What we can do to die well | Timothy Ihrig

88,006 views ・ 2016-09-14

TED


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I am a palliative care physician
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and I would like to talk to you today about health care.
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I'd like to talk to you about the health and care
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of the most vulnerable population in our country --
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those people dealing with the most complex serious health issues.
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I'd like to talk to you about economics as well.
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And the intersection of these two should scare the hell out of you --
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it scares the hell out of me.
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I'd also like to talk to you about palliative medicine:
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a paradigm of care for this population, grounded in what they value.
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Patient-centric care based on their values
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that helps this population live better and longer.
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It's a care model that tells the truth
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and engages one-on-one
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and meets people where they're at.
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I'd like to start by telling the story of my very first patient.
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It was my first day as a physician,
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with the long white coat ...
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I stumbled into the hospital
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and right away there's a gentleman, Harold, 68 years old,
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came to the emergency department.
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He had had headaches for about six weeks
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that got worse and worse and worse and worse.
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Evaluation revealed he had cancer that had spread to his brain.
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The attending physician directed me to go share with Harold and his family
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the diagnosis, the prognosis and options of care.
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Five hours into my new career,
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I did the only thing I knew how.
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I walked in,
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sat down,
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took Harold's hand,
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took his wife's hand
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and just breathed.
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He said, "It's not good news is it, sonny?"
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I said, "No."
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And so we talked and we listened and we shared.
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And after a while I said,
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"Harold, what is it that has meaning to you?
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What is it that you hold sacred?"
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And he said,
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"My family."
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I said, "What do you want to do?"
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He slapped me on the knee and said, "I want to go fishing."
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I said, "That, I know how to do."
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Harold went fishing the next day.
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He died a week later.
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As I've gone through my training in my career,
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I think back to Harold.
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And I think that this is a conversation
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that happens far too infrequently.
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And it's a conversation that had led us to crisis,
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to the biggest threat to the American way of life today,
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which is health care expenditures.
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So what do we know?
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We know that this population, the most ill,
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takes up 15 percent of the gross domestic product --
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nearly 2.3 trillion dollars.
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So the sickest 15 percent take up 15 percent of the GDP.
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If we extrapolate this out over the next two decades
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with the growth of baby boomers,
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at this rate it is 60 percent of the GDP.
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Sixty percent of the gross domestic product
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of the United States of America --
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it has very little to do with health care at that point.
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It has to do with a gallon of milk,
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with college tuition.
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It has to do with every thing that we value
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and every thing that we know presently.
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It has at stake the free-market economy and capitalism
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of the United States of America.
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Let's forget all the statistics for a minute, forget the numbers.
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Let's talk about the value we get for all these dollars we spend.
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Well, the Dartmouth Atlas, about six years ago,
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looked at every dollar spent by Medicare --
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generally this population.
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We found that those patients who have the highest per capita expenditures
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had the highest suffering, pain, depression.
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And, more often than not, they die sooner.
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How can this be?
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We live in the United States,
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it has the greatest health care system on the planet.
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We spend 10 times more on these patients
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than the second-leading country in the world.
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That doesn't make sense.
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But what we know is,
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out of the top 50 countries on the planet
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with organized health care systems,
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we rank 37th.
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Former Eastern Bloc countries and sub-Saharan African countries
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rank higher than us as far as quality and value.
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Something I experience every day in my practice,
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and I'm sure, something many of you on your own journeys have experienced:
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more is not more.
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Those individuals who had more tests,
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more bells, more whistles,
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more chemotherapy, more surgery, more whatever --
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the more that we do to someone,
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it decreases the quality of their life.
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And it shortens it, most often.
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So what are we going to do about this?
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What are we doing about this?
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And why is this so?
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The grim reality, ladies and gentlemen,
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is that we, the health care industry -- long white-coat physicians --
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are stealing from you.
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Stealing from you the opportunity
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to choose how you want to live your lives
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in the context of whatever disease it is.
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We focus on disease and pathology and surgery
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and pharmacology.
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We miss the human being.
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How can we treat this
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without understanding this?
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We do things to this;
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we need to do things for this.
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The triple aim of healthcare:
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one, improve patient experience.
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Two, improve the population health.
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Three, decrease per capita expenditure across a continuum.
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Our group, palliative care,
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in 2012, working with the sickest of the sick --
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cancer,
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heart disease, lung disease,
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renal disease,
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dementia --
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how did we improve patient experience?
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"I want to be at home, Doc."
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"OK, we'll bring the care to you."
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Quality of life, enhanced.
