

1824
01:26:32,260 --> 01:26:38,260
Oh gosh, I was recently I was watching the Vietnam War.

1825
01:26:38,260 --> 01:26:39,460
It's epic.

1826
01:26:39,460 --> 01:26:50,960
The Ken Burns and Lin Novick piece on PBS right now about Vietnam and stunning film in itself.

1827
01:26:50,960 --> 01:26:58,460
And it reminded me of a documentary that I saw a few years back about Robert McNamara.

1828
01:26:58,460 --> 01:27:00,760
What the heck was it called?

1829
01:27:00,760 --> 01:27:10,260
It was a really gosh, it was a stunning movie to hear a man who whose whose decisions were so flawed in a way and so

1830
01:27:10,260 --> 01:27:18,460
consequential to so many people to hear him trying to come to terms with what he had participated in and had meant well

1831
01:27:18,460 --> 01:27:20,760
through was really stunning.

1832
01:27:20,760 --> 01:27:27,160
I can't remember the day it's from the same director did the thin blue line.

1833
01:27:27,160 --> 01:27:28,260
Gosh James, I'm sorry.

1834
01:27:28,260 --> 01:27:32,460
I'm spacing on that name of that movie, but maybe your listeners might know what I'm talking about.

1835
01:27:32,460 --> 01:27:37,860
If you probably Google Robert McNamara documentary, it'll come up.

1836
01:27:37,860 --> 01:27:41,060
That was for some reason just jumps out at me right now.

1837
01:27:41,060 --> 01:27:47,260
In terms of films like, you know, I recently saw loving Vincent and was very moved by that.

1838
01:27:47,260 --> 01:27:57,160
I love I love my classically my favorite movies are things like old like kind of like airplane naked gun.

1839
01:27:57,160 --> 01:28:02,760
Kentucky Fried movie the groove tube Amazon women on the moon.

1840
01:28:02,760 --> 01:28:11,460
These are all these this is sort of kind of sense of absurd sense of humor that I have found very instructive and helpful in my life.

1841
01:28:11,460 --> 01:28:18,660
Being in touch with absurdity is a daily is part of my kind of daily religion and then a kind of corollary to that like movies

1842
01:28:18,660 --> 01:28:22,660
like waiting for Gufman, mighty wind, spinal tap.

1843
01:28:22,660 --> 01:28:30,960
This whole group of people Christopher guest and company who've done just outrageously hilarious work that's part improv part planned again.

1844
01:28:30,960 --> 01:28:32,660
It's absurd. It's farcical.

1845
01:28:32,660 --> 01:28:35,260
It's holds a mirror up and I just love it.

1846
01:28:35,260 --> 01:28:40,160
I remember you saying telling Tim waiting for Goffman.

1847
01:28:40,160 --> 01:28:43,160
He hadn't heard of it, but it was the same people as spinal tap.

1848
01:28:43,160 --> 01:28:46,460
I'm sure it's hilarious.

1849
01:28:46,460 --> 01:28:48,260
It is I guarantee you.

1850
01:28:48,260 --> 01:28:51,660
I just love where you're never sure if you're supposed to be laughing or crying.

1851
01:28:51,660 --> 01:28:56,660
I like when I'm my emotions are being yanked in a couple different directions at the same time.

1852
01:28:56,660 --> 01:29:00,660
Absolutely. Now was the documentary talking about the fog of war?

1853
01:29:00,660 --> 01:29:02,160
Oh, there you go. There you go.

1854
01:29:02,160 --> 01:29:04,460
All right. I just googled it quickly while we were talking.

1855
01:29:04,460 --> 01:29:07,160
So fantastic.

1856
01:29:07,160 --> 01:29:07,860
All right.

1857
01:29:07,860 --> 01:29:09,060
One last questions.

1858
01:29:09,060 --> 01:29:17,960
Is there a guest that you would recommend come on this show to talk to the police fire EMS of the world?

1859
01:29:17,960 --> 01:29:27,160
Man. Well, I don't not an individual what leaves to mind is as we were talking earlier to sort of top of mind is I wonder if there's a patient,

1860
01:29:27,160 --> 01:29:39,860
a family member who could be interviewed and relate in more detail what feels good and what feels bad about how paramedics had responded to the death of their loved one.

1861
01:29:39,860 --> 01:29:43,460
Like we were talking about in terms of these soft codes and things like that.

1862
01:29:43,460 --> 01:29:51,260
It would be stunning to hear from a family member who could impart that sort of the experience.

1863
01:29:51,260 --> 01:29:55,160
I'll think about whether there's anyone I know who could serve in that role.

1864
01:29:55,160 --> 01:30:01,860
But I think hearing directly from patients and families is really key and instructive and valuable.

1865
01:30:01,860 --> 01:30:05,960
So that's one thing that leaves to mind from my field.

1866
01:30:05,960 --> 01:30:09,660
The Queen B of our field is a woman named Diane Meyer.

1867
01:30:09,660 --> 01:30:13,060
She she's a dynamo and MacArthur fellow.

1868
01:30:13,060 --> 01:30:21,760
She started the Center to Advance Palliative Care and it'd be fascinating to hear her thoughts on where our two fields could and should inform each other.

1869
01:30:21,760 --> 01:30:24,660
She's in New York at Mount Sinai.

1870
01:30:24,660 --> 01:30:27,960
She's brilliant person.

1871
01:30:27,960 --> 01:30:30,060
So those are the two top of mind thoughts.

1872
01:30:30,060 --> 01:30:31,160
Okay, fantastic.

1873
01:30:31,160 --> 01:30:32,260
Thank you.

