0:00:11.797,0:00:14.637
This is a picture[br]of my grandfather and myself

0:00:15.168,0:00:17.998
in the mid-1950s walking around Sydney.

0:00:18.778,0:00:21.548
A few years later, in about 1959,

0:00:22.030,0:00:24.940
my grandfather died[br]very comfortably at home

0:00:25.146,0:00:27.856
under the care[br]of his general practitioner.

0:00:28.955,0:00:31.555
This is a talk about death and dying,

0:00:32.195,0:00:34.804
and it's too late to leave,[br]and the doors are locked.

0:00:34.804,0:00:36.471
(Laughter)

0:00:36.471,0:00:39.971
But it's about death and dying[br]only in the very elderly,

0:00:39.975,0:00:42.925
naturally and normally coming[br]to the end of their life.

0:00:44.330,0:00:46.390
So, why was it that my grandfather

0:00:46.394,0:00:48.724
was allowed to die at home[br]quite comfortably,

0:00:49.291,0:00:53.358
but my mother, 25 years later,[br]it was a very different story,

0:00:53.358,0:00:54.678
which I'll come to.

0:00:55.904,0:01:00.204
One of the reasons was that at that time[br]in the general practitioner's bag,

0:01:00.915,0:01:05.555
there wasn't much more or less[br]than what you found in hospitals.

0:01:05.840,0:01:07.560
This isn't all that long ago.

0:01:08.394,0:01:12.694
So hospitals were where you went[br]if you were sort of sick,

0:01:13.303,0:01:15.253
but if you were poor as well,

0:01:15.572,0:01:18.772
and you sat in your bed[br]being very carefully nursed,

0:01:18.872,0:01:22.482
and sometimes you got better,[br]and sometimes you didn't.

0:01:23.551,0:01:25.803
You can see this in films at the time,

0:01:25.988,0:01:30.271
where if anyone gets injured[br]in the street, someone shot or stabbed,

0:01:30.532,0:01:33.952
then there's a bystander[br]shouts, "Quickly call a doctor!"

0:01:34.941,0:01:37.721
A few years later, the bystander says,

0:01:37.721,0:01:40.031
"Quickly call an ambulance!"

0:01:40.352,0:01:43.182
So what was it in hospitals[br]that was changing?

0:01:43.444,0:01:48.094
It was about the early 1960s,[br]and there was an explosion of technology,

0:01:48.552,0:01:52.492
marvelous ways that we could image[br]every single part of the body,

0:01:52.961,0:01:54.211
complex surgery,

0:01:54.574,0:01:57.593
we divided the body into "-ologies" -

0:01:57.593,0:02:02.213
neurology, cardiology,[br]gastroenterology, etc. -

0:02:02.522,0:02:07.542
and the surgeons also divided the body up[br]into different parts that they worked on

0:02:07.610,0:02:09.820
and gave themselves different names.

0:02:10.925,0:02:13.695
And then, of course,[br]there was intensive care.

0:02:14.359,0:02:17.394
And 25 years after my grandfather died,

0:02:17.400,0:02:22.721
I became an intensive care specialist[br]in a large London teaching hospital.

0:02:23.028,0:02:26.277
And I thought I could keep[br]people alive forever.

0:02:26.277,0:02:28.827
These were the early days[br]of intensive care.

0:02:29.322,0:02:32.392
I thought it was infinite,[br]what we could be doing.

0:02:32.471,0:02:35.911
And in many ways, in some ways, it is.

0:02:37.611,0:02:41.357
If I had a relatively normal[br]brain and a liver,

0:02:41.357,0:02:43.387
I could keep everything else going.

0:02:43.882,0:02:46.706
At that time I had[br]six intensive care beds.

0:02:47.485,0:02:52.925
I now work in an intensive care unit[br]where there are 40 intensive care beds.

0:02:53.345,0:02:57.395
4000 Australian dollars[br]per patient per day.

