>> you can watch this and other programs on line at booktv.org. >> up next on booktv "after words" with guest host dr. marty makary a surgeon at johns hopkins hospital and professor of health policy. this week dr. atul gawande in his latest book "being mortal" medicine and what matters in the end. and at the award-winning author argues with all the medical science in the modern era it still deficient in the area of aging and dying. this program is about an hour. >> it's great to see you again. congratulations on your book

"being mortal." >> guest: thank you. >> host: the front cover i love it. it's got a piece of grass on the cover and it's got so much potential symbolism. i immediately thought of walt whitman and his book leaves of grass. he is a famous quote i bequeath myself to the dirt to grow in the graph that i love. what does a leaf of grass mean to you and why did you decide to put on the cover? >> guest: cover? >> guest: it's a biblical reference actually and it refers to the idea that on the one hand we all come from something fertile but also the idea that grass is temperate. in the process of writing this book "being mortal" which i think is terrific by the way, it's one of the few times we can have an honest conversation in a public forum about our mortality and end-of-life issues. did it hit you, did it strike you hey i'm not going to be

around here forever. maybe i should talk to my patients differently about their goals? what impacted writing this book and doing the research for this book have on your own practice? >> guest: a lot. it was kind of the story of the impact it was having to just start investigating why even in my own practice we don't do a very successful job of dealing with mortality. you know we reached by the end of the 1990s a place where 17% of the population died at home with 83% dying and institutions often hooked up on machines unaware of what was happening in the world and a chance to say goodbye, no chance to preserve some quality of life that they came to bn and it was clear that this was not what people wanted and were being successful at it. i began interviewing patients, family members. over 200 patients about their experiences with aging and the

end-of-life. or just dealing with serious illness. i interviewed scores of geriatricians hospice workers nursing home workers and i learned along the way. i learned about what some of them do in a successful process of changing and i began trying it and that my father was diagnosed with a brain tumor in his brainstem and spinal cord and unexpectedly needed to use some of what i was learning as a son instead of as a doctor. >> host: is a tough time for you personally? disco yeah, it was. having the chance to understand why people who are more affected whether as family members or as clinicians, what they do make it less tough though. it was very interesting. i think the core thing that came

out of the lesson for me was that people have priorities besides just living longer yet medicine doesn't recognize that. i was never taught to articulate that. the second part was that the most reliable method of learning what people's priorities are is to ask and i was not asking. also i wasn't asking my own dad and so when his condition began to deteriorate and this is a tumor that was going to make him a quadriplegic as it gradually took his life and he faced options as therapy, radiation and chemotherapy i started asking questions, so what are your priorities? what are the trade-offs you are willing to make and not willing to make? really hard questions to ask and yet changed every step of his care along the way.

>> host: you describe your grandfather. he lived to be 110 years old. he lived in a village in india. tell me about what you learned from his life. just go so he is fascinating because he is the kind of old age that we think we want. the last 20 years of his life he needed 24-hour care basically and yet he did not have to check into a nursing home like you would be today here. he was surrounded by family. he would sit at the head of the dinner table at home as the head of the family. people came to him for business advice or advice about who they should marry. he was respected and venerated and he really was able to live as good a life as possible. what made that possible and why did we lose that? as good as a society you mean.

>> guest: in other words that was what america america had a 19th century. that is what your pet in the 19th century and china and india are leaving right now. leaving the extended family to take care of him worked only by enslaving the young. young women supervise the care and on top of that his sons. imagine reaching they are waiting to inherit your lab. the economic progress of the world occurs because it gives people freedom. they can work where they want and live where they want to marry whom they want. they live to the cities i'm often take different lines of work. they often leave elders behind and we didn't have a plan in the 19th century for what happens to people left behind. the india china and korea don't either and what we have decided medicine will take care of it.