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Think about the human being.
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Two: population health.
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How did we look at this population differently,
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and engage with them at a different level, a deeper level,
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and connect to a broader sense of the human condition than my own?
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How do we manage this group,
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so that of our outpatient population,
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94 percent, in 2012, never had to go to the hospital?
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Not because they couldn't.
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But they didn't have to.
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We brought the care to them.
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We maintained their value, their quality.
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Number three: per capita expenditures.
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For this population,
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that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP,
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we reduced health care expenditures by nearly 70 percent.
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They got more of what they wanted based on their values,
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lived better and are living longer,
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for two-thirds less money.
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While Harold's time was limited,
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palliative care's is not.
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Palliative care is a paradigm from diagnosis through the end of life.
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The hours,
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weeks, months, years,
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across a continuum --
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with treatment, without treatment.
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Meet Christine.
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Stage III cervical cancer,
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so, metastatic cancer that started in her cervix,
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spread throughout her body.
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She's in her 50s and she is living.
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This is not about end of life,
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this is about life.
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This is not just about the elderly,
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this is about people.
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This is Richard.
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End-stage lung disease.
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"Richard, what is it that you hold sacred?"
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"My kids, my wife and my Harley."
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(Laughter)
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"Alright!
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I can't drive you around on it because I can barely pedal a bicycle,
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but let's see what we can do."
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Richard came to me,
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and he was in rough shape.
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He had this little voice telling him
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that maybe his time was weeks to months.
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And then we just talked.
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And I listened and tried to hear --
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big difference.
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Use these in proportion to this.
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I said, "Alright, let's take it one day at a time,"
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like we do in every other chapter of our life.
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And we have met Richard where Richard's at day-to-day.
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And it's a phone call or two a week,
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but he's thriving in the context of end-stage lung disease.
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Now, palliative medicine is not just for the elderly,
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it is not just for the middle-aged.
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It is for everyone.
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Meet my friend Jonathan.
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We have the honor and pleasure
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of Jonathan and his father joining us here today.
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Jonathan is in his 20s, and I met him several years ago.
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He was dealing with metastatic testicular cancer,
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spread to his brain.
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He had a stroke,
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he had brain surgery,
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radiation, chemotherapy.
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Upon meeting him and his family,
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he was a couple of weeks away from a bone marrow transplant,
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and in listening and engaging,
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they said, "Help us understand -- what is cancer?"
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How did we get this far
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without understanding what we're dealing with?
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How did we get this far without empowering somebody
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to know what it is they're dealing with,
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and then taking the next step and engaging in who they are as human beings
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to know if that is what we should do?
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Lord knows we can do any kind of thing to you.
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But should we?
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And don't take my word for it.
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All the evidence that is related to palliative care these days
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demonstrates with absolute certainty people live better and live longer.
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There was a seminal article out of the New England Journal of Medicine
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in 2010.
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A study done at Harvard by friends of mine, colleagues.
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End-stage lung cancer:
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one group with palliative care,
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a similar group without.
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The group with palliative care reported less pain,
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less depression.
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They needed fewer hospitalizations.
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And, ladies and gentlemen,
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they lived three to six months longer.
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If palliative care were a cancer drug,
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every cancer doctor on the planet would write a prescription for it.
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Why don't they?
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Again, because we goofy, long white-coat physicians
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are trained and of the mantra of dealing with this,
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not with this.
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This is a space that we will all come to at some point.
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But this conversation today is not about dying,
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it is about living.
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Living based on our values,
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what we find sacred
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and how we want to write the chapters of our lives,
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whether it's the last
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or the last five.
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What we know,
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what we have proven,
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is that this conversation needs to happen today --
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not next week, not next year.
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What is at stake is our lives today
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and the lives of us as we get older
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and the lives of our children and our grandchildren.
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Not just in that hospital room
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or on the couch at home,
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but everywhere we go and everything we see.
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Palliative medicine is the answer to engage with human beings,
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to change the journey that we will all face,
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and change it for the better.
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To my colleagues,
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to my patients,
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to my government,
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to all human beings,
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I ask that we stand and we shout and we demand
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the best care possible,
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so that we can live better today
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and ensure a better life tomorrow.
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We need to shift today
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so that we can live tomorrow.
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Thank you very much.
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(Applause)
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