1874
01:30:32,260 --> 01:30:42,960
And then the very last thing before we talk about where we can find you and the book when it comes out is what do you do to decompress when you're not cycling or working?

1875
01:30:42,960 --> 01:30:46,760
So I love going to the movies.

1876
01:30:46,760 --> 01:30:50,760
I love getting on my bicycle, but I also love doing nothing.

1877
01:30:50,760 --> 01:30:56,160
Like sometimes I'll just go sit in my backyard and just literally just sit there and I don't have a meditation practice.

1878
01:30:56,160 --> 01:31:05,560
But in terms of kind of rebooting and reorienting myself, I'm a fan of sitting and doing absolutely nothing for a little while.

1879
01:31:05,560 --> 01:31:09,460
I find it pretty challenging, but I also find it extremely restorative.

1880
01:31:09,460 --> 01:31:13,760
So the last question, where can people find you online?

1881
01:31:13,760 --> 01:31:17,460
And then where will the book be available when it gets published?

1882
01:31:17,460 --> 01:31:23,660
So I had to hit pause for the book.

1883
01:31:23,660 --> 01:31:30,860
I was going to try to start my next sort of organization while I was working on the book and we started going on the Center for Dying and Living as a title.

1884
01:31:30,860 --> 01:31:33,860
And there's a website out there, Center for Dying and Living.org.

1885
01:31:33,860 --> 01:31:36,960
I believe it is, but it's kind of it's in stasis right now.

1886
01:31:36,960 --> 01:31:38,660
So there's not much there.

1887
01:31:38,660 --> 01:31:39,660
Stay tuned.

1888
01:31:39,660 --> 01:31:43,460
But I'm otherwise reachable electronically through Twitter.

1889
01:31:43,460 --> 01:31:45,460
I think it's at BJ Miller MD.

1890
01:31:45,460 --> 01:31:53,060
And then my email is through UCSF, you know, BJ.Miller at UCSF.edu.

1891
01:31:53,060 --> 01:31:58,660
The book again, the title may change, but it's currently called How to Die, a Field Guide.

1892
01:31:58,660 --> 01:32:05,860
That's going to be published by Simon and Schuster and likely on shelves at the end of 2018 or beginning of 2019.

1893
01:32:05,860 --> 01:32:10,060
Hopefully, there'll be a big marketing push to get that thing out in the world.

1894
01:32:10,060 --> 01:32:11,660
So we'll see.

1895
01:32:11,660 --> 01:32:12,260
Excellent.

1896
01:32:12,260 --> 01:32:16,060
We'll keep everyone up to date with that and may publish the links when it comes out.

1897
01:32:16,060 --> 01:32:18,160
So, well, thank you so much.

1898
01:32:18,160 --> 01:32:18,860
I just looked at the clock.

1899
01:32:18,860 --> 01:32:20,060
I didn't realize how long I've been talking.

1900
01:32:20,060 --> 01:32:20,760
So I apologize.

1901
01:32:20,760 --> 01:32:24,360
That's a little bit more than the hour that we had scheduled.

1902
01:32:24,360 --> 01:32:26,260
Well, it's a pleasure talking to you.

1903
01:32:26,260 --> 01:32:26,860
Yeah, well, thank you.

1904
01:32:26,860 --> 01:32:31,360
It's been an amazing talk and I'm so glad that we were able to get you on.

1905
01:32:31,360 --> 01:32:45,260
But I really appreciate you reaching out to us and, you know, taking the time to talk about that and obviously talking about your own personal journey, which can't be, A, can't be fun, but B, can't be fun when every single interview you have to recount that story.

1906
01:32:45,260 --> 01:32:46,360
Well, I don't mind, James.

1907
01:32:46,360 --> 01:32:47,060
It's the life.

1908
01:32:47,060 --> 01:32:48,360
It's the story I live.

1909
01:32:48,360 --> 01:32:52,360
So I'm just appreciate your interest at all.

1910
01:32:52,360 --> 01:32:55,360
And I really just to salute what you're doing, James.

1911
01:32:55,360 --> 01:32:58,260
There is the first the world of first responders.

1912
01:32:58,260 --> 01:33:06,960
It's not a world I pretend to understand totally, but Lord knows you guys do an incredible amount of good in the world and probably relatively unsung for that world.

1913
01:33:06,960 --> 01:33:08,160
So thank you for what you do.

1914
01:33:08,160 --> 01:33:16,160
And also thank you for the efforts of this podcast to bring well-being and health to this very important segment of the world.

1915
01:33:16,160 --> 01:33:21,460
First responders, because it shouldn't be a sacrificial life to do this work.

1916
01:33:21,460 --> 01:33:23,360
So I'm just glad you're doing what you're doing.

1917
01:33:23,360 --> 01:33:33,360
And I love it if we kind of would all stay in touch and look for ways to inform each other on this work to keep life less miserable and more wonderful for people.

1918
01:33:33,360 --> 01:33:33,960
Absolutely.

1919
01:33:33,960 --> 01:33:39,860
Well, maybe we can do a part two in the future when around when the books about to come out and we can kind of make sure everyone's looking out for it.

1920
01:33:39,860 --> 01:33:41,560
That sounds great.

1921
01:33:41,560 --> 01:33:42,060
Brilliant.

1922
01:33:42,060 --> 01:33:42,360
All right.

1923
01:33:42,360 --> 01:33:43,760
Well, thank you.

1924
01:33:43,760 --> 01:33:44,660
Thanks so much, James.

1925
01:33:44,660 --> 01:33:54,660
Take care.