>> host: just turned over to health care and they will fix and take care of entry. >> guest: my dad was having trouble with memory or he is fought -- having falls in the home. let's taken to the doctor and what happens quickly take them to the doctor and say we like fixing problems. we have a procedure we can do for that, therapy we can offer. sometimes we can't make them go away and we throw up our hands. and we say you know well i can either try the therapy or see another specialist. that's the failure of our understanding. there are things to fight for besides just living longer are trying to repair an unrepairable problem. >> host: when we go through school it seems like metal schools -- medical schools in nursing schools attracted people and these are the types of high school students who want to be a nurse are a remarkable person.

and then they come out in this dilemma. is it confusion, ill preparedness, a sense of this is out of my league? where did things go wrong when you've got such great people going into it and then they are faced with dealing with the problem that they may feel is out of their league? >> guest: there are few things that happen. number one is here now i had a geriatric clinic right below my clinic in for years i walked past her without ever knowing what they did in there. 97% of medical schools don't teach geriatric so i went down and i said let me hang out with you for a day in the geriatricians did. among the things he did was recognize the most life-threatening thing for some of his patients over 80 was that they might fall and if they fell and broke her hip they had an

average of only six months to survive and they were miserable. more important than getting a mammograms more important than the colonoscopy was preventing them from falling and he knew how to do that. he knew how to examine to look for ways at the toenails and the calluses could make someone unsteady and arrange for a podiatrist to help address those problems. >> host: if they could reach their feet. >> guest: he made them take off their socks to observe and let them struggle to take off their shoes and the ability of care they could have at home. he went further and recognize that people who are -- drugs and have a higher chance of falling so he reduced the drugs so he wouldn't have trouble with dehydration. >> host: so the drugs were not really necessary? >> guest: they weren't addressing the priorities. the priority was survival. a party with having as good a

life as possible for as long as possible and when you understood it that way then you are making different choices and trade-offs. it didn't matter that it was just a pulsing body but she was alive she was elected to the thing she wanted to do and what she said was their biggest priority was keeping her home. if you ask, if i ask you do you know the four risk factors for someone for their likelihood of falling and the three most important things that we can do? we don't know that. and so we didn't teach people along the way in medical school what is the science of aging population and of dying? what are the skills required to help people achieve the best possible outcomes. it actually is something that requires the employment of medical technology but its goals

and i think what has happened is our medical values, are fundamentally about health survival without recognizing the well-being. the second force that pushes us is money. who are the lowest paid people in our profession? us the surgeons, the geriatricians, the psychiatrist, that primary care physicians and it's because these professions really take time to talk to people but having the payment allow people to have the time to talk and get an understanding of what matters in people's lives and make the plans accordingly just doesn't remotely pay off in society. you can do an operation that we can do that colonoscopy. >> host: i didn't even know there was a field of medicine called geriatrics in medical school, did you? >> guest: no i didn't.

>> host: if i understand the degree like pediatrics grew where folks were specialized in infectious diseases or primary care but they did that for older patients and as i think about these issues you are talking about i'm thinking what is happening to geriatrics today? >> guest: at a time when we have more elderly people than ever we are training fewer people today in geriatrics than we did a decade ago. in fact it's reached the point where they geriatrics profession itself says we are so far behind the eight ball the country has been ignoring the fact that we don't train geriatricians and we now pay geriatricians that we have to give up that there won't be enough to geriatricians for need out there. we have to train these basic skills to an internist, to schools and residents said they are right. we have to make these basic skills what are the checklist?

by last book. what are the checklist that have to be executed that are the most important for people who are facing aging and address their particular health needs but also looking back being able to ask the key questions and get some skills and improvement along the way and how to ask people about their priorities in life effectively while helping them understand you still care. just because you are talking about the worst-case scenario does not mean you are saying you know giving up. >> host: medical school seems to be and i may be overly reducing it but it seems to be the equivalent of learning so many core language is the only way to memorize anything is to pare things diagnosis, treatment, diagnosis, treatment and it's almost like we can come out with this reflex.

