 This is Think Tech Hawaii. Community Matters here. I'm Marcia Joyner, and we are navigating the journey. As you know, for those that have been with us all these weeks, navigating the journey is about taking charge of what we want and how we want and to exploring the options and choices of the end of life. And a couple of weeks ago, we talked to Dr. Samuel Harrington, and he wrote this wonderful book, At Peace, Choosing a Good Death After a Long Life. Needless to say, there's far too much information to spend one half hour with the doctors. So, he agreed to come back and let's explore some more. So, Dr. Harrington, there you are. Aloha. Aloha, Marcia. Thank you for having me. Oh, it's a real pleasure. The idea of choosing a good death after a long life. I love the idea of choosing a good death. So, tell us about Dr. Harrington. How did you come with this idea of At Peace? Well, I was a gastroenterologist trained in the super subspecialty of doing things to people at the end of life, including putting tubes into bile ducts and putting tubes into the esophagus when they're closed with cancer, putting tubes into the stomach for nourishing terminally ill patients or patients with very advanced disease. But although I was excited by those technologies early in my career, I was much less excited as time went on and I saw that there was a disconnect between how we were treating patients at the end of a long life and how we should be treating them or how we should be caring for them. And my parents aged, dwindled and died during my 35 years of medical practice. And I felt that they showed me a better way to deal with end of life issues than the technology that very advanced physicians are tempted to bring to bear when dealing with elderly patients. So, the book, I have to read this one quote, which I love. Okay, now don't tell me I lost it that quick. Okay, we'll come back to it once I find it. And so, now, the end of life and choosing, I'll find it, when we choose, we choose as opposed to allowing all of the crap that we go through with hospitals and all these tubes and all this stuff. So, in choosing a good death, what do you mean by choosing? Well, I mean that if we allow physicians to make all the decisions for us or if we allow our families to push us into doing more than we want, we will lose some control over our end of life decisions. And I mean, it's very important to recognize that 80 to 90 percent of elderly patients express a preference to die at home, but 60 to 70 percent of elderly patients die in hospitals or nursing homes, skilled nursing homes. And it is fundamental to understand that if one wants to die at home, it's important to say no to medical care, to make the choice to say no to aggressive medical treatments, to say no to hospitalization. So, the book is about helping people make that choice, understanding that that choice is in their best interest under many circumstances and understanding that aggressive medical care has the tendency to become self-perpetuating as a momentum to treat that turns into excessive medical care and a medicalized death. And by medicalized death, I mean a death that takes place in the intensive care unit of a hospital or after prolonged hospitals stay where more technology is brought to bear in dealing with a semi-conscious patient than is either appropriate or desired by that patient when they started the treatment process. Well, I want you to know that having read your book, I made a decision. I am 80. I am old enough to die. Therefore, I don't want any more CAT scans, MRIs, mammograms, all this other stuff. Because when they start looking for something, they'll usually find it, right? So, like I said, I have made that choice. No more DEXA scans. I don't know what a DEXA scan is anyway. I don't even know what they're looking for or why I need to have a DEXA scan. So, the more technology, the more advanced the technology, the more they try out on it. So, thank you. I have made that choice. Yeah. Well, I appreciate that. I think that that's the kind of discussion you want to have with your family and everybody should be on the same page in that regard. And in a sense, what you're doing is you're taking control of some of the decision-making. That is really one of the fundamental lessons of the book. I was very impressed as I researched the book by how many people have tried to define what characterizes a good death. And one of the articles that I was deeply impressed by was by a woman, Karen Kell, K-E-H-L, from the University of Wisconsin, who wrote an article called Moving George Pease and Analysis of the Concept of a Good Death. And although she had 13 attributes of a good death, I've sort of condensed some of them down to the top five attributes. And the single most important attribute of a good death is control. So when you start making decisions for yourself, you assert control on the process. The second most important attribute of a good death is comfort. That is, of course, to avoid a painful situation. The third most important attribute is closure. And closure sort of condenses some of attributes. The one where families can reconcile and come together, the patient can reconcile with family members and friends and make people understand that the death is appropriate in time and place. And then the fourth attribute of a good death is affirmation, that the patient themselves is validated, that the patient's values are appreciated. And finally, the final attribute in this short list of five is trust. The patient is passing away in this settings that are familiar, that the patient trusts with caregivers that they appreciate and trust. So I'll just repeat that the attributes of a good death are control, comfort, closure, affirmation and trust. But if we were to reverse those and look at the opposite meanings of each of those, sort of the obverse