 Good evening. Welcome to Conversations About Ethics. I'm Ruth Bergen, Director of the Center for Medical Humanities and Ethics, and I am here to give you the housekeeping information before we introduce our speaker. But before I get into that, I want to mention that palliative care, our subject tonight, is gaining prominence as a growing number of Americans are living with one or more chronic illnesses. The focus is on enhancing the quality of life and relieving symptoms, pain and stress for the patients and their families. Really, palliative care is applied ethics. We're tremendously excited to welcome Dr. Diane Meyer, a pioneer and a recognized leader in the field. Her presentations today and tomorrow represent the 16th installment in the Conversations About Ethics series, which explores ethical dilemmas that influence healthcare delivery throughout the life cycle. Conversations About Ethics is presented twice annually by the Ecumenical Center and the Center for Medical Humanities and Ethics at the UT Health Science Center. And it is important to mention that this is through the generous support of our neighbors across the street, Methodist Healthcare Ministries. Would anyone representing Methodist Healthcare Ministries or Ecumenical Center please stand? I know there's at least one doctor from Methodist that I've worked with that's here. And there will be another workshop on this subject tomorrow over at the Ecumenical Center. So here are the housekeeping details. Dr. Diane Meyer and the planning committee have disclosed no relevant financial relationships with any commercial interests related to this activity. If you are seeking continuing education credit, please be sure to sign in at the appropriate desk as a record of your attendance. If you are seeking continuing medical education credit, you should have received two pieces of paper on the way in. Please fill out the smaller paper and return it to us before you leave. The larger paper is for you to keep. It has instructions on how to claim your credit on the CME website which you'll do two to four weeks from now and you'll receive an email from us when it is time to do so. Any of these details seem unclear, please see one of our volunteers at the education tables after the event. Now, for all of you here tonight, we really value your feedback. We ask you to thoughtfully evaluate this evening's program using either a paper survey or the QR code or link on the back of your program. Tonight's presentation is titled Transforming Health Care for an Aging Society and I would like to invite my colleague, Dr. Jason Morrow, an ethicist and palliative specialist to join me and introduce our speaker. The word palliative from palliative care comes from the Latin palliare, which is Latin for to cloak. It also comes from the word palliativis also from Latin, which means under cloak or covert and I experience both the blessing and burden of that cognate in my practice and that I get to help people cover their pain and suffering but in some ways I also travel covertly because palliative care has not always been even during my practicing career in the mainstream of the medical establishment. With our contentious political climate and polarized public discourse, we face a remarkable challenge in speaking the truth about the role of comfort and healing and caring for the aging and for the dying. Many of us did not see the death panels coming. While the storm and drong has somewhat abated, we should all recognize how fragile is respectful discourse, how precious are the virtues of courage and reason and humanity. What does a cloak offer? It offers shelter. It offers sanctuary. Shakespeare's 34th sonnet scolds someone who advised traveling without a cloak. This work may have been a reflection on youth and aging on purity and moral transgressions. It may also apply to the supplication of the sick to those who meekly seek the comfort of the healing. In this way we are reminded that when physicians speak honestly of what may come, they empower their patients and respectfully embrace them as fellow mortals. Why didst thou promise such a beautyous day and make me travel forth without my cloak? To let base clouds or take me in my way, hiding thy bravery in their rotten smoke. It is not enough that through the cloud thou break to dry the rain on my storm-beaten face, for no man well of such a salve can speak that heals the wound and cures not the disgrace. Let me introduce someone whose healing strives for grace and who would not dare advise us travel without a cloak. Diane Meyer is a physician and leader whose honesty, courage, and reason and humanity has transformed the care of the aging and of the dying in America and beyond. She is director of the Center to Advance Palliative Care, a national organization devoted to increasing the number and quality of palliative care programs in the United States. Under her leadership and advocacy, the number of programs in the United States has more than tripled in the last 10 years. She founded the Hertzberg Palliative Care Institute at the Icon School of Medicine at Mount Sinai in New York City in 1997 and was its director for 15 years. Dr. Meyer is the recipient of numerous prestigious awards, including the MacArthur Fellowship in 2008. She was named one of 20 people who make health care better in the United States by health leaders Media 2010 and received an honorary doctorate of science from Oberlin College in 2010. In 2012, she was awarded the American Cancer Society's Medal of Honor for Cancer Control in recognition of her pioneering leadership of the effort to bring non-hospice palliative care into the mainstream. Other honors include the Open Society Institute Faculty Scholars Award of the Project on Death in America and the American Academy of Hospice and Palliative Medicine Lifetime Achievement Award in 2009. Dr. Meyer has published more than 200 original peer review papers and several influential books. Dr. Meyer received her Bachelor of Arts from Oberlin College and her MD from Northwestern University Medical School. She completed her residency in Fellowship Training at Oregon Health Sciences University in Portland. She lives in New York City. In his classic article in 1982, The Suffering, Nature of Suffering and the Goals of Medicine, Dr. Eric Cassell wrote, The obligation of physicians is to relieve suffering stretches back to antiquity. Despite this fact, little attention has been given explicitly to the problem of suffering in medical education, research and practice. No person has more capably and passionately given their attention to the problem of suffering in all of these domains. Dr. Meyer has answered the call from some of the most powerful literary voices among us mortals, from Shakespeare to Cassell and to the millions of patients who need a cloak for their journeys. An exemplary educator, researcher and practitioner, it's my honor to welcome Dr. Diane Meyer. I have to calm down after that introduction. That is by far the most literate, poetic, kind introduction I've ever had and I've had a lot of introductions. Thank you so much, Jason. As we go through this lecture tonight, I'm mindful that it's an ethics lecture. Let me just hear some of the core ethical principles that should underlie the practice of medicine in this country. Anybody? What's one of the most important ethical principles? Do no harm. Beneficence and non-malificence. What else? Respect for patients. Respect for self-determination. Another one more really important one, justice. Justice that like people are treated similarly, that people are treated based on their needs, not who they are, whether they have health insurance or not, what color they are, what age they are or where they live. As we go through this talk tonight, I think you will hear each of these principles addressed. And I'll be, what is this squeaking? If it's a baby, that's great. It is a baby. Okay. Can you guys see these slides? There seems like there's maybe too much light up here. I don't know if it's possible to turn the lights down up here. But my objectives for today are basically through stories and data to make the case for integrating the principles and practices of palliative care into everybody's care of people with serious illness. Every nurse, every social worker, every doctor. And I'll show you some data lest you think I'm merely asserting things to prove that actually this does work. So I'm going to begin with this slide, which really the important thing to notice is what's in the red circle here, which is the enormous concentration of spending among a very, very small number of patients. 