there's a diagnosis? i maltreatment and what is great about bad as you can learn all this knowledge but what is concerning is you can miss out on a sense of what's appropria appropriate, appropriateness and that really seems to be one of the focuses of the issues around your end-of-life as you describe it in the sense that when is it appropriate? wire retreating high cholesterol and somebody who has a life expectancy of two years when the cholesterol -- >> guest: in the medication makes him dizzy and likely to fall. >> guest: i think it brings up a core point which is how do we deal with appropriateness? the great fear that people have is that dealing with appropriateness is that it's no longer about mine choices and i think we are seeing an evolution of what it means to be a doctor. 50 years ago it was the

paternalistic doctor. the doctor would tell you what you are going to get and might not tell you what's really going on with you never would go through the options. yes doctor whatever you say in that kind of thing. we don't want to worry people's pretty little heads about what's going on. we rebelled in the 70s, 80s and 90s about that and by the time you and i were trained we were talked to be almost a retail model. you go through option a, auction b an option c in the talk about the risks and benefits and make a whole menu of options in the nay what would you like to do? which one do you want? invariably you find this. they say i don't know. what are we taught to say? it's not my decision. this is your decision. and what is evolving is the

recognition and i began to see it when i follow the geriatricians and they pelleted care doctors. they play the role role of a counselor in the culture says here are the options but i need to ask you a few questions to understand your life. >> host: people want guidance. they want options but they want guidance. desk of the guidance has to come from your understanding of what their priorities are enlightened enough to be good at listening to the short conversation. they are good at that conversation. what's the understanding of your health? what are your fears and worries for the future? what are the goals that you ha have? what are the outcomes that would be unacceptable to you and based on that oh well option a that doesn't work an option b doesn't work. option c might be the way to go. or none of them work and we have to make up a solution here. i had a woman who said you know what my priorities is a wedding

i want to get to this weekend on saturday. she was admitted to the emergency room with a obstruction from her tumor. but we focused on was how do we get her to use medical technology not to put her in the icu were to do surgery but to get her to that wedding? that's when it gets cool again to be a doctor in no? >> host: that's great. the first time you had to bring bad news to the patient do you remember that time and what was it like? >> guest: i remember it because mainly as an intern you would be asked to go in and get the informed consent or consent them. you would in there -- invariably be explaining this operation and talking about the risks and benefits. you have this risk of terrible bleeding and he might have an

infection and invariably they raised their eyebrows and they say no one said anything about that. we all have our way of evading it. you learn and they end up saying oh researches forms. don't worry about it. just legalese and. >> host: how how can even validate publications are like. >> guest: what's fascinating is when i met the people who are really good at walking through a conversation about what you want to do in the resuscitation order or consent they treated that conversation the same way that people treated teaching us how to do an operation. they broke it down. they studied what the component parts are and they recognized there are certain questions that are more effective than others.

for example one of them explained to me you need to track yourself and you should be talking less than 50% of the time and i began tracking myself. i was talking 90 plus% of the time in the patient would not and then you would say do you understand? yeah, yeah i understand that was her conversation. that set of skills, how do you break that? there are good ways and bad ways. a the bad ways give all the facts and none of the meaning. >> host: teach the medical vocabulary. >> guest: exactly. here's the data and here are the chances of this and hear the chances of that. effect of conversation is what i know and i'm worried. i'm worried about these kinds of complications and i'm not worried about these other ones. i'm very hopeful about certain things. i wish that, they talk about i

worry, i hope, i wish. i wish it were true that we could cure this. i hope that we will be able to buy you more time. i'm worried you may end up back in the hospital again and that's saying to people here is the data, here's your understanding and i'm on your side on this. and i admit i have some uncertainties. you and i have all been fooled. i tell the story of my dad. i thought towards the very end that this was it, this was the moment and he woke up. what are you guys doing? i have three more days. >> host: as you say some of those phrases i'm concerned. it reminds me of the importance of the art of language as a doctor. i remember in med school mentors

told me don't ask patients are you taking your medications because they will get the sense of but ask them. a lot of people have a tough time taking their medications as they should, how do you been doing with that? it's amazing. with one set of vocabulary there's a huge disconnect during alienation and then when you phrase things a certain way and you talk about end-of-life issues as you are it's almost like inviting a conversation. >> guest: there are two things missing. words matter. words matter in the stories matter. part of writing about this and doing an investigation there was deliberately a journalistic investigation. i was less interested in taking out the details and the nuances and complexities that make it so when you do a randomized trial you look at only what everyone he has and what we do and a

