 This is Stink Tech, Hawaii. Community matters here. I'm Marcia Joyner, navigating the journey. Navigating the journey is dedicated to exploring the options and choices for the end of life care. And to assist people to talk about their wishes. It's time to transform our culture so we shift from not talking about dying to talking about it. It is time to share the way we want to live at the end of our lives and to communicate about what kind of care we want and what we don't want. We believe that the place for this to begin is not in the intensive care unit. So together we explore the various paths to life-ending. Together we can make these difficult conversations easier. Together we can make sure that our own wishes and those of our loved ones are expressed and respected. So if you're ready, join us. We ask. Navigate the journey. And today we have someone that is absolutely very special who has written a book at peace, choosing a good death after a long life. Dr. Sam Harrington. And he is world-renowned, a physician, retired physician. And he has written this marvelous book, so we're going to talk to Dr. Harrington. And he is in May of all places, a whole world from us. So, good morning, Sam. Good morning, Marcia. Thank you for having me. Of course it's evening in Maine in the sun it's setting, but that's the beauty of the life on the mid-coast of Maine. Where exactly, when you say mid-coast of Maine, where is that? Well, it's about halfway between Portland and Eastport. And we're on the east side of Penobscot Bay on the name of Deer Isle. And we're on the south of the town of Stonington, which is the most important lobster fishing community in the United States, because it lands more lobster than any other community in the continental United States. So, you know, of course, being in Hawaii, which is half a world away, our question is what's the weather like? It's beautifully cool and changeable. But, Sonny, the weather, there's an old saying that if you don't like the weather in Maine, wait five minutes, or you can walk around your house, it'll be cool on one side and warm on the other, and never hot. Oh, never hot, but how cold? How cold is it? Well, it gets very cold in the winter. About 50 degrees right now, which is shorts and t-shirt weather for most people who are on here. Well, and we won't go into that one. I can't imagine 50 degrees. Yes. So, tell us about you, about Sam. I have read so many great, great reviews about your book. So, tell us about you. How did you get started in this going down this path of a good, choosing a good death? I started, I grew up in Milwaukee, Wisconsin, and I practiced medicine in Washington, D.C. for 30-plus years. And growing up in Milwaukee, I observed my mother, a pediatric nurse, care for many of her neighbors who were dying at home. Not many, probably two, or three, but it was a formative experience for me. I went into medicine, went into internal medicine and gastroenterology, became a gastroenterology, performing, putting tubes into people toward the end of their lives. And I realized over the course of my 35 years of training and practice that medicine had changed from the time I went into practice to the later in 2013. And it had gone, the arc of medicine had gone from what I would describe as a healing art in 1982 to a commercial enterprise in 2013 with an explosion of technology that we were committed to using. And on a smaller scale, I also witnessed my parents age, dwindle and die, and understood my parents did not want us to do things to them at the end of their lives. They wanted us to do things for them and to disconnect between what my parents wanted and what we were doing to patients in the hospital, in the intensive care unit. And I don't mean every patient. I mean elderly patients who had the expectation that they would get out of the hospital and be well, but that was a false expectation in many cases. So that disconnect between what we do to people and what we should do for them informed me and inspired me to write this book, which I started in about 2014 while my father was dwindling and then rapidly finished about in 20 months after he passed away quietly at home. So you say that your father objected to all this extra stuff and wanted to be at home and live much longer than had he had all that extra medical surgery and what have you. Well, there is that. That's a component of it, but it's a more difficult sort of sophisticated issue. He wanted to be, he wanted to die at home, like 80 to 90 percent of elderly patients would express that preference. And he instinctively understood that at home one has to say no to hospitalizations, to say no to aggressive medical care. And so the book is written to help other patients understand that choice, to understand when it is appropriate for them to say no to hospitalization. And it started with a conversation with my father about a medical condition that he had known as an abdominal aortic aneurysm. And that's a ballooned blood vessel in the abdomen which gets to a certain point and threatens to rupture. And when it ruptures, catastrophes happen and most patients will die. And an elderly man like my father at the time would be unlikely to survive emergency surgery. And he knew this because he was a lawyer but he had had, one of his clients had actually died of an aortic aneurysm and my father worked feverishly during the last few days of that man's life to get his estate in order. My dad was a tax and estates lawyer. So he knew that if he allowed this aneurysm to rupture he would die. And yet, so I felt it was my job and that of my sister to have a repair done to prolong his life. At age 88 he was very vigorous. He was in perfect picture, perfect health, at least on the outside. And we encouraged him to have a procedure which was like a giant cardiac catheterization which would cure or would temporarily strengthen the aneurysm and give him three to five years of life. Whereas surgery would be a permanent cure but is a major operation and risk multiple complications and a prolonged hospitalization, maybe convalescence in a nursing home, all of which he was not very interested in. So the good news is he did in fact accept our reasoning that he should have the temporary procedure. He lived three years and he met twelve