When Atul Gawande – surgeon, physician, son of a surgeon –  wrote Being Mortal in 2014, I wonder if he knew what staying power it would have. This timeless book captures many of the challenges we face in the US and other countries around aging, decline, disease, the medical system, and yes, ultimately death. Listen to this episode to hear a few compelling passages from the book about the importance of conversation and what a difference a little knowledge can make. (No, it’s not Dr Gawande reading, just me.)

Transcript:

Hi, I am Diane Hullet, and you’re listening to the Best Life Best Death podcast Today, listeners, it’s just me and folks. It’s story time. I’m gonna read you a couple things from a book that is one of my favorites, being Mortal by Aul Gowane. This book was published in 2014, and it fell into my hands because my parents picked up a copy.

They both read it and then they sent it to me. They said, we think you should read this book. It’s really an important one. And it, it kind of, I think it clarified for them some of their thinking and some things they wanted my brother and I to know about their points of view about the end of life. So I read it then.

Was deeply moved by this beautifully written story by a doctor, a surgeon who is the son of a surgeon who interweaves both their personal story as a [00:01:00] family and his father’s various decline and also aging well. And he weaves that in with, uh, you know, facts, figures. Research studies in all kinds of different aspects about the end of life.

And I, I just think it’s a wonderful read. It’s a beautiful read and it’s a very broad read, so it’s giving you this, this big scope about how we do aging and dying here in the us. Um, again written 20 years ago, so there’s been some changes since, but. I just think it’s a wonderful place to start if you’re looking for a book to read.

So today, story time, I’m going to, uh, read you a few parts of this. Decline remains our fate. Death will someday come, but until that last backup system inside each of us fails, medical care can influence whether the path is steep and [00:02:00] precipitate or more gradual, allowing longer preservation of the abilities that matter most in your life.

Most of us in medicine don’t think about this. We’re good at addressing specific individual problems, colon cancer, high blood pressure, arthritic knees give us a disease and we can do something about it. But give us an elderly woman with high blood pressure, arthritic knees, and various other ailments besides an elderly woman at risk of losing the life she enjoys and we hardly know what to do and often only make matters worse.

Okay. Several years ago, researchers at the University of Minnesota identified 568 men and women over the age of 70 who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric nurses and [00:03:00] doctors, a team dedicated to the art and science of managing old age.

The others were asked to see their usual physician who was notified of their high risk status. Within 18 months, 10% of the patients in both groups had died, but the patients who had seen a geriatrics team were a quarter less likely to become disabled, and half is likely to develop depression half. They were 40% less likely to require home health services.

These were stunning results. If scientists came up with a device, call it an automatic derailer that wouldn’t extend your life, but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart.

We’d have pink ribbon campaigns to get one for every person. Over 75 Congress [00:04:00] would be holding hearings demanding to know why 40 year olds couldn’t get them installed. Medical students would be jockeying to become defra. Well, how do you say that? DEFRA specialists and Wall Street would be bidding up company stock prices.

Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery, or insertion of automatic derailer. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

How do we reward this kind of work? Chad Bolt, the geriatrician, who is the lead investigator of this University of Minnesota study can tell you a few months after he published the results demonstrating how much better people’s lives were with specialized geriatric care. The [00:05:00] university closed the division of geriatrics.

The University said that it simply could not sustain the financial losses Bolt said from Baltimore where he had moved to join the John Hopkins Bloomfield School of Public Health. On average. In bolt’s study, the geriatric services cost the hospital $1,350 more per person than the savings they seem to produce.

And Medicare. The insurer for the elderly does not cover that cost. It’s a strange double standard. No one insists that a $25,000 pacemaker, this was written in 2014, I’m sure it’s four times that now, a $25,000 pacemaker or a coronary artery stent save money for insurers. It just has to maybe do people some good.

Meanwhile, the 20 plus members of the proven geriatrics team at the University of Minnesota had to find new jobs. Scores of medical centers across the country have shrunk [00:06:00] or closed their geriatrics units. Many of bolt’s colleagues no longer advertise their geriatrics training for fear. They’ll get too many elderly patients.

Economically, it has become too difficult, bolt said, but the dismal finances of geriatrics are only a symptom of a deeper reality. People have not insisted on a change in priorities. We all like new medical gizmos and demand that policymakers ensure that they are paid for. We want doctors who promise to fix things, but geriatricians who clamors for geriatricians.

What geriatricians do bolster our resilience in old age and our capacity to weather what comes is both difficult and unappealingly limited. It requires attention to the body and its alterations. It requires vigilance over nutrition, medications, and living situations, and it requires each of us to contemplate the [00:07:00] unfixable in our life, the decline we will unavoidably face in order to make the small changes necessary to reshape it.