careful case study is recognized the stories are really powerful and they tell you a lot about the experiences of the body, the experiences of illness and in this case this experience of mortality. i think you know we are increasingly willing to recognize that those are just as important contributions to knowledge and our skills and professions as the straightforward quantitative one. >> i think of a time i was in the trauma bay and my patient died and i was told the mothers next-door. i walk in there and the mother is happy and says how is my son doing? instantly this massive emotion, mad at myself for not thinking through this ahead of time, what should i tell her and a little

bit of my training may be completely miss this part. to what extent when you are researching the issues with end-of-life care did you look back and feel like how could this be missing? >> guest: all along the way. i'm a surgeon and you are a pancreatic surgeon so you are dealing with every patient having to have the kind of discussion. only some of mine are folks with whom i'm worried they are potentially at end-of-life. one of the first essays i wrote was about a 23-year-old who died from him, and at subsequent times i've written about family members and the struggles of how are we supposed to cope in these situations? >> host: i'm curious.

you break bad news all the time and you have seen a lot of people die. was this mostly familiar or did you feel like you sopping super new to you that were helpful? >> host: iselle things that were new in this book because you have done a tremendous amount of research and used a lot of observations. i really encourage myself to ask what are to ask whether to ask whether your goal dissipation? last week i had a patient who was 81, frail and day-to-day pancreas surgery in order to remove the pancreas but instead i stopped and said what are your goals? i really want to spend time with my husband and if i could get another year i would be happy. it was clear to me that she would outlive the cancer and it accomplished the goals that she wanted to accomplish. just go words matter bot and a lot of times the question is hard for people. they don't necessarily have career goals -- clear goals but

when you ask what your priorities and a couple of them get you there one of the outcomes that you would find unacceptable and one of the outcomes that you really hope for here were another set of words that i hadn't recognize is what are the goals if your treatment doesn't work or if your health worsens? these are harder to have sometimes. it's the listening when things aren't going the way you hoped. you have got some understanding at that level where to help them walk. i sometimes make a turn on the pathway. >> host: we are going to take a quick break and continue the conversation. >> on the go?

"after words" is available via podcast through itunes and xml. visit booktv.org booktv.org and click podcasts on the upper left side of the page. select which podcast you would like to download and listen to "after words" while you travel. >> host: atul gawande cdc came out with a report updating the numbers on life expectancy and now a life expectancy is up to 79 and if you make it to age 65 on average you will live to 83 if you are a man and 86 if you are a woman. as a matter of fact most of the statistics are better except for one. the suicide rate has gone up by two percentage points. do you think that depression is one of the underappreciated underrecognized epidemic problems and how does it connect to the issues of older people? >> guest: i do think it is and

what you see is very interesting which is that as people age they are happier as they get older. people in all of these studies compare a 30-year-old and a 77-year-old in the 7-year-olds are more likely to be happy and have lower rates of depression. they are likely to have more complex emotions. they can have poignancy which is this idea of negative and positive emotions at the same time until you incarcerate them and i use those words deliberately. putting people into nursing homes are housing situations where they don't feel that they are at home. the most common thing you hear from people in nursing homes is when do i get to go home? those are the groups that have much lower levels of happiness and i think that's the crucial binding.

