What we can do to die well | Timothy Ihrig

87,942 views ・ 2016-09-14

TED


Please double-click on the English subtitles below to play the video.

00:13
I am a palliative care physician
0
13387
1525
00:14
and I would like to talk to you today about health care.
1
14936
2991
00:18
I'd like to talk to you about the health and care
2
18393
3709
00:22
of the most vulnerable population in our country --
3
22917
2847
00:25
those people dealing with the most complex serious health issues.
4
25788
5251
00:32
I'd like to talk to you about economics as well.
5
32202
2802
00:35
And the intersection of these two should scare the hell out of you --
6
35028
4456
00:39
it scares the hell out of me.
7
39508
1771
00:42
I'd also like to talk to you about palliative medicine:
8
42199
2675
00:45
a paradigm of care for this population, grounded in what they value.
9
45835
6317
00:52
Patient-centric care based on their values
10
52544
3197
00:55
that helps this population live better and longer.
11
55765
3577
01:00
It's a care model that tells the truth
12
60458
2350
01:03
and engages one-on-one
13
63744
1240
01:05
and meets people where they're at.
14
65008
1821
01:09
I'd like to start by telling the story of my very first patient.
15
69460
3763
01:13
It was my first day as a physician,
16
73247
2036
01:15
with the long white coat ...
17
75307
1491
01:17
I stumbled into the hospital
18
77519
1482
01:19
and right away there's a gentleman, Harold, 68 years old,
19
79025
2800
01:21
came to the emergency department.
20
81849
1601
01:23
He had had headaches for about six weeks
21
83474
1983
01:25
that got worse and worse and worse and worse.
22
85481
2149
01:28
Evaluation revealed he had cancer that had spread to his brain.
23
88460
3633
01:33
The attending physician directed me to go share with Harold and his family
24
93148
5295
01:39
the diagnosis, the prognosis and options of care.
25
99791
3322
01:44
Five hours into my new career,
26
104114
2954
01:47
I did the only thing I knew how.
27
107092
2034
01:49
I walked in,
28
109922
1284
01:51
sat down,
29
111790
1344
01:53
took Harold's hand,
30
113717
1420
01:55
took his wife's hand
31
115935
1355
01:58
and just breathed.
32
118142
1277
02:00
He said, "It's not good news is it, sonny?"
33
120500
2201
02:03
I said, "No."
34
123132
1408
02:04
And so we talked and we listened and we shared.
35
124564
3351
02:08
And after a while I said,
36
128867
1233
02:10
"Harold, what is it that has meaning to you?
37
130124
3225
02:13
What is it that you hold sacred?"
38
133373
1629
02:15
And he said,
39
135026
1315
02:16
"My family."
40
136365
1404
02:18
I said, "What do you want to do?"
41
138525
2021
02:20
He slapped me on the knee and said, "I want to go fishing."
42
140570
3167
02:23
I said, "That, I know how to do."
43
143761
1871
02:26
Harold went fishing the next day.
44
146646
1954
02:29
He died a week later.
45
149760
1632
02:32
As I've gone through my training in my career,
46
152455
2619
02:35
I think back to Harold.
47
155098
1487
02:36
And I think that this is a conversation
48
156609
2420
02:40
that happens far too infrequently.
49
160782
2184
02:43
And it's a conversation that had led us to crisis,
50
163737
3765
02:48
to the biggest threat to the American way of life today,
51
168173
2664
02:50
which is health care expenditures.
52
170861
2106
02:53
So what do we know?
53
173926
1177
02:55
We know that this population, the most ill,
54
175127
2929
02:58
takes up 15 percent of the gross domestic product --
55
178080
2584
03:00
nearly 2.3 trillion dollars.
56
180688
2794
03:04
So the sickest 15 percent take up 15 percent of the GDP.
57
184307
3560
03:07
If we extrapolate this out over the next two decades
58
187891
3165
03:11
with the growth of baby boomers,
59
191755
1991
03:14
at this rate it is 60 percent of the GDP.
60
194838
3916
03:20
Sixty percent of the gross domestic product
61
200177
2279
03:22
of the United States of America --
62
202480
1624
03:24
it has very little to do with health care at that point.
