 It's a great pleasure to get to talk to you a little bit about what I've been thinking and writing about over the last four years in researching the work for this book. And the premise of this was much more personal than what Jim's premises have been, which is to see a whole country. I was trying to see something very small, which was understanding our gridlock around the issues of aging and the end of life and the ways in which we've politicized it to the point that we literally could not talk about it over the last four or five years with the accusation that even just having doctors and patients sit down to have a conversation about their goals for end of life would be considered a death panel. It was to the point that politicians felt that they could not even remotely address the topic. But what I felt I saw was in my own medical training was that even as a doctor, I didn't have a good grasp of what the true issues were. I opened my book by saying that I learned a lot about a lot of things in medical school, but mortality was not one of them. When we are wanting to become physicians, we're interested in figuring out how you save lives. Health and prolonging life is our hope. When you enter the field, our professors taught us about the skills of understanding disease and how you fix disease. But how you deal with the unfixables, aging, chronic illness, terminal illness, the end of life, we actually didn't see that as a fundamental part of our job. But I spent five years investigating the topic for two reasons. Number one, I'm about at my mid-career as a surgeon. I'm at 12 years since I came out of my training. And to my surprise, I spend a large part of my time trying to deal with problems that are not fixable. You're most likely weak to have surgery in your life. Do you know what week that is? It is your last week of your life. And that is a week where you can understand it. You get all of the pain, all of the suffering, all of the cost of surgery, but none of the benefit. But of course, if I knew which was your last week of life, that would make the decision making a lot easier. So how do we become competent? And that was one motivator, was I did not understand what it would mean for me to be competent at dealing with people who face the possibility of the end of their life, but the great hope that this wasn't the end of their life. And after five years of investigating, researching, I'll try to tell you a little bit about what I took away. And one of the things is a different understanding of the problem. It's fundamentally a problem that is the consequences of good news. We've added 30 years to life expectancy in the 20th century. At the beginning of the 20th century, the average survival for an American or in any developed country was around 47 years. At the end of the 20th century, the average American lives 79 years. Most of that came from improvements in public health before the 1950s, 1960s, and improvements in the ways that we could manage childbirth and early childhood illness. The dramatic change since the 1960s is that most of the gains have occurred in late life. And so we have added more than five years to the average life expectancy of somebody who is age 65. We now live, on average, two decades longer after age 65, and that continues to go up. A dramatic consequence was that at the end of the 1940s, around 1950, most of us died in our home. That was because there wasn't really much value or point to going to a hospital and that we just hadn't discovered all that much that we could do. By 1990, 83% of us died in an institution, most commonly the hospital, second most common is the nursing home. The average American will typically spend over a year of their life in a nursing home now as part of the course of our lives. Part of the story has been the medicalization of this last phase because now there's so much that medicine can do. We have 13 organ systems, and we've discovered 60,000 ways that those organ systems can fail. There are many things that medicine can offer. There's almost always something we can do, but it doesn't necessarily cure and it doesn't necessarily always reduce the suffering people experience. But we've had a treatment focus, an idea that the experience of mortality is fundamentally about stopping and doing whatever we could to stop disease. But it can't be stopped. And the cost has been in dollars. Still 25% of our Medicare spending is in the last year of life, most concentrated in the last few months and in suffering. And that's what I wanted to try to understand. Between 1988 and 2010, the amount of pain we experienced at the end of life, the amount of depression, the difficulties with confusion have all increased without any evident benefit. And the amount of expenditures have gone up with it. My argument by the end of the book is that we've had a 50-year experiment with medicalizing mortality as treating it as just another condition of the human body to be fixed and that that approach has been failing us. But what to do? How do we understand it in ways that we might be able to see what we can do? And I think that the core of it has come down to this very personal experience I have, which is when I'm seeing somebody who has problems of either severe debility from aging, they're coming to see me, and I'm supposed to address the problem or a terminal illness, I've not felt competent in understanding the answer to their question. And their question is over and over again, should we do something? Should we do anything to try to fix this problem? Because what else have I got? Or should I just give up? Do we just give up and deal with it? And that struck me and has struck me again and again as not much of a choice and often the wrong choice. But I didn't know how to understand it as any different. It felt like it was just the wrong question. But then what is the right question? And in the course of the research, I found that a good answer to that came from a seemingly unrelated study. It's by a psychologist, a study that's been going on now for more than 20 years by a psychologist at Stanford named Laura Carstensen. And what she did was she started tracking people ages 18 to 94. She took a cohort of several hundred people and said, I'm going to track them across the course of their lives from wherever they are at their ages. And they would carry around a beeper. This was the