 I'm delighted to introduce our first speaker. Our first speaker today is Dr. David Chiedemeier. David and I were just reminiscing on when he came to the Ethic Center. I'll just give you a moment of history as part of my introduction. The Ethic Center started in late 1984 when President Hannah Gray sent me a note saying that she had approved the idea of our launching in Ethic Center. We advertised for our first fellow in the New England Journal about a month later and received a number of applications, but selected one fellow, John Le Puma, John raise your hand as our first fellow, and John started in July of 1985. We had four fellows. One was John Le Puma, who stayed on as David says for a year of remediation, and then John Lantos, who's here, David Chiedemeier, who'll be our speaker, and Abby Zugar, Abby who's writing for the New York Times on medicine and ethics and humanities, wonderful group. And out of that experience, John Le Puma and David Chiedemeier became lifelong friends and writing partners in quite a number of projects, including the one I referred to yesterday, the book on ethics consultation, which came out in 1993, somewhere like that, yes. So it's a nice history. David Chiedemeier currently is a physician at the Theta Clark Palliative Care Program and a community associate in the Medical College of Wisconsin Medical Humanities Program. The title of David's talk today, and I'm looking forward to it with eager anticipation, is the following. Just Me and My Harp, Lessons from a Lifetime of Ethics and Palliative Care Consultation and Harmonica Playing. David, it's a pleasure to welcome you back. Thanks so much. Thanks, Mark. Thanks. Thanks so much. First thing you must learn when you play the harmonica is that a little goes a long way. Sometimes you need to be quiet. And as musicians say, rest. They mean, of course, rest and listen, rest and wait. The next thing is really to learn the limits of your instrument, the notes you can play and the notes you can't. For example, the blues harp is missing almost half the notes in its three octave range. Listen to the notes available as I go up the instrument from bottom to top. I'm going to breathe out and then in in each of the 10 holes, just a standard harmonica you can get at the store. Mind the gaps. Lots of missing notes. Also, oddly, two of the notes are the same. Also, oddly, at holes 7 through 10, unlike holes 1 through 6, the exhale notes are higher than the inhale notes. Hope you noticed that. Really makes it hard. So this little harp is full of quirks and limitations, just like you and I are, as people, as ethics and palliative care consultants. Now, you can find more notes with experience. For example, you can learn to bend. And I'm still learning to coax out more notes. The expert in the world actually can get all the notes on this harp by overblowing and overbending as well as bending. And that's Howard Levy out of Joliet, Illinois can play the entire chromatic scale with that harmonica. I'm also learning to coax out more notes in my medical work. For example, a woman in the ICU with COPD has said that she wants to stop the ventilator. The problem is she's afraid of knocking on heaven's door. I mean, she has mouthed and written the following words in a sideways scroll on the clipboard. I don't want to be a burden. I don't want to die today. I echo it back. I say, what do you mean you don't want to die today? And that's called call and response in the harmonica world. You just echo it back. And she looks around at us, her husband, her son, her oldest granddaughter, her nurse. And then a really odd thing happens. I kind of count on these kind of things to happen when you're doing call and response. You're just waiting. And then the nurse says to her, do you want to go to be with God again? Again, such an odd thing to say when you think about it. Again? But somehow it's the right question. It seems somehow to help the woman. It's a question about going home. And she nods her head, yes. I mean, success often depends on good timing in this call and response. Listen to the patient. Don't step on their vocals. And also don't play another instrument here when the nurse hears our soloist. Don't play over their solo. So I will take this person off the ventilator. Maybe tomorrow or the next day, not today. I'm now seeing a patient with dementia. And I always ask people, my really only mental status question is, what are you watching on TV? He looks up uncertain. These are hard consults because he can still talk, just a word or two. He can still eat. He's holding the food in his mouth. He sits in a chair all day, seemingly devoid of the motivation which has characterized his entire life. His family wants him to get up and walk around. But I have the opposite advice. Stay in your easy chair. As always, Dylan has the best words. His song is, clouds so swift, rain won't lift, gate won't close, railings froze. Get your mind off wintertime. You ain't going nowhere. Whoa, are you going to fly down in the easy chair? Oh, and for this one, the trick is you have to use a different harp than everybody else. Remember, it's hard to play a different song if you start just like everybody else. You might even want to use a minor tuned harp. I mean, dementia is that bad. So I recommend a completely different approach. What's there not to do? Let's not attempt resuscitation. Don't re-hospitalize him except for trauma or bleeding. Stop doing tests. Stop trying to make him better. He ain't going nowhere. You know, like a tambourine player, as a harp player, it's best not to take yourself too seriously. Anybody can do it. I wouldn't pay it any mind. It's