63
204128
2694
03:27
It has to do with a gallon of milk,
64
207148
1814
03:29
with college tuition.
65
209540
1524
03:31
It has to do with every thing that we value
66
211625
2463
03:34
and every thing that we know presently.
67
214112
3125
03:38
It has at stake the free-market economy and capitalism
68
218514
4191
03:42
of the United States of America.
69
222729
1754
03:46
Let's forget all the statistics for a minute, forget the numbers.
70
226965
3156
03:50
Let's talk about the value we get for all these dollars we spend.
71
230145
3380
03:54
Well, the Dartmouth Atlas, about six years ago,
72
234822
2593
03:57
looked at every dollar spent by Medicare --
73
237439
2753
04:00
generally this population.
74
240216
1611
04:01
We found that those patients who have the highest per capita expenditures
75
241851
3936
04:08
had the highest suffering, pain, depression.
76
248050
3375
04:12
And, more often than not, they die sooner.
77
252182
2561
04:15
How can this be?
78
255824
1525
04:17
We live in the United States,
79
257789
1404
04:19
it has the greatest health care system on the planet.
80
259217
2490
04:21
We spend 10 times more on these patients
81
261731
2505
04:24
than the second-leading country in the world.
82
264260
2186
04:27
That doesn't make sense.
83
267196
1453
04:29
But what we know is,
84
269764
1359
04:31
out of the top 50 countries on the planet
85
271147
3171
04:34
with organized health care systems,
86
274342
3583
04:37
we rank 37th.
87
277949
2098
04:42
Former Eastern Bloc countries and sub-Saharan African countries
88
282017
4286
04:46
rank higher than us as far as quality and value.
89
286327
3536
04:52
Something I experience every day in my practice,
90
292485
2538
04:55
and I'm sure, something many of you on your own journeys have experienced:
91
295047
4053
04:59
more is not more.
92
299927
2880
05:04
Those individuals who had more tests,
93
304196
1989
05:06
more bells, more whistles,
94
306209
1270
05:07
more chemotherapy, more surgery, more whatever --
95
307503
2428
05:09
the more that we do to someone,
96
309955
2449
05:13
it decreases the quality of their life.
97
313283
2597
05:17
And it shortens it, most often.
98
317422
2271
05:21
So what are we going to do about this?
99
321896
1825
05:23
What are we doing about this?
100
323745
1403
05:25
And why is this so?
101
325461
1612
05:27
The grim reality, ladies and gentlemen,
102
327097
1904
05:29
is that we, the health care industry -- long white-coat physicians --
103
329025
3398
05:32
are stealing from you.
104
332447
1410
05:34
Stealing from you the opportunity
105
334877
2191
05:37
to choose how you want to live your lives
106
337974
2360
05:40
in the context of whatever disease it is.
107
340358
2481
05:42
We focus on disease and pathology and surgery
108
342863
2769
05:45
and pharmacology.
109
345656
1381
05:49
We miss the human being.
110
349319
2076
05:53
How can we treat this
111
353434
1527
05:54
without understanding this?
112
354985
1793
05:59
We do things to this;
113
359029
1939
06:02
we need to do things for this.
114
362948
3477
06:08
The triple aim of healthcare:
115
368161
1780
06:09
one, improve patient experience.
116
369965
3092
06:13
Two, improve the population health.
117
373081
3194
06:17
Three, decrease per capita expenditure across a continuum.
118
377467
4783
06:23
Our group, palliative care,
119
383591
1743
06:25
in 2012, working with the sickest of the sick --
120
385358
4017
06:31
cancer,
121
391000
1151
06:32
heart disease, lung disease,
122
392175
1345
06:34
renal disease,
123
394017
1151
06:35
dementia --
124
395192
1197
06:37
how did we improve patient experience?
125
397681
2158
06:41
"I want to be at home, Doc."
126
401010
1599
06:42
"OK, we'll bring the care to you."
127
402633
2211
06:44
Quality of life, enhanced.
128
404868
1812
06:47
Think about the human being.
129
407732
1358
06:49
Two: population health.