0:02:58.045,0:03:01.675
But it's not only the number of beds[br]that have changed,

0:03:01.676,0:03:05.726
it's also the type of patients [br]that we're treating now in intensive care.

0:03:06.924,0:03:09.254
Many of them are over the age of 60,

0:03:10.052,0:03:12.889
many of them are in their 80s and 90s,

0:03:12.889,0:03:17.359
and many of those are[br]in the last few days or weeks of life.

0:03:18.390,0:03:20.150
So how did this happen?

0:03:20.321,0:03:22.471
Well, it's sort of like a conveyor belt.

0:03:22.873,0:03:25.773
With my grandfather,[br]he got sick in the community,

0:03:25.908,0:03:29.828
it was expected that he got treated[br]and managed at home.

0:03:31.130,0:03:33.991
If you get sick[br]in the community these days,[br]

0:03:34.581,0:03:36.951
we almost always call an ambulance.

0:03:36.951,0:03:41.781
It's very frightening[br]to have someone become very sick.

0:03:42.159,0:03:45.549
The ambulance takes you[br]to the nearest emergency department.

0:03:45.549,0:03:48.429
Emergency departments are highly stressed.

0:03:48.818,0:03:51.648
They resuscitate you, they package you,

0:03:51.992,0:03:55.652
and they get you ready [br]for admission to the hospital.

0:03:56.678,0:03:59.308
And then you become[br]even sicker in the hospital.

0:03:59.453,0:04:03.929
And here I am,[br]at the end of the conveyor belt,

0:04:03.929,0:04:06.829
in the intensive care unit,[br]waiting for you.

0:04:08.376,0:04:12.486
This is a picture of my mother[br]and my brothers and sisters.

0:04:13.399,0:04:16.819
It wasn't the same[br]as my grandfather, for my mother.

0:04:17.360,0:04:19.520
The last six months of her life,

0:04:19.726,0:04:23.056
she was admitted 22 times[br]to acute hospitals.

0:04:23.947,0:04:27.597
She wasn't told[br]what exactly was wrong with her.

0:04:27.957,0:04:29.965
People didn't tell her

0:04:29.971,0:04:33.714
that as you get older,[br]things start to deteriorate,

0:04:34.223,0:04:35.493
and you become sicker.

0:04:36.560,0:04:38.860
She wasn't given any choice about this.

0:04:39.070,0:04:43.120
It was simply she got sick,[br]and she got put on this conveyor belt,

0:04:43.368,0:04:44.888
admitted to hospital.

0:04:45.921,0:04:49.911
I had to be a son[br]in those situations, not a doctor,

0:04:50.282,0:04:53.782
so I didn't interfere[br]with any of those decisions

0:04:54.291,0:04:57.571
until finally a very special doctor[br]sat us all down and said,

0:04:57.756,0:05:00.566
"Your mother is old, and she's dying,

0:05:01.205,0:05:03.075
and we should let her go in peace."

0:05:03.387,0:05:05.757
That was such a relief for all of us,

0:05:06.136,0:05:08.326
and of course,[br]it was a relief for my mother.

0:05:08.326,0:05:11.285
And so, 48 hours,[br]approximately, after that,

0:05:11.285,0:05:14.245
my mother passed very comfortably away.

0:05:15.240,0:05:16.750
What did my mother die of?

0:05:17.452,0:05:21.782
Well, when I was an intern,[br]we were allowed to write down "old age,"

0:05:22.203,0:05:24.467
but we're not allowed to do that any more.

0:05:24.467,0:05:26.267
We have to make up a medical term.

0:05:26.363,0:05:27.745
So for example,

0:05:27.745,0:05:29.773
everyone that dies, their heart stops,

0:05:29.779,0:05:32.290
so we write down[br]"cardio vascular disease."

0:05:33.010,0:05:34.617
So cardio vascular disease

0:05:34.617,0:05:37.437
is the most common way of dying[br]in our community.

0:05:37.437,0:05:40.007
(Laughter)

0:05:40.737,0:05:44.577
What was really troubling for me was[br]that my mother kept asking me,

0:05:44.589,0:05:46.071
"What is wrong with me, Ken?