of each one of those attributes, control becomes hopelessness, comfort becomes pain, closure becomes isolation, affirmation is denial and trust becomes frustration. And those negative attributes, helplessness, pain, isolation, denial and frustration are basically a description of what it's like to die in the intensive care unit. And that's what I'm trying to help people avoid. I remembered early in the book and in our discussion how you talked about the violence with which the, trying to get that person to breathe again, what's that apparatus that they bang on your chest? That's called CPR, cardiopulmonary resuscitation. And you talked about the violence and that their last memories are of violence. That really broke my heart to think that's what we're doing to patients and that that is the standard care. Well, it is the standard of care to resuscitate patients unless they have delineated, asked that they not be resuscitated. And sometimes that request is overlooked. So it's very important for elderly patients to give consideration to that point. I had a discussion with my father. My mother pre-deceased my father when she was about eight and two. She was diagnosed with stage four lung cancer and it was clear that resuscitating her would not be wise or practical or appropriate. So he became a do not resuscitate early in the course of her terminal illness. But my father kept, retained her do not resuscitate bracelet and put it on himself. And he was about 36 or 87, even though he had no terminal illness. And that prompted me to discuss with him the wisdom of doing that because you really want to do more than just wear and do not resuscitate bracelet. You want to discuss with your physician that it means you want to be registered with your physician's office and have a formal status so that that's appropriate with whatever jurisdiction you live in so that emergency medical technician if called to the house for one reason or another will understand that it would be inappropriate to start resuscitation. But what I tried to describe to my father and with respect to what you were saying, every time CPR is done, it involves pressing chest, the sternum to squeeze the heart below it, and the result is almost universally cracked sternum and broken ribs. So that if a patient does in fact return to life, they then suffer weeks, days, weeks, hours of pain, breathing, they generally require mechanical ventilate. And I described to my father the results of one of the biggest studies of CPR and efficacy. And I pointed out to him that in this study of 400,000 people, when a person collapsed on the streets and CPR was started, 82% of those patients would get a rival when they got to the emergency room. 18% or 18 out of 100 patients survived to get to the hospital, of which 13 out of 100 people died before they were discharged. And of the five who were discharged, three were permanently damaged and two came back to normal. So the likelihood of my father surviving CPR would be on an order of 2% or less because we're having this discussion when he's 88. And he opted to discuss with his physician a permanent do not resuscitate status. And he got his own bracelet and became sort of officially enrolled. And I thought that was a wise decision. We need to take a break for one minute and we'll be right back. This is Stink Tech, Hawaii, raising public awareness. Welcome to Hawaii. This is Prince Dykes, your host. The Prince of Investing coming to you guys each and every Tuesday at 11 a.m. Right here on Think Tech, Hawaii. Don't forget to come by and check out some of the great information on stocks, investments, your money, all the other great stuff. And I'll be your host. See you. Aloha. And we are back. We are talking to Dr. Samuel Harrington about at peace choosing a good life. The book you can buy on Amazon or any of your favorite places to buy books because it's a road map or at least I'd like to think it's a road map to choosing how you want to leave this life, which is exactly what we've been talking about for the last couple of years on navigating the journey. This is a exquisite road map and no, I don't get any royalties on the book. So just buy the book. You know, I was telling you there was one line in here that I absolutely loved. I am not afraid to die. I just don't want to be there when it happens. Woody Allen. I just love that. That's Woody Allen's vision of passing away, which of course is sort of the equivalent of my father's description of hoping to wake up dead and to die in one's sleep. But it's that kind of vision that family members can use to help understand how to make decisions with and for our elderly parents or ourselves as we age. Well, like I said, your book is such a good, and I call it a road map for the lack of a better phrase, on exactly those things and there was one chapter here about how death arrives. And I thought, I'd never thought of that before. How does it arrive? Or do I need to tell you where we got that? You might have to point me to the chapter. How does the end finally arrive? It is chapter 6, page 92. That is correct. I try to outline in that chapter a variety of death scenarios using death certificates to show the sequence of events that lead up to a patient's death because we as physicians, when we sign a death certificate, have to describe three or four steps to indicate what led up to the patient's death because everybody dies when their heart stops or their lungs stop or their brain stops. So that doesn't really advise the coroner about the process. My father's death certificate, for example, I would have filled it out. If I had filled it out, it would have read that he died of dehydration because he stopped eating and drinking about four days before passing away and that for five weeks he was having trouble swallowing when it up to dehydration. The swallowing was