days of the beepers. I think nowadays the only people have beepers are doctors and drug dealers. But we're catching up. But she would page them. And at that moment she would ask them a certain question and they would have to write it down in a notebook. And I think it's gotten more sophisticated now. She texts them and it's on a phone. But the bottom line, she's been following for 20 years and asking questions like, what are you feeling at this moment in time? What are your emotions? Are you angry? Are you sad? Are you anxious? Are you stressed? Or she might ask a question like, if you have half an hour right now and you could do anything you wanted, who would you rather spend that time with, your sister or the singer of your favorite song? Would you rather tonight? Would you rather have a nice quiet time at home? Or would you like to go out to a bar at 2 AM, plastered against the walls in a smoky, loud room, shouting at the top of your lungs, hoping to meet somebody new? And what she found was that there are different signatures. A young signature and an old signature. The younger signature is, yeah, you want to go to the bar and you're not interested in hanging out with your sister. But as we get older, we get less interested in, so younger people want to grow social networks and have desires focused on getting achievement, acquiring, and getting recognition. Getting and having is our kind of focus. As we get older, the older signature is that people would gravitate towards having smaller networks of people, narrower, but wanting deeper, more intimate relationships with those people. And they are less concerned with acquisition than simply being and making a difference for those people they're most connected to. Another interesting aspect of it that really struck me was that the emotions that people experience are different. For example, in older age, people can experience an emotion that people at a younger age didn't seem to display very much or even seem capable of called poignancy, the ability to experience negative and positive emotions at the same time. The other striking thing about the emotional change, though, is that people got happier. This is striking because people got unhealthier over the course of the study. They developed more disabilities, more physical frailties, more illnesses and losses of some of their functions, but they were also less likely to be depressed at age 75 than at age 40. They had less anxiety. They were calmer about the world. And that struck me as really fundamental. There are two things that are interesting about it. One is what the older signature describes is something that we would call wisdom. Every David Brooks would call it your eulogy character. No one says it's all about how you acquired it. We know those stories. And yet, why does it take so long? Why would it take so much time for people to develop those desires and those ways of focusing and those emotions along the way? And there are various theories. It takes experience. You have to learn it. You have to go through those processes. It's a kind of learned skill, almost. Another possibility is it's structural. It has to do with our brains. And in fact, there are functional MRI studies showing that people's structural construct in their brain changes. But there was evidence that Laura Carsonson found that ultimately demolished the idea of any of that. And it came from the fact that she was doing the study at Stanford in Northern California early in the era of the HIV epidemic when they were early treatments, but they were not always very successful. And so there was young people in the study who had terminal illness. And what was interesting was that they developed the older signature. They could be 25 years old, and they wanted to be closer to people that they were close to, that they developed those, they got calmer, less prone to anxiety and depression, ironically, despite being closer to the end of life. And there were a couple lessons that then really came out of she's continuing the study, and then 9-11 happens. And then the entire cohort shifted to the older signature. Suddenly people wanted to be with their families. Suddenly people were wanting to be more focused on connection to their community and to people around them than necessarily on being out in the just acquiring and having and climbing the way that they had. And then three months later, we all went back to our respective corners and back to just the way we were. But the lesson of it that they took away was that when life is fragile and uncertain, that is when you shift your emotions, your goals, your desires, and what you want to achieve. But the final lesson of it was that people who are in one phase of their life don't understand they're going to become like the people in the other phase of their life. We don't recognize the ways in which our emotional expectations will change. You just have to read Zeke Emanuel's article about what his opinion is about turning 75 in the Atlantic Monthly, where he says, look, I don't want any medical treatment when I'm age 75. I know now what I will want then, because he doesn't realize that he will change. His comments are, I won't have the abilities to accomplish what I can accomplish now without recognizing that what he cares about accomplishing now won't be what he cares about then. Maybe he will be just the same. But for most of us, it changes. Now, the result is that we therefore are in a different age that the trajectory of life has remarkably changed, not just because we get to live a longer life. And that has led to a different trajectory. It's that there is no longer a clear relationship, or there is a clear relationship now between your age and your risk of dying in a way that there was not a century ago. A century ago, you could be five years old. You could be 25 years old. You could be 45 years old. Life was fragile. And if you made it to 70, it was just that you were lucky. And you made it through all of the uncertainties of life. People were constantly aware that life was limited, that life had contingency. Now, you can reach 65 and still have 20 years ahead of you, which for all intents and purposes might as well mean we're immortal, because it does not register until you are the prospect of living a shorter life. It doesn't really get there until it's just maybe a few years ahead of you that you