0:05:46.071,0:05:48.311
If only they'd find out[br]what was wrong with me,

0:05:48.924,0:05:50.794
then we could do something about it."

0:05:51.152,0:05:53.622
This is very difficult to explain

0:05:54.557,0:05:58.193
because when you get old, you get sick,

0:05:58.193,0:06:01.673
and it's very difficult to put your finger[br]on exactly what's happening.

0:06:01.820,0:06:05.940
And also, medicine[br]is based on the diagnosis.

0:06:06.669,0:06:08.655
That's what we learn about for six years:

0:06:08.655,0:06:10.375
the diagnosis.

0:06:10.899,0:06:12.239
A single diagnosis.

0:06:12.461,0:06:14.281
Hospitals are wonderful places

0:06:14.416,0:06:17.686
if you have a single problem[br]that can be fixed.

0:06:18.854,0:06:21.424
However, when you become old,

0:06:21.660,0:06:26.527
the combination of all the so-called[br]chronic diseases or co-morbidities -

0:06:26.527,0:06:28.957
whatever the medicalized word is -

0:06:28.957,0:06:30.667
add up to something

0:06:30.667,0:06:33.694
that as yet, we haven't got[br]a name or a number for.

0:06:35.023,0:06:36.713
I like this word: frailty.

0:06:37.176,0:06:39.906
Because it comes at it[br]from the patient's point of view.

0:06:40.265,0:06:42.555
It's not a series of medicalized terms,

0:06:42.765,0:06:43.935
it's frailty.

0:06:44.347,0:06:49.397
And I'm sure many of you in the audience[br]have experienced people that are older,

0:06:49.531,0:06:51.825
and you know what happens[br]as you get frail,

0:06:51.825,0:06:53.425
as you get more frail.

0:06:53.677,0:06:57.427
And I particularly like this frailty score[br]because it' got nice pictures.

0:06:57.547,0:06:59.021
So you start off at number one,

0:06:59.021,0:07:01.226
you are very fit[br]in your sixties, seventies,

0:07:01.446,0:07:04.256
and then you gradually[br]get more and more frail,

0:07:04.366,0:07:05.936
more and more vulnerable.

0:07:06.248,0:07:09.141
Until you find it[br]very difficult to get around,

0:07:09.141,0:07:11.646
until you become even more vulnerable.

0:07:11.646,0:07:13.522
Then you are confined to a wheelchair,

0:07:13.522,0:07:17.342
and finally, you haven't got[br]the strength to get out of bed.

0:07:19.239,0:07:21.899
Despite all the specialties[br]and all the drugs

0:07:21.899,0:07:24.479
and all the marvelous things[br]we can do in medicine,

0:07:24.817,0:07:28.397
age-related frailty is not curable.

0:07:30.069,0:07:32.234
So TED Talks are not only[br]about the problem,

0:07:32.234,0:07:33.834
they are also about the solution,

0:07:33.834,0:07:35.767
and what I'd like to talk to you about

0:07:35.767,0:07:39.447
is what we are trying to do about it[br]in my own hospital.

0:07:41.213,0:07:47.783
It's not really about high technology[br]or IT or anything like that.

0:07:47.794,0:07:49.544
It's not fancy stuff.

0:07:49.544,0:07:52.584
But I'm very fortunate[br]to work in an organization

0:07:53.186,0:07:56.216
that has a culture of looking at things[br]in a different way,

0:07:56.843,0:08:00.696
putting the patient in the center,[br]rubbing all the other things out,

0:08:00.696,0:08:03.316
and thinking, well,[br]how can we do this in a better way.

0:08:04.818,0:08:07.728
So, believe it or not,

0:08:07.745,0:08:10.684
doctors in hospitals[br]find it very, very difficult

0:08:10.684,0:08:12.944
to recognize people at the end of life.

0:08:13.598,0:08:16.048
I know that sounds very hard to believe.