the result of multiple small strokes and the strokes were the result of a blood clot in that one. Now it is caused by lymphoma that he had for eight years. So I outlined five steps. I misspoke because I would have outlined five steps if I were filling out my father's death certificate. In fact, because he was in hospice, the death certificate did not have to have that amount of detail for the coroner and so it was much more simplified. In that chapter I also outlined a couple of death certificates that relate to cancer, that relate to congestive heart failure, that relate to chronic lung disease. These are the typical chronic illnesses from which elderly patients die. Tell me then, as you're a normal, no craziness, no strange diseases, but just normal at the end of life when the body begins to shut down and it doesn't want food and yet we panic saying, oh, grandma's not eating, what can we do? How can we make, when we don't understand that this is a normal progression or regression, whichever the case may be, how do we deal with that? What's the process? Well, no, maybe we don't know that the body is shutting down. Well, this is where being in a hospice circumstance is so helpful because hospice nurses, of course, are trained in this process and trained to help family members work through it with them. So, for example, my father went into hospice about seven months before he passed away and he wanted to be admitted to hospice and I was encouraging it and there was a little bit of difficulty getting him in because he appeared to be vigorous and the first hospice said they couldn't find cars to go if he would die in six months. The second hospice that we interviewed was more open to that. So for the first five or six months he was in hospice, they were making visits on a weekly basis but there wasn't very much for them to do. But then as he began to deteriorate, their visits became more frequent and ultimately on a daily basis and they would sit down with my sister who was visiting and taking responsibility for this final visit and the hospice nurses would sit down with my sister and describe what they expected, what was happening, what to look for, that kind of thing. So the frightening things that happened during active, actively dying are explained by medical experts and my sister and others that have been cope with the process and deal with virtually every eventuality. Of course, everybody is going to die in their own way but generally there will be some commonalities and that's where the hospice professionals have so much to offer. Now, we're talking about this and I'm okay obviously talking about it but there are people that say when you begin to talk about all this paperwork that you need for the doctor in the hospitals and the people say can we talk about something pleasant? Do we have to talk about this? How do we say hey, this is not a difficult conversation that we need to have? Well, I don't have a very good answer to that in the sense that there's no magic way to get people to want to talk about it. You can tell them that talking about death isn't going to kill you if you want to take the kind of hard-wredged approach. I feel however that it's so irresponsible to not talk about it that it is the responsibility of every family member to bring it up at every opportunity until some understanding is reached because the alternative of not talking about how our loved one wants us to treat them is for us to over-treat them, hospitalize them and to medicalize their death because that is what our healthcare system is built to do and that is the expectation. That's why it costs so much. We have to help our family members make those decisions. At the beginning of the show we were talking about how do you know when it's appropriate to say no to aggressive medical treatment? That is what we really have to have the conversation about. How do we say no so that we can go home so that we can appropriately get into hospice? Before it's too late in that sense. One of the misconceptions about hospice is that it's reserved for the last few days of life. So that 40% of hospice patients are admitted to hospice with only 14 days of life and an immediate timeframe or length of stay in hospice is something like 20 to three or four days. That's just not enough to get all the benefits that hospice has to offer. One should be in there for three to six months to feel better. You have six months with hospice? We have six months that you can use for hospice. That is the standard. To be admitted to hospice the expectation is a patient will die within six months if the disease is allowed to advance naturally. But as I said, my father was in hospice for seven months. It's not a crime to be in hospice to not pass away within six months. So you can be reinstituted. And of course if people stop aggressive treatment going to hospice then we're covered dramatically which happens quite regularly and become much healthier then they can leave hospice and come back when they start declining. Well, you know, the one thing I want to say about, we will remind people that every day in intensive care is $10,000 a day average. Do you really want to leave your family with that bill? So, I hate to say this. I did tell my family, we live right on the water, I did tell my family just roll me over into the drink but one cousin said, no, no, no, no, no, don't do that. You're toxic and it'll kill the fish. So with that I don't get to drop me into the drink. That anyway, doctor, it is always a pleasure to talk to you and again the book is on Amazon and any place that you buy books I please do suggest that you get it. Again, I don't get any royalties but it is a great avenue, a pathway to making choices about the end of life. Doctor, thank you so much for spending this time with us. Thank you, Marcia, for the opportunity. Aloha. Aloha.