130
409114
1931
06:51
How did we look at this population differently,
131
411069
2851
06:53
and engage with them at a different level, a deeper level,
132
413944
2848
06:56
and connect to a broader sense of the human condition than my own?
133
416816
3201
07:01
How do we manage this group,
134
421091
2584
07:04
so that of our outpatient population,
135
424584
1769
07:06
94 percent, in 2012, never had to go to the hospital?
136
426377
4898
07:11
Not because they couldn't.
137
431919
1633
07:15
But they didn't have to.
138
435213
1785
07:17
We brought the care to them.
139
437022
1729
07:19
We maintained their value, their quality.
140
439356
4029
07:25
Number three: per capita expenditures.
141
445220
3007
07:28
For this population,
142
448746
1398
07:30
that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP,
143
450168
5053
07:35
we reduced health care expenditures by nearly 70 percent.
144
455245
4734
07:40
They got more of what they wanted based on their values,
145
460873
3449
07:44
lived better and are living longer,
146
464346
2059
07:47
for two-thirds less money.
147
467464
1769
07:54
While Harold's time was limited,
148
474880
2035
07:57
palliative care's is not.
149
477663
1901
08:00
Palliative care is a paradigm from diagnosis through the end of life.
150
480288
4676
08:06
The hours,
151
486677
1177
08:08
weeks, months, years,
152
488361
2392
08:11
across a continuum --
153
491916
1158
08:13
with treatment, without treatment.
154
493098
1884
08:15
Meet Christine.
155
495006
1356
08:17
Stage III cervical cancer,
156
497196
1931
08:19
so, metastatic cancer that started in her cervix,
157
499151
3021
08:22
spread throughout her body.
158
502196
1483
08:24
She's in her 50s and she is living.
159
504719
2643
08:28
This is not about end of life,
160
508743
1593
08:30
this is about life.
161
510360
1515
08:33
This is not just about the elderly,
162
513180
1890
08:35
this is about people.
163
515094
1662
08:37
This is Richard.
164
517929
1212
08:39
End-stage lung disease.
165
519706
1641
08:42
"Richard, what is it that you hold sacred?"
166
522427
2426
08:45
"My kids, my wife and my Harley."
167
525581
3015
08:49
(Laughter)
168
529094
1011
08:50
"Alright!
169
530129
1150
08:52
I can't drive you around on it because I can barely pedal a bicycle,
170
532544
3238
08:55
but let's see what we can do."
171
535806
1491
08:58
Richard came to me,
172
538385
2537
09:00
and he was in rough shape.
173
540946
2897
09:04
He had this little voice telling him
174
544444
1781
09:06
that maybe his time was weeks to months.
175
546249
2401
09:09
And then we just talked.
176
549488
1266
09:10
And I listened and tried to hear --
177
550778
4089
09:14
big difference.
178
554891
1287
09:16
Use these in proportion to this.
179
556202
2169
09:20
I said, "Alright, let's take it one day at a time,"
180
560479
2525
09:23
like we do in every other chapter of our life.
181
563028
2527
09:26
And we have met Richard where Richard's at day-to-day.
182
566573
4409
09:31
And it's a phone call or two a week,
183
571006
3022
09:35
but he's thriving in the context of end-stage lung disease.
184
575059
4163
09:43
Now, palliative medicine is not just for the elderly,
185
583040
2493
09:45
it is not just for the middle-aged.
186
585557
2604
09:49
It is for everyone.
187
589535
1531
09:51
Meet my friend Jonathan.
188
591090
1539
09:53
We have the honor and pleasure
189
593903
1480
09:55
of Jonathan and his father joining us here today.
190
595407
2320
09:57
Jonathan is in his 20s, and I met him several years ago.
191
597751
2832
10:00
He was dealing with metastatic testicular cancer,
192
600607
3322
10:04
spread to his brain.
193
604700
1252
10:06
He had a stroke,
194
606465
1182
10:08
he had brain surgery,
195
608375
1548
10:09
radiation, chemotherapy.