0:08:16.709,0:08:20.196
So we are working on a tool[br]that gives us some idea

0:08:20.204,0:08:23.437
about people that have got months[br]or perhaps a year to live.

0:08:23.437,0:08:24.877
It's called the crystal tool.

0:08:24.880,0:08:28.720
It's very simple, can be used[br]by people at the bedside.

0:08:29.752,0:08:32.877
It's just a combination[br]of things that are logical,

0:08:32.877,0:08:35.967
like age and the frailty score[br]and things like that.

0:08:36.971,0:08:41.650
Now, with everything[br]that we do in medicine,[br]

0:08:41.650,0:08:42.890
there's uncertainty.

0:08:42.890,0:08:45.280
Uncertainty is inherent in medicine.

0:08:46.192,0:08:51.722
So take, for example, a 20-year-old person[br]with a terminal brain tumor -

0:08:51.724,0:08:54.604
we do all the tests,[br]and we find that it's terminal.

0:08:55.141,0:08:56.293
The first thing we do -

0:08:56.293,0:08:58.640
well, the first thing[br]the person wants to know is,

0:08:58.640,0:09:00.120
"How long I've got to live?"

0:09:00.405,0:09:05.069
So just using all the data we've got [br]of everyone with that particular tumor,

0:09:05.069,0:09:07.229
we can say, "Well, maybe a year.

0:09:08.066,0:09:09.326
It could be six months.

0:09:09.343,0:09:10.613
It could be two years.

0:09:10.897,0:09:14.642
Maybe, in exceptional circumstances,[br]it may be three years,

0:09:14.642,0:09:19.602
but the disease is terminal,[br]and we can't do much about it."

0:09:19.815,0:09:21.875
And it's the same thing with the elderly.

0:09:22.744,0:09:28.123
Some score like this will at least able us[br]to move to the next stage.

0:09:29.226,0:09:31.546
And the next stage[br]is not rocket science either.

0:09:31.820,0:09:33.300
But believe it or not,

0:09:33.351,0:09:38.441
doctors are very uncomfortable[br]talking to elderly people about dying.

0:09:38.946,0:09:40.736
I'm not too sure why that is.

0:09:41.217,0:09:46.797
So the next step after we recognize[br]these people is to begin a discussion

0:09:47.276,0:09:49.896
in an honest and empathetic way.

0:09:51.297,0:09:54.105
The next step after that is also logical,

0:09:54.105,0:09:56.636
but believe it or not,[br]this doesn't occur either.

0:09:56.636,0:10:00.586
It's to empower the patients[br]and their carers with choices.

0:10:01.175,0:10:04.385
So you'd be honest about[br]where we think they are in life,

0:10:04.757,0:10:08.827
how long they've got to live,[br]and how would they like to live that life.

0:10:09.067,0:10:11.773
Maybe they'd like to keep[br]coming in and out of hospital,

0:10:11.773,0:10:15.113
maybe they'd like the most[br]aggressive treatment available,

0:10:15.407,0:10:18.605
but at least, it would be[br]based on proper data

0:10:18.605,0:10:21.135
and a proper way to make a decision.

0:10:22.037,0:10:24.697
However, many people, we've found,

0:10:24.708,0:10:27.398
don't want to keep coming[br]in and out of hospital

0:10:27.675,0:10:30.365
once they know they haven't got[br]terribly long to live.

0:10:30.887,0:10:33.979
In fact, about 70% of people,

0:10:34.441,0:10:37.451
in this country, in America[br]and the United Kingdom,

0:10:37.757,0:10:40.637
when are asked, would rather die at home.

0:10:41.476,0:10:43.647
Now, this contrasts with,

0:10:44.247,0:10:49.734
about 70% of you will die[br]in acute institutions, in hospitals.

0:10:50.149,0:10:52.099
So there's a discrepancy here,

0:10:52.444,0:10:54.234
which sort of reinforces the fact

0:10:54.253,0:10:57.723
that we are not talking to people[br]about this in the proper fashion.