When the prevailing fantasy is that we can be ageless, the geriatrician uncomfortable demand is that we accept that we are not,

again, can we make the small changes necessary to reshape our aging as we walk towards later years of our life? I think this is quite fascinating and what he goes on to say is. Ah, you know, well, well, I’ll just read this next section. Here’s another part. I asked Chad Bolt, the geriatrics professor, what could be done to ensure that there are enough geriatricians for the surging elderly population.

Nothing. He said it’s too late. Creating geriatric specialists takes time, and we already have [00:08:00] far too few In a year, fewer than 300 doctors will complete geriatric training in the United States, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade.

Geriatric psychiatrists, nurses, and social workers are equally needed and in no better supply. The situation in countries outside the United States appears to be little different, and in many it’s worse. Yet Bowl believes that we still have time for another strategy. He would direct geriatricians toward training all primary care doctors and nurses, and caring for the very old instead of providing the care themselves.

Even this is a tall order. 97% of medical students take no course in geriatrics, and this strategy requires that the nation pay geriatric specialists to teach rather than provide patient care. But if the will is there Bolt estimates that it would be possible to establish courses in every [00:09:00] medical school, nursing school, school, of social work, and internal medicine training program within a decade.

We’ve got to do something. He said Life for older people can be better than it is today. Now I sort of had in my head that before I got on to record this episode, I would take a look and see whether that’s changed quite a bit in the last 10 years or not. But I confess that I did not do that. So this is something we could all kind of look into.

Who are the geriatricians in your area or what’s going on at the medical schools that you’re familiar with? Are nursing schools, are people getting more training in this? I’m, I’m curious about that. And I also think about something called slow medicine, which is essentially a geriatrics approach. There are slow medicine groups on Facebook, and I think people have found those really interesting because it is partly just this simple attitude of get the basics in nutrition, fingernails and toenails in good shape [00:10:00] hygiene.

Isolation is something to really, really address and simplifying medications. So when those things are in place, then what happens somewhere in the book is a story of someone who, you know, was on like 26 medications, and when she met with a geriatrician, they simplified that significantly and what a difference it made, you know?

Then the side effects weren’t all bouncing off each other. So meds are good, but sometimes they can be simplified. Okay, let’s read another section. This is a section that I particularly love because as you know, if you’ve been listening for a while, I, I really believe in the power of conversation and how things shift when we put words to it.

Talk to those we love. Talk to our doctors, talk to our caregivers. So this is about an insurance company, Aetna. Who knows if Aetna is even still around the way insurance companies have been [00:11:00] changing. So there was a concurrent care program in which patients were able to both continue care and enroll in hospice, because typically you can’t continue, for example, chemotherapy or radiation and also be enrolled in hospice.

But at this time. Lemme see if I can find the year in 2004. So this is practically ancient in an ancient study. A two year study of this concurrent care program found that enrolled patients were much more likely to use hospice. The figure leaped from 26% to 70%. That was no surprise since they weren’t forced to give up anything.

In other words, they weren’t forced to stop care they were doing for their disease. The surprising result was that they did give up things. They visited the emergency room half as often as the control patients did. Their use of hospitals and ICU dropped by more than two thirds. Overall [00:12:00] costs fell by almost a quarter.

The result was stunning and puzzling. It wasn’t obvious what made the approach work. Aetna ran a more modest concurrent care program for a broader group of terminally ill patients. For these patients. The traditional hospice rules applied in order to qualify for home hospice. They had to give up attempts at curative treatment.

But either way, they received phone calls from palliative care nurses who offered to check in regularly and help them find services for anything from pain control to making out a living will for these patients too. Hospice enrollment jumped to 70% and their use of hospital services dropped sharply among elderly patients.

Use of intensive care units fell by more than 85%. Satisfaction scores went way up. What was going on here? The program’s leaders had the impression that they had simply given seriously ill patients, someone [00:13:00] experienced and knowledgeable to talk about their daily concerns, and somehow that was enough.

Just talking. This explanation would seem to strain credibility, but evidence for it has grown in recent years. Two thirds of the terminal cancer patients in the coping with cancer study reported having had no discussion with their doctors about their goals for end of life care, despite being on average just four months from death.

A. But the third who did have discussions were far less likely to undergo cardiopulmonary resuscitation, CPR, or to be put on a ventilator or to end up in intensive care unit. Most of them enrolled in hospice. They suffered less, were physically more capable, and were better able for a longer period to interact with others.

In addition, six months after these patients died, their family members were markedly less likely to experience persistent [00:14:00] major depression. In other words, people who had substantive discussions with their doctor about their end of life preferences were far more likely to die peace and in control of their situation and to spare their family anguish.

Powerful. Powerful, right? People who had substantive discussions with their doctor made a huge difference for both them and their family. Here’s another one. A landmark follow following on that paragraph comes this one. A landmark 2010 study from the Massachusetts General Hospital had even more startling findings.

