What we can do to die well

I am a palliative care physician

and I would like to talk to you
today about health care.

I'd like to talk to you
about the health and care

of the most vulnerable
population in our country --

those people dealing with the most
complex, serious health issues.

I'd like to talk to you
about economics as well.

And the intersection of these two
should scare the hell out of you --

it scares the hell out of me.

I'd also like to talk to you
about palliative medicine.

A paradigm of care for this population
grounded in what they value.

Patient-centric care based on their values

that helps this population live
better and longer.

It's a care model that tells the truth

and engages one-on-one,

and meets people where they're at.

I'd like to start by telling a story
about my very first patient.

It was my first day as a physician,

with a long white coat,

and I stumbled into the hospital

and right away there's a gentleman --

Harold.

68 years old,

came to the emergency department.

He had had headaches for about six weeks,

it got worse and worse
and worse and worse and worse.

Evaluation revealed that he had cancer
that had spread through his brain.

The attending physician directed me

to go share with Harold
and his family the diagnosis,

the prognosis,

and options of care.

Five hours into my new career,

I did the only thing I knew how.

I walked in,

sat down,

took Harold's hand,

took his wife's hand ...

and just breathed.

He said, "It's not good
news is it, sonny?"

I said "no."

And so we talked and we
we listened and we shared,

and after a while I said,

"Harold, what is it
that has meaning to you?

What is it that you hold sacred?"

And he said,

"My family."

I said, "What do you want to do?"

He slapped on the knee and said,

"I want to go fishing."

I said, "That I know how to do."

Harold went fishing the next day.

He died a week later.

As I've gone through my
training in my career,

I'd think back to Harold.

And I'd think that this is a conversation
that happens far too infrequently.

And it's a conversation
that had lead us to crisis.

The biggest threat to the American
way of life today,

which is health care expenditures.

So what do we know?

We know that this population --

the most ill --

takes up 15 percent of the gross
domestic [product],

nearly 2.3 trillion dollars.

So the sickest 15 percent
take up 15 percent of the GDP.

If we extrapolate this out
over the next two decades,

with the growth of baby boomers,

at this rate it is 60 percent of the GDP.

I [offer] 60 percent
of the gross domestic product

of the United States of America --

it has very little to do
with health care at that point.

It has to do with a gallon of milk,

with college tuition.

It has to do with everything that we value
and everything that we know presently.

It has at stake the free-market economy

and capitalism of the United
States of America.

But forget all
the statistics for a minute.

Let's forget the numbers.

Let's talk about the value we get
for all these dollars we spend.

Well, the Darmouth Analyst,

about six years ago,

looked at every dollar spent
by Medicare

[in this] population.

We found that those patients who have
the highest per capita expenditures

have the highest suffering, pain,
depression and ...

more often than not,

they die sooner.

How can this be?

We live in the United States of America,

it has the greatest health care
system on the planet.

We spend 10 times more on these patients

than the second-leading
country in the world.

That doesn't make sense.

But what we know

is out of the top 50
countries on the planet,

with organized health care systems,

we rank 37th.

Former Easter Block countries

and sub-saharan African countries
rank higher than us

as far as quality and value.

Something I experience
every day in my practice,

and I'm sure it's something many of you
on your own journeys have experienced,

more is not more.

Those individuals who had more tests,

more bells,

more whistles,

more chemotherapy,

more surgery,

more whatever --

the more that we do to someone,

it decreases the quality of their life.

And it shortens it most often.

So what are we going to do about this?

What are we doing about this?

And why is it so?

The grim reality ladies and gentlemen

is that we the health care industry --

long white coat physicians --

are stealing from you.

Stealing from you the opportunity

to choose how you want to live your lives
in the context of whatever disease it is.

We focus on disease
and pathology and surgery,

and pharmacology ...

we miss the human being.

How can we treat this

without understanding this?

We do things to this ...

we need to do things for this.

The triple aim of healthcare.

One: improve patient experience.

Two: improve the population health.

Three: Decrease per capita expenditure
across a continuum.

Our group Palliative Care,

in 2012,

working with the sickest of the sick.

Answer: heart disease,

lung disease,

renal disease,

dementia.

How did we improve patient experience?