just a ragged clown of an instrument. So you can use your hands to make those wah-wah sounds. They're really funny. So the tambourine man, he hears the train coming, but chugging in the whistle of the train. Chugging, that reminds me of a man who's fallen off his bar stool after chugging too much beer and he's broken his neck. The man's now paralyzed and he has a severe head injury. He's really expected to die. His family's in shock because, let's face it, he had told his wife he was just going out for a couple of beers. Like the song says, take me on a trip upon your magic swirling ship. My senses have been stripped. My hands can't feel to grip. My toes too numb to step. Wait only for my boot heels to be wandering. I'm ready to go anywhere. I'm ready for to fade. Into my own parade, cast your dancing spell my way. I promise to go under it. So all I can put in the chart is this patient is dying a natural death. And I chuckle, sadly I really do. It's not aimed at anyone. I meant to write a natural Wisconsin death. In Wisconsin, we're like hobbits. We die from drinking too much beer. So I give the man a couple hours head start with morphine and adivan and a scopolamine patch. And then I take him off the ventilator. His family members cry at the bedside. But me, I keep my feelings inside like a clown with sad eyes. So it is that I find myself smiling at a young man and woman when they step onto the hospital elevator. They've just been released from the OB ward. And I see that they have a newborn curly-haired baby tucked in the car seat. Such long, curly hobbit hair. A future Wisconsinite. The door opens and they walk out with me, the ragged clown quietly skipping behind. How much to practice the harmonica? How much to practice medicine? Never enough. Every day. You need to practice your tongue slaps and bends so you're ready for the mighty quinn. You also need to practice your octaves and chords because chords help you at family meetings. You can listen to the many voices, all somehow related to each other. And practicing these songs teaches you that it's not necessary to sound exactly like the legends. No one else is Bob Dylan. What's important is that you play with the same spirit. So I try to keep all this in mind when I come to see the young man in the ICU. He was one of six naked people. But we're in an SUV when it tipped over and it cast them all out into a different spot on the freeway. I suppose they were thinking when they're driving along without their clothes on, what could possibly go wrong? So the person I'm seeing has multiple facial fractures, an open skull fracture with brain substance leaking from his nose, a dislocated ankle, and a penile de-gloving injury. And as much as all of that hurts, he also has no insurance. He's not yet a US citizen. I learned from his family that he's a good cook. He's in excellent shape. He fancies himself the most handsome of his brothers. He's always feared mutilation. In Mexico, he refused to watch the machete movies because he said he would never want even a little cut. He wanted to be a personal trainer at a major gym. I start the consult by trying to determine my starting note. It's Mark Siegler taught us. Medical indications, patient preferences, quality of life, external factors. Different modes interact differently in each case. External factors, that shouldn't be my first thought. I want to choose another start for this sad song. I meet with the family several times. I join in meetings with docs, nurses, care managers, chaplains, members of the ethics committee. Everybody is talking. Everyone has something to say except his mother. She does not speak to the translator or to us. She murmurs only inaudible single words. She's tiny, respectful, meek, silent. A lot of red tape was cut to get her here from Mexico and she can only stay for a few more days. After the surgeon has given a particularly eloquent discussion of her son's injuries, at her last meeting of the week, she finally turns to me with her question. Will I be able to stay here for the end of my son? Sad-eyed lady of the lowlands, I don't know what to say. I'm the clown, I'm the sad-eyed prophet. The room is quiet, everyone looks to me to answer this unanswerably sad question. What mode should I play in? Maybe the first position, it starts on the tonic note, it's mild and comfortable. Dylan played in this almost all the time, this basic first mode, served him well. This is the medical indications mode. Or maybe the second mode, somehow it's like a person's voice, expressive, personal. This is the patient preferences mode. Or maybe the third mode, it works for immigrant music, sad, doleful ballads. This is the quality of life mode. Or maybe the fourth classic sad minor song. Once in a while Dylan used this all along the watch tower. This is the external factors mode. Well, I make my decision. I mean, I wanna start in the first position medical indications, but I also weave in a little bit of the third and fourth because it seems to need that too. I mean, this is a complicated song. I breathe in, simple as playing the harmonica, breathe from the diaphragm, breathe deep and focus on getting just that right tone. I mean, I feel as if I'm up on the stage, just me and my harp. I'm playing to his mother and I remember his devastating injuries. I remember hearing the ventilator breathing in and out for him. I hear his mother's quiet voice, the simplicity of her question, the start of the song that she's just played for her son. I breathe out. I answer the brother's question, which was, when will you stop the ventilator? But I'm speaking to his mother. Now I say, now and then we wait.