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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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."

NOTE Paragraph

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(Laughter)

NOTE Paragraph

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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.

NOTE Paragraph

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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?

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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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.

NOTE Paragraph

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Thank you very much.

NOTE Paragraph

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(Applause)