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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 a story
of my very first patient.
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It was my first day as a physician,
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with a long white coat,
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and I stumbled into the hospital
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and right away there's a gentleman,
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Harold.
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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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it got worse and 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
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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
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,
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he 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 --
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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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I [offer] 60 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 everything that we value
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and everything that we know presently.
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It has at stake the free-market economy
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and capitalism of the United
States of America.
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Let's forget all
the statistics for a minute.
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Let's 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 Darmouth Atlas,
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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 and ...
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more often than not,
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they die sooner.
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How can this be?
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We live in the United States of America,
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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
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is 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 Easter Bloc countries
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and sub-saharan African countries
rank higher than us
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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 it's 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,
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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 --
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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
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,
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working with the sickest of the sick.
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Cancer,
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heart disease,
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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,
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a deeper level,
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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 out of our outpatient population
94 percent in 2012
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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,
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their quality.
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Number three: per capita expenditures.
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This population --
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that today is 2.3 trillion dollars
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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,
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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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"All right.
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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 talking to him
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 I 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, "All right, 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
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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,
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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,
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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
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without empowering somebody
to know what is is they're dealing with,
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and then taking the next step
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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
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people live better and they live longer.
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A seminal article out of the New England
Journal of Medicine in 2010.
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A study done at Harvard,
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friends of mine --
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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 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,
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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:
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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)