we have become a society that has made it possible to have a great life because we have pensions and social security for when you retire. people are able to sustain themselves. they can live independently. they can get knee replacements and other things that can keep us going for longer. there is no better time to be all and history but when you become dependent and you no longer can take care for yourself any you are having false or your memory is going and you need help that is one it suddenly turns the tide and we are put into institutions that no longer honor what we get to have been the home which our choices, autonomy. even with small things. in an institution their topic is health and safety and in fact they will tell you bring a television. we are an incredibly safe place for your parent though we don't talk about the weather can the

parents go and the elderly person simply go to the refrigerator and get what they want to eat whenever they want? will they be allowed to wake up whenever they want? what happens is there's a scheduled time to wake up. there is the pill line to get ready for and you get dressed at a certain time because it's all in the staff's schedule that's required. they look more and more like hospitals and in the hospitals they are all built around the nursing station. some of the interesting pioneering places they build them around the kitchen and move the nurses out into the site area because of not about the nurses. it's about being in a home, in a kitchen. people are allowed to open the door and get what they want. do you know how controversial that is? >> host: just a little bit of autonomy like that. >> guest: of the argument is

it's not safe. an alzheimer's patient is supposed to be eating only a puréed diet might go and get a cookie. it's fascinating. you see the writeups of patients who are violating rules and the most common reason these people is they would violate a food row. you will see alzheimer's patients having cookies. you know what? let them have the dam cookie. it's not only important at the cookie but what we sacrifice is the idea that these are people who live for something more than bingo and safety and just being alive today. these are people that histories. they were teachers, they were policemen and they were doctors. they care about the connections to the outside world from the church to other places that they were part of and they care about

being able to live for larger purposes. one of the fascinating experience to talk about is a pioneer who brought pets into nursing homes and had to battle all kinds of regulations make it possible that even people with dementia have pets they have something to care for the world than ever person a reason -- a purpose in a reason to live. those folks woke up. they became active in life. they ended up needing less medication than they even live longer. >> host: is the autonomy really symbolic of people and that they are given some of their dignity back? is that really what is part of the happiness when you describe your own mother-in-law i think it was? she liked to wear certain shoes. that was part of her identity and she wore them proudly. the nursing home for safety reasons relegated her not to

wear the shoes. have we taken away dignity later in life and in certain contexts and the united states in places as you describe where people are incarcerated? just go yes. i think there are places where people are getting the idea that this has to change in the culture of change in nursing homes and assisted living and even in making home health care has become one of the most amazing sources of innovation. we talk about technology innovation. right now in this country in every state there's a revolution in how this kind of care is provided and major things are small. it's allowing people to have a lock on the door which means that the workers have to knock on the door to have permission to come in. it's respecting privacy, moving from double rooms to single rooms.

when an invite since college will we have had to live with an unknown roommate who might be up all night, crazy. people care about these fundamental things. the homes that exist understand the people who they market to are not the parent. they marketed to kids because often the kids are decision-makers. someone i spoke to said this great quote. they said safety is what we want for those we love but autonomy is what we want for ourselves. we make a win ask what is the safety record at how lonely -- we don't ask a lonelier people and how do you ensure people have purpose in their days? how engaged are people able to be with the world and what's important to them? are people even getting to learn

and pursue new things in their lives? the places that i've i visited and wrote about have done that. it has change the experience. it described meeting a 94-year-old man who is was having some trouble with memory. he didn't have all of his teeth but then he describes some of the things he was getting to do and for the first time in my life i was not afraid. >> host: you nicely point out how it's both a sense of autonomy and company or companionship that contributes to happiness. do you think this seeds for loneliness are increasingly starting earlier with a personalized society that we live in? this is really the first time in civilization where folks leave to go to college and they may

live alone and soon after they graduate from college most people live alone and they have their personal lesson that and devices in personal subscriptions to movies. it's such a personalized individual or society. you think that's why we are seeing an emergent of the shared culture businesses like air bnb or uberor is it the car, these sorts of businesses that try to say hey we are a retirement community trying to create more of a community rather than a facility in trying to create more of a sense of shared activity and shared interest in outpatient? >> guest: given the choice many people will provide the pathway that provides at least pathway to the human being. i don't want to have to connect with the human being if i don't have to and its manifest in lots

of interesting ways that we have seen over the last century that when people got pensions and social security the first thing the elderly did was they moved out. they'd rather live alone than live in the family with their kids and be under the rules of the house. they didn't want to live by their son or daughter's rules and the son or daughter don't want to live by their rules and live in their house so we live in an increasingly what the sociologists called intimate distance, near one another but not too near. i think where we are hungry though is that we do still want the contact and the intimate relationship and friendships relationships that take investment that sometimes involve conversations and people don't always get along. retreating to your own states is absolutely necessary in order to