1% of American patients, the sickest, most complicated 1%, account for a quarter of all healthcare spending. The sickest 5% account for half of all healthcare spending. And the sickest 10%, 66%, two thirds of all healthcare spending. Now, if you, like me, read the paper, you might think that a lot of that spending is waste. That we are wasting money and resources on care of the very sick, which is a bizarre thing to say because who else are we supposed to be putting these resources towards? Right? The people who need the resources are the sick. Like, we're not wasting money taking care of the very sick. We're doing what we're here to do. That's why we have a health system to take care of the very sick. But the point here is that if you were a policymaker or you were running a healthcare system or you were running an insurance company and you were trying to figure out how there would be enough resources to make sure that access to medical care was always there for your community, that the next person in need would be able to get care because you were able to keep the doors open, you have to think about efficiently using your resources and not wasting them. Right? You need to spend them in a manner that preserves the comments. That means all of our access to care when we need it. Right? And you need to do it in a way that is not rationing care that people need, but is actually matching the care that we give to what people need, neither more nor less. And the reason I start with this slide is because these data on the concentration of risk and spending are often used to imply that we are wasting money on the care of the dying. And I want to say just the opposite. Of course we are spending the most money on the sickest people. Who should we be spending it on? It's not wrong to spend the money. It's how we're spending the money. That's a problem. We're spending the money in ways that do not meet the needs of our sickest and most complex patients. So the other reason I bring this up is how many people here are doctors or nurse practitioners or PAs? Okay, so have you guys heard of MACRA? Okay, so Medicare is is doing a pivot on how we're going to get paid. We were and we still are getting paid. The more we do things to people, the more money we make. Under MACRA that is being flipped on its head. The more money we spend, the less money we make. So there's good news and bad news there, right? The incentive to do unnecessary harmful things is going away. Unfortunately, perhaps the incentive to do good, valuable things is going away. So part of the what MACRA does is also measure the quality of what we do so that we don't stint, we don't ration, we don't undertreat. But if again if you were running an insurance company or a Medicare or a health system, where would you focus your efforts? On the healthy 50%? No. You would focus your efforts on the sickest and most complex. Not only because that's where all your spending is, but that's also where the vulnerability to poor quality is. So all of health policy is finding itself willy nilly focused on the palliative care patient population. People with serious and complex illness, because that's the population with the need and the incredibly high spending. So I actually was an ivory tower academic most of my life, as Sandra knows. And in 2009, I took my first sabbatical, like almost 30 years into my academic career. And I went to Washington to do a health policy fellowship, because I realized if I was to have any success in diffusing the palliative care innovation, I needed to understand policy. And as an ivory tower academic, I knew absolutely nothing about policy. Bizarre but true. So I went to Washington for a whole year, learned a lot. But one of the things I heard very soon after I got there was this thing called the value equation, which sounded very jargony. And it sounded really complicated and, you know, algebra, trigonometry, something, but it actually is very simple. Quality in the numerator and cost in the denominator. Everything about Obamacare, everything about rational health policy is about improving value. So could somebody give me an example of a very, very high value intervention that is something that say saves millions of lives at very, very low cost. Vaccination is the classic. Actually, the best example is separating drinking water from sewage. That led to a 30 year gain in life expectancy. In one century. I'm not kidding. Way better than vaccines did. Much more impact on life expectancy than antibiotics, and way more impact on life expectancy than anything we do in our fancy hospitals. These basic public health measures are very, very high value. So let's flip it. Can anybody give me an example of an intervention, a common intervention that not only fails to benefit people, may actually hurt them, may shorten their life, may cause a lot of suffering at enormous cost per person. Don't all talk at once. Some chemotherapy, some chemotherapy really helps people. But chemotherapy, when somebody has failed third line, that's burden with no benefit and probably leads to a sooner death. My favorite example is at Mount Sinai, our ICUs are filled with end-stage dementia patients on ventilators. The ventilator's not going to restore the person to health. It's causing tremendous physical suffering in someone who has no clue why people are sticking needles in them, sticking things down their throat, restraining them. It's terrifying. If you were from Mars, you would think it was torture. Yet this is routine in our health care system. So low value care characterizes a lot of what we do in the modern health care system. That is care that does not do much good and may do harm at enormous cost. And so the big conclusion that I'll begin with, that you'll hear repeated, is that because of that concentration of risk and spending in a very small fraction of the US population and the data I will show you on the impact of palliative care in that very population to improve quality and by improving quality reduce cost, you will not get to improve value without full integration of palliative care principles. So this is not talking about the specialty of palliative care. This is talking about palliative care everywhere, palliative care in the nursing home, palliative care in the cancer center, palliative care in the cardiology heart failure practice, palliative care and primary care in surgery in Peds. So I'm going to begin with a story of a real patient. This is a patient I met now. It's about three years ago. Mr. B, I have permission to tell their story and to use this photo. This photo was actually taken at their 60th wedding anniversary about six months after I met them. And you can see that Mrs. B makes all her own clothing and always makes Mr. B a matching tie. She is a force. But when I met him six months before that, what happened was I was carrying the beeper for the palliative care service. Me and my medical student were, as usual, I was behind making rounds. And it was about 6.30 at night and I was carrying the beeper. I got a page from an attending in the ED who, as it turned out, had been a medical student of mine how many years before? Many years before because now he was an attending. Too many years to count. And he had rotated with me on palliative care many years earlier. And he said, Dr. Meyer, I'm sorry to call you so late. And I'm not sure that this patient is appropriate for palliative care because he's not dying. I taught him nothing. But this couple is abusing the emergency room for low back pain. That's a quote. And that's why I remember it. That this guy who used to be my med student thought it was okay to say to me that a patient was abusing the emergency room just for starters made me remember it. Anyway, so we got down there, me and my student, we met, Mr. B was on a stretcher, curled up in a ball, knitted brow, not talking to anybody, furious at his wife for bringing him to the emergency room. She was in tears. And the story was he had come, he had, they had had dinner at 5.30 or so after dinner he had gone into the bathroom and sat down on the toilet. And when he tried to stand up, his back went out, back went into spasm. I didn't know what that was like until a few years ago when I turned around to get the shampoo in the shower. And my back went out. Like I couldn't move. That's how painful that is. So it happens to a lot of people, happened to him more often. He has spinal stenosis. He has stage four prostate cancer, but he's had that for like 12 years and it's been quiescent. His main problem is actually arthritis of the spine. And his wife tried to get him up. She tried to pull him up and she couldn't pull him up and he was screaming at her, leave me alone, leave me alone. She went down the hall to see if any of the neighbors were home. Everyone lives in apartments in New York City. So none of her neighbors were home because it was only 5.30. And she called her doctor's office. And what did she get when she called the doctor's office? What did it say? If this is a medical emergency, and I suggest each of you call your own doctor after five o'clock and see what you get. You will all get this. If this is a medical emergency, hang up now and call 911. As she said, it was an emergency to me. So he described his pain as an 8 out of a possible 10 and what had he been taking for it. So much extra strength Tylenol that it was a miracle that he had not necrosed his