The researchers randomly assigned 151 patients with, with stage four lung cancer to one of two possible approaches to treat. Half received usual oncology care. The other half received usual oncology care, plus parallel visits with a palliative care specialist. These are specialists in preventing and [00:15:00] relieving the suffering of patients and to see one, no determination of whether they are dying or not is required.

If a person has serious complex illness, palliative specialists are happy to help. The ones in the study discussed with the patients their goals and priorities for if and when their condition worsened the result. Those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives, and they lived 25% longer.

In other words, our decision making in medicine has failed so spectacularly that we’ve reached the point of actively inflicting harm on patients rather than confronting the subject of mortality. If end of life discussions were an experimental drug, we, the FDA would approve it. Patients entering hospice have had no less [00:16:00] surprising results.

Like many other people, I had believed that hospice care hastens death because patients forego hospital treatments and are allowed high dose narcotics to combat pain. But multiple studies find otherwise in one researchers followed 4,493 Medicare patients with either terminal cancer or end stage congestive heart failure.

For the patients with breast cancer, prostate cancer, or colon cancer, the researchers found no difference in survival time between those who went into hospice and those who didn’t. And curiously, for some conditions, hospice care seemed to extend survival. Those with pancreatic cancer gained an average of three weeks.

Those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost zen. You live longer. Only when you stop trying to live longer. [00:17:00] One more section. Can mirrored discussions achieve such effects? Consider the case of lacrosse Wisconsin. It’s elderly residents have unusually low end of life hospital costs.

During their last six months, according to Medicare data, they spent half as many days in the hospital as the national average, and there’s no sign that doctors or patients are halting care prematurely, despite average rates of obesity and smoking. Their life expectancy outpaces the national mean by a year.

I spoke to Gregory Thompson, a critical care specialist at Gunderson Lutheran Hospital while he was on ICU Duty one evening, and he ran through his list of patients with me. In most respects, the patients were like those found in any ICU terribly sick and living through the most perilous days of their lives.

There was a young woman with multiple organ failure from a devastating case of pneumonia. A man in his mid sixties with a ruptured [00:18:00] colon that had caused a rampaging infection and a heart attack. Yet these patients were completely different from those in the ICUs I’d worked in. None had a terminal disease.

None battled the final stages of metastatic cancer or untreatable heart failure or. To understand lacrosse, Thompson said you had to go back to 1991 when local medical leaders headed a systemic campaign to get medical people and patients to discuss End of life wishes. Within a few years, it became routine for all patients admitted to a hospital, nursing home or assisted living facility, to sit down with someone experienced in these conversations and complete a multiple choice form.

That boiled down to four crucial questions at this moment in your life. The form asked, number one, do you want to be resuscitated if your heart stops? Number two, [00:19:00] do you want aggressive treatments such as intubation and medical mechanical ventilation? Number three, do you want antibiotics? Number four, do you want tube or intravenous feeding if you can’t eat on your own?

By 19 96, 80 5% of lacrosse residents who died had written. Had a written advance directive like this up from 15%, and doctors virtually always knew of the instructions and followed them. Having this system in place, Thompson said, has made his job vastly easier, but it’s not because the specifics are spelled out for him.

Every time a sick patient arrives in his unit. These things are not laid out in stone. He told me whatever the yes no answers, people may have put on a piece of paper. One will find nuances and complexities in what they mean, but instead of having the discussion when they get to the [00:20:00] ICU, we find many times that it has already taken place.

Answers to the list of questions change as patients go from entering the hospital for the delivery of a child to entering for complications of Alzheimer’s disease. But in LA Cross, the system means that people are far more likely to have talked about what they want and what they don’t want before they and their relatives find themselves in the throes of crisis and fear.

When wishes aren’t clear, Thompson said Families have also become much more receptive to having the discussion. The discussion, not the list was what mattered. Most discussion had brought La Cross’s end of life cross down to half the national average. It was that simple and that complicated. I’ll stop there, but boy, I just wanna underscore that sentence right before.

When people [00:21:00] were more likely to have talked about what they want and what they don’t want before they and their relatives find themselves in the cr throes of a crisis and the throes of fear, it made everything a little better. Still hard, still difficult, still complicated, but they had some traction and some understanding and some practice in those hard discussions.

I love this line in the ending line of that section. It was that simple and that complicated. Whew. Okay. That’s story time with Being Mortal by Aul Gowane. Uh, I’ll be curious if you enjoyed this as you’re listening to this on your walk or your commute or as you’re folding laundry. Uh, I kind of like story time.

I have to do another one of these. You’ve been listening to the Best Life Best Death podcast, and I’m your host Diane Hullet. As always, you can find out more about the work I do at Best LifeBestdeath.com. Thanks for listening.