196
609947
2012
10:13
Upon meeting him and his family,
197
613579
1796
10:15
he was a couple of weeks away from a bone marrow transplant,
198
615399
2831
10:18
and in listening and engaging,
199
618254
2261
10:20
they said, "Help us understand -- what is cancer?"
200
620539
5046
10:27
How did we get this far
201
627764
1653
10:30
without understanding what we're dealing with?
202
630513
2301
10:33
How did we get this far without empowering somebody
203
633276
2414
10:35
to know what it is they're dealing with,
204
635714
1912
10:37
and then taking the next step and engaging in who they are as human beings
205
637650
3608
10:41
to know if that is what we should do?
206
641282
2096
10:43
Lord knows we can do any kind of thing to you.
207
643402
3079
10:49
But should we?
208
649133
1205
10:53
And don't take my word for it.
209
653870
1684
10:55
All the evidence that is related to palliative care these days
210
655578
4452
11:00
demonstrates with absolute certainty people live better and live longer.
211
660054
4121
11:04
There was a seminal article out of the New England Journal of Medicine
212
664199
3344
11:07
in 2010.
213
667567
1150
11:09
A study done at Harvard by friends of mine, colleagues.
214
669621
2664
11:12
End-stage lung cancer:
215
672309
1381
11:13
one group with palliative care,
216
673714
2118
11:16
a similar group without.
217
676695
1682
11:19
The group with palliative care reported less pain,
218
679782
3352
11:23
less depression.
219
683901
1217
11:25
They needed fewer hospitalizations.
220
685556
2907
11:28
And, ladies and gentlemen,
221
688487
1407
11:30
they lived three to six months longer.
222
690639
3643
11:35
If palliative care were a cancer drug,
223
695805
3441
11:39
every cancer doctor on the planet would write a prescription for it.
224
699867
3417
11:44
Why don't they?
225
704845
1214
11:47
Again, because we goofy, long white-coat physicians
226
707570
3344
11:50
are trained and of the mantra of dealing with this,
227
710938
4046
11:56
not with this.
228
716401
1234
12:02
This is a space that we will all come to at some point.
229
722697
3744
12:07
But this conversation today is not about dying,
230
727709
2724
12:10
it is about living.
231
730457
1373
12:12
Living based on our values,
232
732289
1324
12:13
what we find sacred
233
733637
1419
12:15
and how we want to write the chapters of our lives,
234
735080
2417
12:17
whether it's the last
235
737521
1834
12:19
or the last five.
236
739379
1397
12:22
What we know,
237
742258
1414
12:24
what we have proven,
238
744277
1387
12:26
is that this conversation needs to happen today --
239
746475
2537
12:29
not next week, not next year.
240
749946
2059
12:32
What is at stake is our lives today
241
752029
2830
12:34
and the lives of us as we get older
242
754883
1800
12:36
and the lives of our children and our grandchildren.
243
756707
2540
12:40
Not just in that hospital room
244
760310
1873
12:42
or on the couch at home,
245
762207
1910
12:44
but everywhere we go and everything we see.
246
764141
2388
12:48
Palliative medicine is the answer to engage with human beings,
247
768326
5220
12:53
to change the journey that we will all face,
248
773570
3454
12:58
and change it for the better.
249
778304
1500
13:02
To my colleagues,
250
782148
1407
13:04
to my patients,
251
784823
1264
13:06
to my government,
252
786702
1174
13:08
to all human beings,
253
788303
2059
13:10
I ask that we stand and we shout and we demand
254
790386
3370
13:14
the best care possible,
255
794641
1591
13:17
so that we can live better today
256
797352
2230
13:19
and ensure a better life tomorrow.
257
799606
1681
13:21
We need to shift today
258
801311
1967
13:24
so that we can live tomorrow.
259
804452
2881
13:28
Thank you very much.
260
808838
1151
13:30
(Applause)
261
810013
1288
About this website

This site will introduce you to YouTube videos that are useful for learning English. You will see English lessons taught by top-notch teachers from around the world. Double-click on the English subtitles displayed on each video page to play the video from there. The subtitles scroll in sync with the video playback. If you have any comments or requests, please contact us using this contact form.

https://forms.gle/WvT1wiN1qDtmnspy7