liver. Because he figured if some was good, more was better. As most of the public do not know that Tylenol is a very dangerous drug. In doses only slightly higher than what it says you're supposed to take on the back of the bottle. But he fortunately his liver was still functioning. But as it turns out this was his fourth ED visit in two months. Fourth in two months. Because of course whenever he got in pain it was after five o'clock right or the middle of the night or the weekend. Two of those admissions were similarly for pain. One of those with a fall and then he had an agitated delirium that turned out to be due to a fecal impaction. Here's what he said get me out of here. He was furious at her for calling 911. He had had enough of our tender ministrations. I'm a three prior visits and here's what she said. He hates being here but what could I do? The pain was terrible and I couldn't reach the doctor. I couldn't move him myself. So I called the ambulance. It was the only thing I could do. So let me ask you who is abusing the emergency room? Is it the patient? This system is perfectly designed to get this result right? Every single one of our doctors has the same tape. The system is designed for people to go to the emergency room. So we're blaming patients for this. What's wrong with us? Okay so let me tell you what happened to him before me and my medical student got down there. 4911 calls for ED visits. The three prior led to a hospitalization. He was hospitalized three times over what was basically an eight-week period because the ED docs did not know what to do about this severity of pain in an 88-year-old demented patient. His creatinine was 2.2 so they couldn't give him NSAIDs. Right? Tylenol wasn't working and no one would ever give opioids to an 88-year-old with dementia, right? So they sent him up stairs each time. What happened upstairs at least on one of those occasions unfortunately someone put a fully catheter in him in the ED because they were busy and they didn't have time to take him to the bathroom. So they put a fully catheter in and then people forgot about it and did not remove it and he got a urinary tract infection and he got septic. We nearly, he became doubly incontinent, delirious and actually had a major backsliding in terms of function and quality of life because of being in the hospital. And his wife was a basket case you know with him all day until they threw her out every night at 10 o' clock in the hospital. So what happened when me and my medical student got down there? As perhaps you can all already tell I'm something of a rebel. So even though I knew it was absolutely forbidden to give opioids to an 88-year-old dementia patient with low back pain that's exactly what I did. Look through the chart, talk to his wife, got the story and decided to try it, a trial. So we use this concentrated liquid morphine that comes in a 5 milligram per ml dose so you can pull up a very small volume in a syringe and gave him half of an ml, 2.5 milligrams, which would not have been enough to touch anybody in this audience but I thought 88 cognitively impaired opioid naive, let me start really low. So we gave the 2.5 and I just stayed there. What was I worried about? I was worried maybe he would stop breathing, I was worried maybe he would get really agitated and more confused so I just didn't leave, I just stayed there. After 40 minutes there was absolutely no change, no benefit at all, he was just as miserable, he was refusing to speak to anyone so I gave him a second dose of 2.5 and I stood there and in 20 minutes he was a different person. Far from being more out of it or having trouble breathing he was sitting up, he was flirting with the nurses, he was holding his wife's hand, he asked to be escorted to the bathroom, so what did I prove to myself? It worked, right, and he could tolerate it. In fact exactly the opposite of what everyone was worried about is what happened. The pain was what was causing him to be so withdrawn and confused. When the pain was managed he returned to himself but I was nervous because I'm a creature of my culture about sending an 88 year old and his 83 year old wife home with morphine. So we're very fortunate at Mount Sinai to have a house calls practice called the visiting doctors practice which is actually not visiting doctors, it's visiting doctors and there's practitioners and medical students and social workers and pretty much everybody visits but it's for people like Mr. B who are functionally homebound and I had the beeper number of the director of visiting docs and I paged her and I said Linda I'm about to send an 88 year old dementia patient home on morphine, can you see him tomorrow morning? So I have enough influence now that she said yes but actually they always put palliative care patients, people with pain or other distress at the top of their waiting list which is a very long waiting list unfortunately. So made the house calls referral, figured out how to manage his pain, the house calls practice has real 24-7 phone coverage so when you call that number you do not get a tape and what does it mean that you don't get a tape it means they spend a lot of money on 24-7 coverage and they measure themselves by speed of response and they are committed to returning a call within ten minutes of receiving it. Why? Because if you're in excruciating pain or you can't breathe and you call and no one calls you back you call 9-1-1. People don't call in the middle of the night or after hours if it's not an emergency. So if you don't get back to them quickly they're going to go to the ER. So that's what this practice does. We I sent this thank God for the student I sent the student across the street to the pharmacy to get the prescription filled for the concentrated liquid morphine and another prescription for something called MiraLax which is polyethylene glycol powder and it's by far the most effective laxative we have. You mix it with water and me and the students sat with Mrs. B in the nurse's lunchroom because it was the only place to sit and had her practice over and over pulling up the right dose of morphine into the one cc syringe. We marked it with a black magic marker and we made her practice until not only we but she were confident that she could do it accurately because she was terrified that she would hurt him give too much and then we had her mix up the laxative one scoop and eight ounces of water every day whether he needs it or not and we practiced that three or four times and then we did something called talkback teachback where after we wrote down and told her how often to give this medicine what to do if it didn't work we had her tell us back until again we were all confident that she understood it and then we sent them home in a taxi around nine o'clock so this was three and a half hours of my time well worth it I might add because otherwise he would have been sent upstairs. Turned out when the visiting docs got there the next morning there were loose throw rugs all over the apartment loose electrical wires everywhere no grab bars in the bathroom no elevated toilet seat in the bathroom they did a refrigerator biopsy which is what the house calls practices do and the only food in the fridge was left over Chinese food. Why? Turned out that Mr. Mrs. B could not go out grocery shopping because Mr. B would freak out if she left get very agitated and he couldn't go with her and so she just ordered in Chinese the worst possible thing for both of them obviously and when their daughter who of course lives in California would call they'd say everything was fine because they didn't want to worry her and their primary doc who is a colleague of mine a friend of mine and a cardiologist had never made a home visit and had actually hadn't seen them in many months because Mr. B couldn't get into the office. So basically all his medical care was through 911 because he couldn't get there and we have a health care system that's designed around people coming to us instead of us going to people. So we arranged meals on wheels with permission of the bees we called the daughter in California now she orders online groceries every week that get delivered which she knows how to do Mrs. B doesn't have a computer. It turned out that with further conversation they were very active members of their church and had not been able to get to church again because Mr. B couldn't make the block and a half walk to church and with their permission we called the pastor the minister and he was very embarrassed and chagrined and it turned out that when Mr. and Mrs. B stopped coming to church was right when he had started he was a new minister so they kind of fell through the cracks and no one told him that they had stopped coming and like every other faith community literally every other faith community in this country they have a friendly visitor program for their shut-ins which no one had tapped so they were enthusiastically assigned three times a week they send a high school student on community service on