0:10:59.635,0:11:02.045
The long term solutions[br]are not in hospitals.

0:11:02.215,0:11:04.495
The long term solutions are things like

0:11:04.787,0:11:07.707
putting the family doctor[br]more in the center of care;

0:11:07.895,0:11:09.785
advance care directives,

0:11:10.023,0:11:13.183
you need to be thinking about this[br]while you're able to,

0:11:13.437,0:11:15.867
talking with your loved ones[br]and writing it down.

0:11:16.791,0:11:21.131
But then we also need[br]to move resources and support people,

0:11:21.131,0:11:23.376
if they are going to die in the home,

0:11:23.376,0:11:25.621
so that they are looked after,

0:11:26.113,0:11:28.336
so that they've got respite care.

0:11:29.669,0:11:33.629
I'd like to be controversial here[br]and say that I don't believe

0:11:34.041,0:11:38.795
the last few months or year of life[br]in a very elderly person

0:11:38.795,0:11:40.525
is a medical challenge.

0:11:41.255,0:11:44.385
Maybe if they've got pain,[br]or they are uncomfortable - sure.

0:11:44.413,0:11:48.263
But most of it is about community support:

0:11:48.428,0:11:50.108
facilitating the carers,

0:11:50.672,0:11:53.672
making sure their house is clean,[br]making sure they've got food,

0:11:53.684,0:11:55.310
making sure they're washed

0:11:55.795,0:11:57.657
and all of those sorts of things.

0:11:57.657,0:12:00.957
This is not so much a health[br]or medical problem.

0:12:02.774,0:12:05.575
So dying in the elderly has been hijacked.

0:12:07.082,0:12:10.157
Patients are divided[br]into individual organs,

0:12:10.157,0:12:14.207
and we try to fine-tune[br]and make these individual organs better.

0:12:15.379,0:12:18.607
A little bit like birthing was[br]in the 50s or 60s,

0:12:18.607,0:12:20.207
which was also hijacked.

0:12:20.215,0:12:22.046
Women in labor were taken to hospital,

0:12:22.046,0:12:25.147
strung up, legs apart, baby taken out,

0:12:25.147,0:12:27.397
baby put in with all the other babies,

0:12:27.696,0:12:29.936
fathers not allowed[br]to be with their wives,

0:12:29.947,0:12:32.127
fathers not even allowed to hold the baby.

0:12:32.128,0:12:36.245
This was the normal way[br]that we conducted birthing

0:12:36.249,0:12:37.677
in the 50s and 60s.

0:12:37.677,0:12:41.556
That's similar to what's happening[br]with the elderly at the moment.

0:12:42.898,0:12:44.998
So this is where many of you will die:

0:12:45.780,0:12:47.610
surrounded by high technology,

0:12:47.797,0:12:50.737
cared for by well-meaning people

0:12:51.108,0:12:55.648
with a lot of expertise[br]in their own particular area.

0:12:57.973,0:12:59.841
It's also

0:13:00.796,0:13:05.183
that we hear about medical miracles[br]almost on a daily basis,

0:13:05.183,0:13:06.823
and that's exciting.

0:13:07.369,0:13:11.439
But we hear about what health can do,[br]what modern medicine can do,

0:13:11.829,0:13:15.679
but we don't hear very much[br]about what modern medicine can't do.

0:13:15.686,0:13:18.756
We need to be far more honest[br]with our community

0:13:19.094,0:13:21.754
about the limitations of modern medicine.

0:13:23.185,0:13:28.236
There's rarely a day goes by[br]when I do my ward rounds with colleagues

0:13:28.240,0:13:33.647
that one of us doesn't say, "Please,[br]don't ever let this happen to me!"

0:13:34.643,0:13:38.225
So this is one of the most important[br]decisions in your life.

0:13:38.225,0:13:42.525
You need to take control[br]over your own end of life.

0:13:43.311,0:13:44.691
Thank you very much.

0:13:44.788,0:13:48.379
(Applause)