navigate. the hard part about aging comes when you can no longer be independent and retreat to your own corner because you need human beings to help you be able to manage anything from how do i change that lightbulb to getting to where you want to go and the frustration of having to wait and understand my needs and how do i negotiate that world? the crucial part about it though is we have completely assumed that just because you are dependent you don't have a life worth living anymore. what growth could there be and in fact there's a huge amount that's possible. that is reigniting the desire for connection to the world because you can still make contributions along the way were just have some joys of the

connections of the people you're close to. >> host: it's an amazing institution today in america in terms of the function and yet point out what they are not doing well in terms of giving people an institutional life and not giving them the autonomy they may need for happiness or companionship for things like the pet program. you also point out the book despite the title being "being mortal" has a lot of positive ways in it and which have been inspired by what you have seen other individuals and changes in the way things are done. >> guest: i do think it's coming from turning upside down the upside down the industries who created these places. i thought when i started researching the book nursing homes were coming into existence because people were living longer and we would come up with a rational way that makes sense for how do we take people

through these phases of their lives? we built a ton of hospitals in the 1950s. >> host: as the result of a law that passed around that time. >> guest: that's right. suddenly we had abilities that allow every community to build a hospital and a hospital filled up with elderly people whose problems could not be -- in the hospital said what do we do with these people? as medicare was created there was financing for allowing people to go to a nursing home for 60 days and it was called a nursing home. the idea was we would be nursing people back to hell. we were not creating these places to knowledge. [inaudible] so it was built around priorities of health and safety. safety is really important and many of these places in the 60s were fire traps. people would die in them and they were neglected.

they weren't created out of an understanding that this is really about the well-being home. nursing people to well-being can happen regardless of what prevails we face in the idea that people articulate priorities for what were the lines that we do not cross that make me feel like i'm at home. i think those are the things that we are now discovering. it's no coincidence the baby boomers are hitting the age where they are starting to think about that set of issues. we have parents who are starting to think about those sets of issues and this generation is not going to put up with being simply wards of the nursing state. >> host: the subject of end-of-life is a tough subject to talk about. for one reason because it's polarizing to folks.

that is people have that individual experiences or they have seen somebody on a ventilator for longer then that the person would have ever wanted or vice versa, undertreated. can you nicely discuss the issues of end-of-life care by also focusing on life not just a good death, focusing on achieving what you want to achieve during the end-of-life. what inspires you to take that positive approach to what otherwise is a very polarizing subject which from my understanding is not evoked a polarized reactions you would normally think from this book. >> guest: even talk about it and here's the fear that people have. it's going to be all about what you take away. it's just trying to guide people to give up sooner and what i saw

for meeting people and watching what happens is it's really about fighting for a set of goals that are different than what was understood and i realized the goal is avoiding death. number one death is messy and it's not entirely under our control but second that is just a tiny moment towards the end and it is about life and living even as you face tremendous constraints as we all face tremendous constraints. beginning to recognize that was what people were doing is what came out of looking closely at what we were regarding discovering. i think it also gets us out of the box of this incredibly polarized senate debates about talking about death panels. >> host: what are death and also that are watching no? >> guest: well it's a little

bit unfair. on one level it's a specific notion that by allowing for the possibilities of discussion, not just allowing but encouraging there be discussions about people's priorities at the end-of-life that we were really looking for ways to hasten peoples and. >> host: rationed care. >> guest: ration care. here's the important thing to understand the fundamental mistake we have made one powerful one book that terminal care patients. half of them got usual oncology care and the other half were given oncology care plus having meetings with the palliative care specialists and expect goals and priorities for persons remaining time.