Mondays and Wednesdays from three to six or three thirty to six and on Fridays a member of the congregation goes and they send a car on Sunday to pick them up and take them to services and they give them lunch and they bring them home of all the many things we did that is the most important is addressing the social isolation and restoring friendship and love and community to this very isolated couple that was three years ago he's still alive he's 91 his prostate cancer is not changing much I think his dementia is probably vascular because it has not progressed much he's going to fall and break a hip or crack his head he could die anytime if someone had asked me three years ago would I be surprised if he died no I would not have been surprised if he died but I would have been wrong because here he still is and here he still is not because we're rationing or withholding needed care he's still here because we actually assessed what he needed and delivered on it so let me ask you guys which one of these two columns is easier to get in the current health care system which one is lower quality which one is higher cost right all right it's way higher cost the left hand column so the challenge to all of us is to make the left hand column a never event and the right hand column the standard of care so when you're thinking about what do we need to do to repair this very broken health care system think about Mr. B right now the system is perfectly designed to give us the left and it's almost impossible to get the right so is Mr. B's experience a typical it is not these are the data three-quarters of Medicare beneficiaries are in an ER at least once in their last six months of life it's like the modern death ritual you can't get off the planet without first spending at least one day in the emergency department again because that's how the system is designed you know even when we know Mr. B this was his fourth ED visit it's not like we couldn't predict this was going to happen again but there was no new plan or system put in place okay now it's time for a quiz to wake you guys up remember I told you that the five percent of American patients account for half of all health care spending so if I were to ask you if we're going to do a pie graph what percentage of the costliest five percent do you think are in the last 12 months of life not six months but last year of life give me a guess 90 percent everybody agree with that can I get some other guesses 11 11 percent of the costliest five percent turn out in retrospect because we don't know in prospect we only know in retrospect who dies right to have been in the last 12 months of life the majority of these patients like Mr. B are not dying that's why hospice is not the solution who are these patients half of them have very high spending once total hip replacement trans aortic valve replacement kidney transplant and admission for community acquired pneumonia but they get better and they return to baseline and the following year their costs go down so half of the costliest five percent are actually benefiting from all this money they get better that's really important it's not all people trudging towards the grave and the remaining 40% are the Mr. B's of the world with high-cost year over year over year they're not dying but their care needs are not being met at home and they end up using hospitals and 911 calls to meet their medical needs because it's the only system in place any questions about this is a very very important there's this notion that somehow the need is for people who are dying we have hospice for people who are dying it's the chronically ill that we're abandoning yeah that uh okay most but not all are over the age of 65 they are demented they are frail they have exhausted overwhelmed family caregivers they have social and behavioral health challenges they are functionally impaired and they may or may not have a serious illness mr. B I mean he has moderate mild to moderate dementia and he has arthritis and he has quiescent prostate cancer he's not dying of any disease he's going to die of old age and frailty probably but the factors that drive his utilization have nothing to do with those ICD-9 codes they have to do with his exhausted overwhelmed wife they have to do with the fact that she he can't get through the day without her that he can't walk a quarter of a block without getting exhausted that he is confused if he's left alone those are the drivers and here's some data to support this these are Medicare data on the right hand bar you will see that two-thirds of the costliest five percent of Medicare beneficiaries are functionally dependent what that means is they can't get through the day without another person they need someone to bathe them to toilet them to dress them to make sure that they eat and take their meds they need another human being and this is even more powerful data on dementia as a predictor of risk this compares on the right community dwelling older people who are cognitively intact no dementia to an age-matched group also living in the community who do have a diagnosis of dementia and what you see here is four times as much nursing home use in the dementia group twenty times more long-term nursing home use fifty percent more hospitalization twice as much home health use and three times as many burdensome transitions what is it about dementia that causes people to end up using so much Medicare dollars exactly caregiver stress what does the exhausted overwhelmed family caregiver do call 9-1-1 because that's the only option we provide it's not the dementia per se that drives people to the hospital it's the family caregiver I don't know about you but in our electronic health record we do not have a mandatory field for we don't have a mandatory field for memory loss we don't have a mandatory field for family caregiver burden assessment yet arguably those variables are the most important things for us to find if we're trying to target the highest risk highest need population we've got to ask these questions of the clinicians that see people because otherwise how are we going to find them and prevent these four ed visits and three hospitalizations so why is it that people like mr. B have to use the emergency department to get basic social food support pain management needs met these are data from Betsy Bradley a professor at Yale who's been doing a lot of work on the ratio of social to medical spending in OECD nations that's the organization of economic cooperation and development so it's like all the developed nations are part of this organization you can see here that New Zealand let's see Czech Republic Poland Luxembourg UK Italy Finland Germany Austria Switzerland Denmark Belgium Sweden spend about two dollars and fifty cents on social supports for every dollar they spend on medical care okay and guess which one is the US seventy cents on social supports for every dollar we spend on medical care hence mr. B has to use the ER because there we don't spend money on anything else is that a good use of our taxpayer dollars it hurts him it's bankrupting everything else in society we have to start paying attention to things like food and housing and poverty and psychiatric disease and substance use disorder and social isolation and transportation if we actually want to take care of people so this slide reminds me of a quote from Winston Churchill who was said to have said when the US finally got into World War two you can always trust Americans to do the right thing but only after they try everything else first so some of you are old enough to remember when in order to get Medicaid in this country which is insurance for the poor for long-term care you had to agree to go into a nursing home otherwise you couldn't get Medicaid unless you agreed to go into a nursing home clearly the policymakers were hoping that because no one ever wanted to go into a nursing home that it would reduce the Medicaid budget that didn't work because family caregivers couldn't handle it right and they weren't getting any help so they finally did what's called a rebalancing of Medicaid which is to not force people into nursing homes but to actually pay for some help at home home and community-based services which no surprise is what people want they don't want to go into a nursing home and cost less than one-third the cost of putting people in nursing homes perfectly logical took us a while to get there and here's another example some of you are old enough to remember the sequester which happened in 2008 when rather than shut down the government there was a terrible agreement to cut domestic and military spending by equal amounts in order to prevent a government shutdown one of the things that got cut was the Meals on Wheels budget by 50% still has not been restored to this day so Meals on Wheels has very minimal federal funding now in most states where state budgets have no money almost no state support and if you don't have strong volunteers you have no Meals on Wheels only in America can