have. And so the result is we live today with an idea that the good life is one where you are independent, healthy, and doing well economically. That is our national view and our individual view of what the good life is and what we are trying to create. And it does not fit with a trajectory of life where you're going to spend a significant part of your life aging, experiencing frailty, experiencing sickness, experiencing debility. It simply does not fit. The medical focus has been on the idea that health and stopping disease is our priority, that that is what we are here for, your health and stopping disease. But the result is we are lost if it is not possible. And given that all of us will spend 10, 15, 20 years of our life in that phase of life, our national culture and our medical culture have not adapted to the reality that there is something different in that phase of life. And I think what we've lost sight of is something that people understood a long time ago, which is that well-being is more than just your health and your independence and your survival. And the lack of that insight, the lack of that understanding has led to deep suffering. You can see it in our hospitals, where you have people who are undergoing often painful, very debilitating treatments for the sake of time that is rapidly diminishing and sacrificing their time now for the sake of disappearing time later and miserable about it. You also see it in our old age homes. And to my surprise, I spent 2 thirds of the book writing about and touring old age homes. Because what they've become are hospitals. They're built around nursing stations. They look just like hospitals. And the priority they sell you on, safety is what we are going to ensure. That you, if your loved one is going to be in one of these places, that we will assure they're safe and healthy. But of course, that's not the only thing people live for. Well-being is bigger than that. And so you'll see people who are miserable because you're not allowed to have a drink in one of these places. I meet an 85-year-old Alzheimer's patient who's hoarding cookies because they've been written to have a medically ordered pureed diet that they cannot stand. Just let them have the damn cookies. But people are afraid, well, they might choke on the cookie. Well, that's true. But people, as one nursing home administrator said to me, the kids decide, and safety is what you want for those you love, but autonomy is what we want for ourselves. And we've not come to grips with recognizing that in that last phase of life, we have no imagination that a life worth living is possible. Let alone the idea that these might be some of our potentially most happy, successful people in life compared to today. In Laura Carson's study, people got happier. They were more less depression-comer in their lives, less anxiety, until they were institutionalized. And our institutions have become like prisons for people. In the course of doing the book, I interviewed more than 200 patients and family members about their experiences with aging and serious illness and terminal illness. I also interviewed scores of palliative care experts, frontline nursing home workers, geriatricians. And they had some key insights, because some of them were extraordinarily good in knowing what to do and what the question is that we need to be asking people. What they pointed out, what they recognize, is that we are failing to recognize that people have goals in their life besides just living longer. Those goals vary greatly. There's a 19th century book called The Philosophy of Loyalty that points out that people have intrinsic desires to live for something larger than themselves, that they would sacrifice their lives for. And what you would sacrifice your life for is your loyalty. It might be you are loyal to your children and your family. You'd sacrifice your life for them. Or it might be your country. Or it might be an ideal like justice. Or it might be God. But whatever it is, people have goals and priorities besides just living longer. The way we can learn what those goals and priorities are is a highly technical procedure. We ask them. But we don't ask. In medicine, we don't ask. Less than a third of the time, do we ask people what their goals and priorities are if their health worsens? When we do, however, that group of people end up with less suffering because they tend to stop their aggressive therapy sooner. They have less days in the hospital or in the nursing home. They're less likely to die in an institution. They're more likely to go on hospice towards the end of life. And the irony is they live longer. Lung cancer patients in a randomized trial lived 25% longer, one-third lower costs. And that just means we're making bad decisions as we come to the end. The most important ways that these folks who are good at it do it is by asking certain basic questions that allow you to tune the care appropriately. And those few questions are, what's your understanding of where you are with your health or your condition? Prognosis is very hard as a subject. But people will often tell you exactly what they're experiencing. What are your goals and priorities if time becomes short? What are your fears and worries for the future? What are you willing to sacrifice and what are you not willing to sacrifice? Based on those, we don't ask them in our nursing homes. We don't ask them in our medical world. We have treated it as if doing so might be a death panel. But I think that's changing remarkably. I think we are finally accepting that we can ask these questions and then demand that our answers are honored, our wishes are respected. It's partly a medical set of skills that we have to develop in our medical schools and in our among nurses and among people working in caregiving nursing homes. It's partly politics and policy, a politics of being able to understand that well-being is not just your health and your income and that well-being in life means serving people's goals beyond those. But I think it's fundamentally still just cultural, which is to demand that we have a life worth living, that we can recognize our objective is not just survival and income, but well-being. It's not just existing rather than not existing. It's having institutions and policies that allow us to express our own autonomy about who we are. So with that, I thank you. Thank you.