WEBVTT

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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)