you get your artificial heart but you can't get dinner seriously it's it's appalling it's not funny and this is a study from health affairs that found that if if the United States increased by only 1% the number of older people who got home delivered meals it would prevent about 1700 people from ever needing to go into a nursing home and in fact food insecurity is a huge driver of illness emergency room use and hospitals in the United States alright finally getting to my topic here so what is palliative care I think the main thing I want to get across to you is it is not end-of-life care you may deliver it at the end of life but you do not have to be dying to benefit from palliative care in fact the great majority of people who would benefit from it are not dying so it specialized medical care for people with serious illness a serious illness could be cured right or it could be something you live with for decades as a chronic disease or it could be progressive the goal of palliative care is to improve your quality of life by focusing on pain symptoms and stress and family caregiver support it's provided by a team this is really important you can't just do it if you're a doctor or just if you're a nurse you need the whole team because these are the sickest and most complex patients in our society they are the most challenging patients in the health care system you need social work for the housing and the food and the transportation and the friendly visitor program and you need nursing and OT and PT to make the home safe and you need medicine actually medicine was the least important discipline for Mr. B we got his pain managed and got his bowels managed and then you know of course he doesn't have back pain every day he only takes the opioid once a month twice a month when his back goes up but most of what he needed was access to a 24-7 phone number just in case and the social supports and palliative care is appropriate at any age any diagnosis any stage in a serious illness and should and can be delivered at the same time as curative life prolonging or chronic disease treatment one of our residents a young woman named Karen finished her residency probably two years ago was pregnant with her first child delivered the baby in August and two weeks later became really short of breath and of course being a doctor she assumed she must have had a pulmonary embolism because she had you know been at bed rest before the baby was born and she went to see her primary care doc and she describes seeing him come back into the exam room after looking at her her chest x-ray and she said she knew immediately that she had cancer just from looking at his face she you know she'd been the person having to break that news so she knew what that face looked like she had a massive medial steinal lymphoma newborn baby just finished with her residency went to the cancer hospital of record in New York City Memorial Sloan Kettering Cancer Center to see the world's expert on that type of lymphoma very nice guy and he's talking to her about what to expect and at the end of their conversation he asks her if she has any questions now remember she trained at Sinai so she was heavily exposed to concurrent palliative care along with disease treatment so she said I assume you work with a palliative care team guess what he said to her you don't need that you're not dying and Karen said I'm not going through this treatment without that support and the only way she could get it was to get her palliative care at Mount Sinai because they just don't do that at Sloan Kettering Cancer Center right everybody there needs this right so she got her fatigue her shortness of breath her pain her depression her insomnia her existential and spiritual distress addressed by us and she got her curative treatment her bone marrow transplant at Sloan she went with us to testify in front of Congress about how important this was and how every person facing a serious illness like her should have access to this care that you shouldn't have to be a doctor to get it you shouldn't have to be lucky it should be the standard of care she's about a year and a half out from her transplant and three PET scans have all been negative so hopefully she's gonna stay that way but the goal for Karen was cure always cure if she had to wait till she was labeled as dying there would have been a lot of preventable suffering so it's a conceptual shift from life prolonging your curative care until suddenly one day we decide to send you over the wall to hospice to this model where we do both since the eligibility criteria for hospice are that you have to give up disease treatment to get it hospice only comes into place when disease treatment is no longer helping you that's often very late in the disease course and in fact for Mr. B disease treatment and palliative treatment are not different in heart failure palliative treatment for shortness of breath is diuretics right it also prolongs your life there is no distinction between life prolonging and palliative in most diseases COPD and stage renal disease heart failure they're the same it's a false distinction it was the hospice benefit was written with cancer patients in mind and this is a better image because it shows the sine wave how people are stable and sick and get stable again and sick over time usually over many years so remember the value equation quality in the numerator cost in the denominator these are all of the elements of quality that have been shown in randomized controlled clinical trials to improve with palliative care and I draw your attention to length of life which improves with palliative care compared to controls and because quality is better think of Mr. B costs go down it's not rationing it's not withholding necessary care it's meeting people's needs so they don't end up calling 911 in a pain crisis this is a randomized controlled trial that was published in the new england journal a few years ago that randomly assigned lung cancer patients to get best lung cancer care at mass general at harvard really high quality lung cancer care probably the best in the country it's where I would go if I had lung cancer and the other group was randomized to get best cancer care harvard mass general plus concurrent palliative care so why did this study get published in the new england journal of medicine the hardest journal to get published in it wasn't because there was better quality of life and less depression and less and end of life utilization in the intervention group it's because the intervention group lived almost three months longer than the control group and no I spoke to the editors of the new england journal at a meeting about why they accepted this paper they couldn't explain the findings and they didn't believe the findings and they like controversy because they like to be in the new york times that's why they published it there are now five other randomized controlled clinical trials also showing better survival in people who get palliative care than controls why might that be how might palliative care help you live longer as well as better decrease suffering and you have a reason yeah people who are miserable just want to die and that makes a difference if people want to stay alive they do stay alive and suffering is bad for your health it's immunosuppressive what else what else do you see up there that might contribute to better survival yeah that's similar to what was just said you feel better yep the family felt listened to and supported so the patient didn't feel like I better just go ahead and die because I'm killing my family and many patients do feel that way that they're enormously burdening their families yep yes iatrogenesis we call it doctor caused harm less and depression is an independent predictor of mortality in every single disease in which it's been looked at depression kills people who are depressed are immunosuppressed people who are depressed die sooner with every single disease we know and people who are not depressed but if I were a betting person and had to put my money on something it's that these people were much less likely to be hospitalized and if you are a cancer patient you've been getting radiation you've been getting chemo and you go to the hospital for a dyspnea crisis or a pain crisis and you get an infection you die you are much safer at home and that's just a fact hospitals are the third leading cause of death in the United States British medical journal six months ago look it up especially if you are immunosuppressed right if you and I got C. diff or a bad infection we could probably survive it but an 88 year old or a cancer patient so with our best of intentions we do a lot of harm this is another randomized control trial this one was done at Kaiser Kaiser like the VA is is globally budgeted so they can put the money for the patients they are responsible for wherever it is most needed unlike the rest of us in a fee-for-service siloed fragmented system we can't but at Kaiser they did they randomly assigned