great-grandchildren. But at the same time, after three years, he started to dwindle and he had two more years that he did not appreciate, during which he became dependent on others. He lost his independence and he lamented that and he wished that during those years, his mantra was, I had lived too long. And we respected the fact that during that second phase, the last two years of his life, he began to withdraw from medical treatments. When he was told that the aneurysm was re-expanding, he called his doctors and said that he would not have it repaired a second time and that he would accept his fate and he thanked them all for their care and ultimately a few months or a year after that, as he continued to dwindle, he went into hospice care and seven months after that, he passed away quietly at home. So whether one has aggressive treatment like that or not is obviously a personal choice and the results frequently are excellent. As in my father got three excellent years out of that procedure and he remained vigorous, but by putting off the inevitable, he also dwindled and became dependent on others which he did not appreciate. So there's a trade-off no matter what we do in medicine and particularly at the end of a long life. If we treat an acute illness, we are going to cause patients to suffer the consequences of chronic illness. In his case, just dwindling, which we call in medical business, geriatric failure to thrive. So that's, or otherwise, I would describe it as dying of old age, which is pretty much where he was. So I just want you to know that having read your book I changed everything. Your book is a great guide pathway to a good death. I hadn't thought about it before, even though we talk about navigating the journey for, well, we've been on the air for a long time. I had not really given it a personal thought, but I'm 80. And I had decided after reading the book that I am old enough to die. Therefore, I do not want any more dexascans, no more mammograms, no more CT scans, none of that stuff. I want to be calm. Well, I've never been calm, but to be at peace and to take every day as it comes, just enjoy every day. But I did decide I'm old enough to die, so I don't need all that stuff. I think that there's a lot of wisdom in that. I think everybody will come at it from a slightly different perspective and a different emphasis. But recognizing the limitations of medical care are very important. And after a certain age, dexascans and mammograms and colonoscopies, which would have been my expertise, certainly have much less to offer and certainly offer some potential for complications as well as potential for over-treatment. And over-treatment leads to complications. Well, that was where I was in your book, is the over-treatment. I hadn't thought about that before, but once I read it and I thought, oh, yeah, all of that over-treatment. And not only that, but it raises the bill, you know. I understand nationwide that it's for old people. The bill is $10,000 a day in the hospital. So if I'm in the hospital, all those $10,000, what does that do to your estate? What does it do to leave your children but bills? Okay. Well, those are very good points. Those are very good points that in the book I stick to the clinical aspect of things. But I will add on to what you just said, that Medicare pays about $550 billion a year or spends it on people over the age of 65. And $130 billion is spent during the last six months of life. And I'm not arguing that that's too much money or too little money. I'm simply pointing out that if one hundred of billions of dollars is spent in the last year of life, the last six months of life, then some of that must be useless or futile care because after all those patients died. And I think that's something we should think about as a marker of how much we do to patients at the end of a long life, when in fact we should be trying to help them be more comfortable and have a higher quality of life rather than committing them to these prolonged hospitalizations. And you also make the point that spending $10,000 a day would be a burden on the average family. And the concept that one does not want to burden their family is one of the characteristics of a better death to leave their family without more work and more burden. Can I go back to my father's discussion about an aortic aneurysm for a minute? Because I think that that helped me understand the conversation, even as a physician, we had had conversations about end of life decisions such as do not put me on a ventilator, do not start hemodialysis, do not give me some other aggressive form of treatment, do not do heart surgery on me. Because my father looked at the aneurysm and he turned to me and he said, why would I want to fix something that's going to carry me away the way that I want to go? And that was a vision that he shared with me that was much more meaningful than simply saying, don't put me on a ventilator, because it meant he wanted to go quickly and decisively. He did not want to linger. There's a lot to be said to be interpreted in what he said. And the vision of one's death, how we see it and how we communicate it to our families, the way to start a better, more in-depth conversation and have a better understanding of what we're really trying to say to one another. I think that and everybody's going to have a special vision of their own about how they want to die or what they foresee their illness would be one man in my book drank too much and smoked too much and he knew he was going to die of one of those illnesses. He was quite past and about his medical care until he had colon cancer and he decided that that didn't fit his vision. So he would fight that particular disease. He did. He was cured by surgery and after that surgery and the convalescence in a nursing home he went back home to his wife and on every subsequent visit to me, which was basically a brief checkup to ask if he had any new problems, he reaffirmed that he would never go back to the hospital and when he had dwindled enough to justify hospice care, we arranged that for him. So I'm trying to emphasize that a vision can really inform a patient and their family as to how to deal with end-of-life decisions or the decisions leading up to end-of-life care. I hate to