"I want to be at home, Doc."

"OK, we'll bring the care to you."

Quality of life enhanced.

Think about the human being.

Two: population health.

How did we look
at this population differently,

and engage with them at a different level,

a deeper level,

connect to a broader sense
of the human condition than my own?

How do we manage this group

so out of our outpatient population
94 percent in 2012

never had to go to the hospital.

Not because they couldn't ...

but they didn't have to.

We brought the care to them.

We maintained their value,

their quality.

Number three: per capita expenditures.

This population --

that today is 2.3 trillion dollars

and in 20 years
is 60 percent of the GDP --

we reduced health care expenditures
by nearly 70 percent.

They got more of what they wanted
based on their values,

lived better and are living longer,

for two-thirds less money.

While Harold's time was limited,

palliative care's is not.

Palliative care is a paradigm
from diagnosis through the end of life.

The hours,

weeks, month years,

across a continuum --

with treatment,

without treatment.

Meet Christine.

Stage three Cervical Cancer,

so metastatic cancer
that started in her cervix,

spread through out her body.

She's in her 50s and she is living.

This is not about end of life,

this is about life.

This is not just about the elderly,

this is about people.

This is Richard.

End-stage lung disease.

"Richard, what is it
that you hold sacred?"

"My kids, my wife and my Harley."

(Laughter)

"All right.

I can't drive you around on it
because I can barely pedal a bicycle,

but let's see what we can do."

Richard came to me
and he was in rough shape.

He had this little voice talking to him
that maybe his time was weeks to months.

And then we just talked.

And I listened and I tried to hear --

big difference.

Use these in proportion to this.

I said, "All right, let's take it
one day at a time,"

like we do in every chapter of our life.

And we have met Richard where
Richard's at day to day.

And it's a phone call or two a week,

but he's thriving in the context
of end-stage lung disease.

Now palliative medicine is not
just for the elderly,

it is not just for the middle-aged --

it is for everyone.

Meet my friend Jonathan.

We have the honor of Jonathan
and his father joining us here today.

Jonathan is in his 20s

and I met him several years ago.

He was dealing with metastatic
testicular cancer,

spread to his brain.

He had a stroke,

he had brain surgery,

radiation,

chemotherapy.

Upon meeting him and his family,

he was a couple of weeks away
from a bone marrow transplant

and in listening and engaging,

they said, "Help us understand,

what is cancer?"

How did we get this far

without understanding
what we're dealing with?

How did we get this far

without empowering somebody
to know what is is they're dealing with

and then taking the next step
and engaging them

to know who they are as human beings

to know if that is what we should do?

Lord knows we can do any
kind of thing to you,

but should we?

And don't take my word for it.

All the evidence that is related
to palliative care these days

demonstrates with absolute certainty

people live better and they live longer.

A seminal article out of the New England
Journal of Medicine in 2010 --

a study done at Harvard,

friends of mine --

colleagues --

end-stage lung cancer.

One group with palliative care,

a similar group without.

The group with palliative care
reported less pain,

less depression.

They needed fewer hospitalizations,

and ladies and gentlemen,

they lived three to six months longer.

If palliative care were a cancer drug,

every cancer doctor on the planet
would write a prescription for it.

Why don't they?

Again because we --

goofy long white coat physicians --

are trained and of the mantra
of dealing with this --

not with this.

This is a space that we
will all come to at some point.

But this conversation today
is not about dying,

it is about living.

Living based on our values,

what we find sacred

and how we want to write
the chapters of our lives,

whether it's the last or the last five.

What we know,

what we have proven,

is that this conversation
needs to happen today.

Not next week,

not next year.

What is at stake is our lives today

and the lives of us as we get older,

and the lives of our children
and our grandchildren.

Not just in that hospital room

or on the couch at home.

But everywhere we go
and everything we see.

Palliative medicine is the answer

to engage with human beings

to change the journey
that we will all face,

and change it for the better.

To my colleagues,

to my patients,

to my government,

to all human beings,

I ask that we stand and we
shout and we demand

the best care possible.

So that we can live better today

and ensure a better life tomorrow.

We need to shift today ...

so that we can live tomorrow.

Thank you very much.

(Applause)