heart failure COPD and cancer patients to get usual Medicare home care or palliative home care like the visiting docs like mr. B got you can see on the left there were three times as many visits in the palliative home care group and if I was running a home care agency here in San Antonio I'd say well that's nice I'm sure the patients appreciated that but we can't afford that we're going to get shut down if we do that many home visits because we're not getting paid for that but because it was Kaiser they could see what happened everywhere else across their system physician office visits dropped by half ER visits dropped by half hospital days dropped enormously and nursing home days dropped enormously they saved four dollars for every dollar they spent the VA does this and Kaiser do it does it they put money into home-based care like mr. B got because the incentives are aligned right they can put the right care for the right person at the right time in place because they can take money that would otherwise have been spent on a harmful hospitalization and support the care that was needed at home but all hope is not lost because health reform is going to drag us kicking and screaming into exactly this kind of model and I show you this study particularly medical students and young people this is the future health care system if you are being trained only to work in a hospital you are not being prepared for the health care system of the future where the great majority of care for complex chronically ill people will no longer be in the hospital or in the big academic center it will be in the home and the community and you better get yourself some training on delivering medical care there because that is the future my generation I'm going to see it I hope but I probably won't practice in it so there's tons of data on the cost savings of palliative medicine this is a systematic review 46 studies all showing marked reduction in spending again not because of rationing but helping people avoid unnecessary hospitalizations these are the key characteristics of effective palliative care and I'll just go through some of them we we are told to ask our patients and families what are their goals it's a really weird question to ask a patient right like are we asking them to play soccer or shoot hoops it's just not meaningful language so the language that I use with my students is to ask people what is most important to you what's most important to you in the context of this illness people say all kinds of things they say they want to see their garden come up next spring they say they want to see their third-grandchild born they say they want to take the family on a cruise they say they want to go home to the Dominican Republic they know what you're asking right I have never once had someone say I want to live forever I wouldn't surprise me if someone said that but that has not happened in thousands of times yet I think most of us doctors think that's what everyone wants so this is a study of 357 community dwelling older adults who were asked what was most important to them between living longer having relief from bad symptoms or remaining independent what do you think was most important to them you guys are good that's 76% ranked that first followed by pain and symptom relief and pun fully intended dead last living longer so how is the health care system designed just the opposite right I mean in theory this whole 20% of the economy is here to serve what matters most to our patients we have lost our way families are home alone the only reason this health care system works at all is because of the burden we place on family caregivers there are about half a trillion dollars in out-of-pocket costs that are not reimbursed that family members handle for drugs that aren't covered for co-pays for deductibles for hiring 24-hour care for taking days off work for losing your job all together because you're taking care of your mom people who are delivering care to family members are at much higher risk of death disease and a seriously ill loved one is the number one cause of personal bankruptcy in the United States even among people with insurance why aren't we appalled by this this is appalling this is the only developed nation on the globe where the number one cause of personal bankruptcy is serious illness families obviously need help mrs. B is getting a lot of help most of which we are not paying for because most of it is through her church and her daughter ordering food and doing a home safety evaluation but she's managing pain and other symptoms why was I the only doctor among what must have been a hundred doctors who saw mr. B with excruciating low back pain who was comfortable enough to try him on an opioid he saw everybody and their brother in the hospital and no one was willing to try this right what is the number one cause of disabling pain in Medicare beneficiaries arthritis we treated as if it is unimportant but it really hurts and it is really disabling and many old people can't take anti-inflammatories because of their kidneys and their stomach and Tylenol does not work so is it better for people in pain to just keep coming back and forth to the ER in hospital because we're so afraid to use opioids no going to the hospital is a much greater threat to mr. B's life than a low-dose opioid how many of you have read this if you haven't I strongly recommend it to you nobody has done more to improve public awareness and public understanding of the mess that we're in right now then go on day who is a Harvard medical student Harvard resident Harvard surgeon and this is the opening sentence of his book I learned about a lot of things in medical school but mortality was not one of them even at Harvard certainly true at Northwestern don't know about here this is my favorite New Yorker caption contest is the best part of the New Yorker it's the last page so it's a doctor facing away from his patient he should have a computer but he doesn't if I was an artist I would draw a computer there and his patient is in a coffin behind him and the captions are any stiffness sorry about the weight any family history with death so the New Yorker editors thought this was funny but I thought it was true that we actually don't train young clinicians and nurses to recognize when people are dying that's why 20% of us end up in an ICU when we die because our clinicians don't realize that we're dying and that a certain set of skills and tasks are appropriate when people are dying not intubation in the ICU because we never taught people to recognize it it's interesting when I was pregnant with my kids before my son was born I had this overwhelming urge to get the room ready I had to get the you know the bumpers in the crib and the sheets on the mattress and clean up the mess in that room turns out that's a really common syndrome when people are about to go into labor I later was told by my obstetrician that that always happens and I wasn't in labor but I was about to go into labor the dying process is just as predictable and just as consistent as the behaviors of women about to give birth it is a universal series of events that people can be taught to recognize and taught how to accompany patients through but we don't do that so here's an example of that you guys have if you don't have this article we have more copies this is another actual patient of mine her real name was not Jenny but her story is true I have her permission to use the story and to use her photos and she actually went on news hour on PBS and was interviewed about this experience before she died so I don't want Jenny to think I'm abandoning her is what an oncologist said to me when I asked him what he hoped to accomplish by giving chemotherapy directly into the brain because she had lung cancer met to the brain and he said I don't want Jenny to think I'm abandoning her that's Jenny you can imagine when I saw her in my geriatrics practice I thought she was in the wrong place she came to see me because she was a clinical psychologist she had non small cell lung cancer that been diagnosed four and a half years earlier she was told she would die within a year thanks to this great oncologist and the right genetic markers she did really well but she kept asking him what's going to happen when all these new fangled treatment stopped working and each time she asked him he'd say we don't have to worry about that I have more tricks up nicely being a clinical psychologist she knew that he couldn't go there it was his problem but she really wanted to know because she was afraid what's going to happen am I going to suffocate am I going to be in terrible pain am I going to become crazy what are my husband and daughter going to have to deal with so she started googling and she found me on Google and made an appointment to see me out of nowhere and she and her husband came in and she said what's it like to die took me less than 60 seconds to tell her what it's like to die which is you get sleepier and sleepier spend more and