interrupt you like this, but we're going to take a minute break and then when we come back, I want to talk about that, beginning the conversation and who do you talk to, how many people in the family is it a decision. Those are the kind of things I'd like to talk to Dr. Sam Harrington and we will be right back. This is Think Tech Hawaii, raising public awareness. I just walked by and I said, what's happening? Do you watch my show, Bird Zone? I sang this song to you because I think you either are cool or have the potential to be seriously cool and I want you to come watch my show where I bring in experts who talk all about easy strategies to be healthier, happier, build better relationships and make your life a success. So come sit with the cool kids at Out of the Comfort Zone on Tuesdays at 1. And we're back and we're talking to Dr. Sam Harrington, my new best friend and Dr. Harrington, I just let you know we only talk to my best friends. Okay. So in the book you talk about hope and the hard conversation. Do you remember that part of the book? You were talking? Yes. That part of the book deals with the idea that hope is used as an excuse to not have the hard conversation. We don't want people to give up hope. And I, in particular, one of my best friends an English journalist had been diagnosed with pancreatic cancer at age 62 and he lived three years. We were visiting toward the end of that third year without knowing how sick he was. But I overheard his wife in the other room talking with my wife about how they couldn't stop treatment because that would be equivalent to giving up hope. And in the same breath I'd heard him describe that he'd been hospitalized with a bleeding ulcer and the biopsies showed the ulcer was in fact cancer just to the wall of his stomach. And as a doctor I said to myself, well, this is the terminal condition. He is going to pass away in the next few months. But I didn't want to tell him that. I couldn't. He was not my patient. He was a friend. And I agreed with his wife to a certain degree that spontaneously saying, oh, this is the beginning of the end wouldn't help. But that is the kind of conversation that I would have with a patient in my office under more formal circumstances trying to help them understand that hope is important but hope with ineffective treatment is cruel and hope with futile treatment is wrong because that leads to basically treatment that is not going to be of benefit and therefore simply tortures too much or too strong a word just leads to more suffering. So we hope is something that we have to deal with and fit into the conversation in such a way that we don't delay the conversation because we are trying to promote false hope. False hope delays comfort care and false hope delays the reality of dealing with an illness and the reality of the hard conversation. Well, now, I'm skipping through the book simply because of time. You also talked about restarting the heart and how violent that is and that never occurred to me that that was... because that has bothered me since I read this. Certainly. Well, CPR is a technique that came into existence cardiopulmonary resuscitation, CPR, in the 1960s, 1970s and it involves pressing on the chest to circulate blood and blowing in the mouth to circulate air when a patient has collapsed and their heart has stopped. And CPR does have an important role in medicine but it is not nearly as effective as people believe partly because nobody knows... I mean, we don't tell patients the absolute truth about it and partly because CPR on television is surprising 75% of people who want to go survive and are perfectly normal a few minutes later which is absolutely not the case. CPR as performed breaks ribs, bruises the heart and usually doesn't work. So if my father, especially in elderly patients, so if my father had asked me what CPR would do for him, I would have told him that at age 85, the biggest study showed that 82% of patients who collapse outside of the hospital do not survive the trip to the hospital and are pronounced dead on arrival despite CPR being performed. And of the 18%, 13 of those patients will die before they're discharged. Of the 18% who survived to get to the hospital, 13% will die before they are discharged and of the five who survived to discharge, two of them will be relatively normal and three of them will have suffered significant neurologic damage among other things. So there's really about a... I would tell my father that he had a 2% chance of coming back to his apartment and when he was given that information he decided that he would do not resuscitate papers and avoid CPR. Now you mentioned... You mentioned in the book you said do you really want their last thoughts to be a violence? And that really struck me, their last vision, their last thoughts, the patient, to be this violence that is being perpetrated on them. Well, I think... I appreciate that comment. I think that... Well, no, you wrote it. I know. And I meant it because what we do to patients, futile care is very difficult to define but it is easily seen in retrospect. And if we look at the last treatment that our loved one received, be it CPR or two weeks in an intensive care unit or difficult chemotherapy, if we look at the last treatment that our loved one received and we say to ourselves, I wish we had not done that to my mother, I wish I had not done that to my father, but then we have described futile care and the point is to avoid it and foresee it and then subsequently avoid it. Well, you know, you must come back and visit with us some more because we're just getting started and it is a marvelous book and it's, for anyone that cares, it's a roadmap. Yeah, I'm calling it a roadmap to choosing a good death after a long life and my daughter is a hospice nurse and they try, or she does anyway, because she says it's an honor to be with these people at the end. They really give as much as they can so that your last memories are pleasant and they are not this violence. You are not in the hospital with lots of tubes and people you don't know. So will you promise me you will come back and visit some more and we'll talk some more about your book? Certainly. Thank you so much. It's been a real pleasure. I love you. Thank you, Marcia. I appreciate it. I love you.