more time in a better chair you have less and less interest in food and fluid you are sleeping all the time you sink into a coma your breathing becomes rapid as your body shuts down after a couple days of rapid breathing you start having pauses in your breathing some of those pauses can be short some of them can be as long as 30 or 60 seconds and that goes on for a couple days and then during one of those pauses you will die not very scary and that is 90% of the time what happens and if people have shortness of breath or pain or confusion we have very effective medicines that can be given at home by the family it's really not that scary yet her oncologist did not know how to say that because probably because he didn't know I doubt he actually seen very many people die they went somewhere else anyway she cheered right up after we I said that we spent the rest of the half hour talking about her various book groups she was a really interesting person and then her oncologist and I co-managed her for about another 20 months so I did the psychostimulants and the antidepressants and talking about what was to come and he managed the cancer and I was the consultant so I never did anything without checking with him first is it okay if I started on Ritalin by email or text that's how we communicated so she had brain mats and she was maxed out from her radiation therapy and steroids and couldn't really take any more and was having trouble remembering what her patients were telling her in her psychotherapy office and she went to see him and he offered intrathecal chemotherapy and she went home and she called me and she said what should I do you think I should do this so my inner voice was like what but I controlled myself I said I'm not familiar with this treatment in the situation so let me call dr. C and one of us will get back to you so I called him I said Jenny was in today she mentioned that you had suggested intrathecal chemotherapy I don't have much experience with this procedure what are you hoping we can accomplish and he answered right away won't help her so then I had to really struggle to control my reaction so it's sort of a long pause and I said remembering that I was the consultant and he was a treating physician do you want me to encourage her to go ahead with it anyway even though you just said it's not going to help her like I'm thinking maybe he's going to say well there's this one study that showed in certain types of people you know that he could convince me right and this is what he said this was a proverbial light bulb moment for me why do doctors recommend futile treatment because it is the only thing they know how to do and to not do it feels like abandonment and they don't want to abandon their patients because this oncologist love Jenny and because he had no other arrows in his quiver he had no basic training in palliative care it was either give more chemo or abandon what was interesting is as soon as he said this out loud he became conscious of what was motivating this recommendation he said we're not going to do that but until he said it out loud I don't want her to think I'm abandoning her he wasn't conscious of why he was recommending a toxic expensive dangerous futile treatment and he called her and she went on hospice and I was her palliative care doc while she was on hospice but what was the problem here with dr. C not that he was didn't care about her he wasn't doing this for money he wasn't doing this to experiment what was the problem so what's the solution unfortunately the solution is training and I say unfortunately because it's not an easy task to train the entire u.s. workforce in stuff we did not get in medical school or nursing school and we didn't which the public finds shocking and appalling but it is true so this is Jenny and her husband George and her daughter Sarah on one of the many trips to Europe that this oncologist enabled and this is a photo I took of them about a week before she died you can see she had pretty good death but I asked her the question that I often ask my patients when they're nearing the end and I asked her how are you feeling inside yourself it's a really good way to get to instead of saying are you in pain or are you short of breath to get to what's real and I expected her to tell me she was thinking about her mother because she was estranged from her mother and I think I had this dr. fantasy that I was going to fix all this right I was going to make it okay with her mom but instead what she said to me is I don't understand why dr. C hasn't called me or been in touch since I've been home I thought he cared about me she was devastated he did exactly what he didn't want to do he abandoned her with her permission I went back to my office and I called him and I said you know dr. C I was in to see Jenny today and she would really like to see you and he came back very angry why there's nothing I can do for her she's on hospice so sad that that's all he can do is give chemo right so I said to him she's really fond of you she's so grateful to you she wants to say thank you and she wants to say goodbye and he went he made his first home visit she died two days later and he who is now directing the cancer center at the competing medical center in New York City just hired three palliative care clinicians which I just found out I mean this is so Jenny had Jenny's influence had a long tail so here's another New Yorker cartoon there's no easy way I can tell you this so I'm sending it to someone who can so those of us in palliative care think this is a great doctor because he knows what he doesn't know but actually this doctor needs to know how to how to tell every doctor does every nurse does but if we're not trained to do it we offer what we were trained to do so you can get training online from my organization I'm gonna just show you where Texas is against the rest of the nation Texas is green that gives you a C the orange is D the yellow is B and blue is a and that's the penetration of palliative care in hospitals in your state so below average you have some work to do I'm gonna skip this you had a D before you're better yeah there weren't and there were no F's this time either so how do we pay for what Mr. B got by partnering with payers because who has an incentive to keep people out of the hospital patients and insurers right they will pay for home-based care because the alternative is to pay for hospital care so we have to figure out how to partner with payers to build a system that's actually responsive to people's needs these are ads from the American Cancer Society which is trying to convey to the public the value of palliative care can see one's a ballet dancer the word cancer becomes dancer one is a the word chemotherapy becomes mother the third ad is a dad with his four-year-old child it says radiation and it's crossed out to say dad the fourth that is a child on a swing it says stage 4 and the ST gets crossed out to age 4 and the language on the ad is palliative care sees the person beyond the cancer diagnosis it's an added layer of support just like Karen got during her bone marrow transplant so we have a lot to do but there's actually been real progress and I'm going to demonstrate that to you with a quote from an article written by my colleague Betty Farrell in 2003 based on interviews she did in the 90s with survivors of ovarian cancer who had severe neuropathic pain due to the treatment this is one quote I had the most excruciating pain I had ever experienced the pain meds did not even begin to penetrate the pain I thought I was going to die so that was then and this is now we need volume it was on before I met Debbie when she came into the hospital with an acute pain crisis she was really going through a lot in terms of just living with this new diagnosis and then to be suffering from symptoms sort of related to the treatment so that she can live with the diagnosis with me being in the pain I just shut myself out and just stayed in my room the most they saw of me was to come out and get something to eat and go to the bathroom she was really crippled by this neuropathy and you see she does hair and that was one of the things that came out when we were in the hospital you know sort of what bothers you the most about this pain talk to one another and they come and they talk to me with each other not you know they're talking just in a conference among themselves but they include me in that conference that they're having with one another in terms of the medication I'm on how I'm treating the house the medication treating me how I'm sleeping how is my quality of life I mean she she's such a beautiful person and so lovely and social and you can imagine for her not to be in that world it really robs her not just of you know financial security but her identity and I think it's powerful to think that if you can give her some of that back by controlling her pain you're really allowing the miracle of her treatment for her myeloma to fully fully realize itself I would not be back sitting in this chair right now if it wasn't for the program I would be lost without them right now lost she's a perfect example of how palliative care can help I feel I'm in the driver's seat because they're really concerned with how I'm feeling Debbie had myeloma and she comes into the palliative care practice once a month she's on four different drugs for her pain for neuropathic pain opioids anti-seizure drugs and she's back at work and she has no evidence of disease she had been in the ED three times for pain so that's we can do and that's what we should do so I'm gonna close with this quote from Albert Einstein one of my favorites every day I remind myself that my inner and outer life are based on the labors of other men and women living and dead and that I must exert myself in order to give in the same measure as I have received and I'm still receiving it's a great privilege to do this work we're all really lucky so thank you very much I know I went really really over my time because I get carried away but I'm happy to take questions that was truly one of the finest presentations we've ever had had conversations about ethics so thank you so much and I would expect nothing less from an Oberlin college graduate we understand the lateness of the hour and if you need to leave please do so comfortably but we can take a few questions for about the next five or five minutes or so so Dr. Winnaker there's a microphone back up there and a quick solution down front so Dr. Meyer thank you the there seems to be momentum gaining in this country for the physician assisted dying movement you didn't mention it being unmentionable for you but I would like to know where this fits in to the scheme of things if at all and it appears to me that the movement seems to be to be driven more by by particular patient stories and the media rather than by academic medical centers I just like to get your opinion on this a subject dear so I wrote an op-ed or a sounding board in the New England Journal of Medicine many years ago called morals and moralism in the debates on euthanasia and physician assisted suicide in my callow youth supporting it thinking that the most important ethical principle or priority was respect for self determination and then as I got older perhaps wiser but older I and learned how to take care of people with pain and shortness of breath and depression and saw that those things could be treated very effectively if you knew what you were doing which I had to teach myself because I didn't get in medical school or residency that risk of sending this message to patients that even their doctor thinks they would be better off dead is very toxic I mean doctors need to be on the side of the patient and on the side of the patient's life we need to do that to earn the trust that we have what is the power of a doctor saying yeah I agree I think you would be better off dead to someone who is struggling with reasons to keep going it's it's a power we shouldn't have I think plus for example with Brittany Maynard she was repeatedly quoted as saying I could suffer horribly or I could kill myself and that doctors told her that now I hope no doctor told her that but she clearly wasn't getting palliative care because no she doesn't have to suffer horribly and so that message to the public was you have a binary choice suffer the tortures of the damned or kill yourself that is wrong and really inflammatory and manipulative by the people who are advocating for this and by the way you know just as an aside nobody poor wants this the people who want it are almost all highly educated people who like to be in control do we pass a public policy that applies to every doctor in our society including the lowest common denominator of doctors the people who don't know how to identify and treat depression the people who would rather write the prescription for second all then spend an hour talking to this person about what what has brought them to this point where they would rather be dead a public policy has to apply to every single doctor not just the best doctors and frankly I don't think most of my colleagues are prepared or trained or skilled or knowledgeable enough to make that decision with patients so I'm dead set against it as public policy even though I can understand individual people wanting to do it I don't think it's good public policy and again I think it's driven by un-reasoning fear I see we have four people lined up let me ask you to keep your question very succinct so all the resources would be on your website or are there any other kind of trainings or anything else you might recommend yeah so for communication skills training vital talk vital talk net there's some apps there's some online courses and there's some in-person training communication skills training is urgently needed among clinicians and then there is a really excellent curriculum specifically for nurses called LNEC ELNEC the Capsi curriculum has CME and CEU for doctors nurses social workers care managers care coordinators and licensed professional counselors so covers pretty much everybody what role does advanced care planning have in your program in your palliative care program so advanced care planning first of all it's gotten a really bad name through all the death panel stuff of some years ago advanced care planning is just putting the power back in the hands of the patient to help the patient anticipate a potential future so one of my colleagues walked out of a home visit and was hit by a truck that was backing up and fortunately she made it but she might not have she had a closed head injury she was in coma and in our surgery ICU for three months that could happen to any one of us leaving here right so how would we want our family to think about what we would want so the way i put it my advanced care planning conversation with with patients healthy patients is seatbelts bicycle helmets vaccinations colonoscopy anyone i say anyone of us could walk out of here and be hit by a truck i want to hear from you if you were in a situation where you were not expected to recover to ever be able to interact with or recognize your loved ones and we tried to get you back from that but we couldn't i'd say some of my patients say they would want everything done under that circumstance they don't care about the quality they just want to live and others of my patients say they would want only comfort measures if they were not ever expected to be able to recognize or interact with loved ones which kind of person are you that's the extent of my advanced care planning conversation i don't ask people if they want a ventilator or not because if they could be on a ventilator for a week and get off it from a pneumonia of course they would want a ventilator it's a ridiculous question to ask patients because you can't anticipate the situation the situation might be you've got an advanced care plan that says no ventilator some doctor might not put you on a ventilator when you have a treatable pneumonia we shouldn't be asking people questions like that we should be asking questions about what is a quality of life that's unacceptable to you and for most people that quality of life is the loss of relationship the permanent loss of relationship and that really helps me because short of that if that person still has the capacity to relate and be in relationship most people want to stay alive the overwhelming majority it's also important to appoint someone so my colleague who was hit by a truck had appointed a proxy decision maker who was legally empowered to make decisions for her and she wasn't married so it was very important that she had done that that she had that legal document or her partner would not have been able to make her decisions for her so those are the it's it's not that complicated and i have that conversation with all my patients at the same time that i'm talking about seatbelts as much as it pains me to do this i'm going to ask that we bring our session to a close we're very fortunate tomorrow morning at eight o'clock dr myer will be speaking at medical grand rounds so for the faculty that are here and the medical students that's in 409 l she will also be giving a workshop at the ecumenical center and that is unfortunately if you're not signed up it's already sold out good good for the people who are who are johnny on the spot with signing up for that and we also have the benefit of dr myer interacting with our palliative care fellows and the folks that are in training here so we truly are benefiting from two days of a visiting professorship um i'd like to challenge you as you walk out of here this evening to reflect on the stories that you heard and the power of narrative medicine dr myer has the data data is incredibly important we can't change policy without evidence but at the end of the day if we're trying to change culture um of health care um the power of the narrative is something that we all need to harness and with that let's once again thank dr myer for her presentation