the group who had their discussions about priorities ended up choosing therapy earlier. they had fewer days in the hospital and were less likely to die in the icu, started hospice in her less suffering at the end-of-life. they lived in this is the kicker, they would have 25% longer. >> host: even though they got less chemotherapy. what does that tell us about what we are doing? >> guest: indicates that we are making fundamental mistakes in our core decision-making that when we are adding that chemotherapy are trying that last-ditch operation it's out of an unwillingness to recognize that we might be sacrificing quality of life for people that in fact fighting just to have a good day now instead of more time is an ironically then idea. just fighting to have a good day now and not worrying about how much time there might be ironically does not shorten the time and it often lengthens the

time. i think at that failure to recognize the truth. there have been a number of studies. people who start on hospice in her don't end up living shorter. on average they lived equally long or longer. i think it just reflects lack of knowledge even in our own profession about what the evidence is showing. lack of understanding about why this might be. and we have them listen to her on patients about what priorities they have and what they might be. >> host: is a positive attitude part of the reason why people may live longer and the patients that got chemotherapy and didn't do better? >> guest: those studies like pessimist do they live longer than optimists collected think the major difference is when you try that last-ditch operation

for chemotherapy or other kinds of treatments putting them on the ventilator giving people a feeding tube, you would think that people can't eat, when it look at these approaches you get all the complications and the pain and suffering and often very little benefit to the point that the complications and the harm you have done, end up doing outweigh any potential benefit there. and so people end up doing worse. people get beaten down. they could physically beaten down by the toxicity of what you have done is less about the psychology. it's more -- we did a study. the week you are most likely to have surgery in your life is the last week of your life and the day you are most likely to have surgery is the last day of that week. when we go into surgery we don't

know whether things will turn out well in the end or not but when you are doing it with people that are facing terminal unless and this is your last-ditch effort and discussing priorities we are often sacrificing not just the quality of their life better chance of surviving and more often than not that very last stage. i think it's a wake-up call for our patients who if you were clinicians are willing to recognize your priorities discussing with your family and pushing clinicians that make them understand what your priorities are besides living longer and what are the things you do not want to sacrifice as part of your care? i think it's really important to look at that. >> host: does longevity run in families? you will hear patients say you know i get beavers after surgery but there's no infection. my mother had that in her bomb

had that. to what extent can we explore more the genetics? >> guest: what i tell people when my grandfather died at 110 they say you are so lucky. then i say that my mother died at 30 from malaria. there are interesting studies about the contribution of genetics and longevity. how tall you are. 90% of it is determined genetically and we know that by comparing the heights of identical twins but the average difference in the length of ti time, length of survival for identical twins is 15 years. there is on average they differ by 15 years and how long they live. people have a lot of wisdom later in life. older patients can disclose things to their doctor they wouldn't tell their own spouse or they will let you put a knife

to their skin minutes after meeting them just because you are their surgeon. what wisdom do patient share and what are they shared with you about accumulating money or about time spent with family? >> guest: i think you are referring to this great set of research done by psychologist named laura carson said she has been studying by asking people ages 18 to 94 in a study that has been going on for two decades. her team will page them periodically and asked them to record with their emotions are, what their experiences are. she asks him if you have an hour of time would you rather spend it with your sister or another family member or this movie star and the young tend to choose one signature which is that they want to take options that lead

to achieving more, to getting more, accumulating more and having more stuff and they want to meet more people and they love the possibility of going to aloud bar in the hopes of yelling to one another in conversations in the hope that you might meet someone know -- someone new. there's an older signature who says they'd rather spend time with their sister. they would narrow the number of people they focus on and want deeper relationships and more connection to the people they love. they are more focused on being an wanting to make sure they have some ways in which they have some contributions. they could be anonymous and small but contributions in the world. the fascination about it is that as people age, the thought was that our brains are changing to make you more wise that way.

laura carstensen discovered that some of the folks that were following had a terminal illness. this was done during their early hiv/aids and some of the patients would suddenly shift even though they were young to having the older signature and then she did a study during 9/11. when the world became uncertain and fragile and you weren't sure about what was happening everybody moved to a signature of saying i would rather be with family. i want to be connected to those i love and i want to make sure making a difference for them. that was the revealing thing. as time goes on when we are unaware of firm mortality which we are most of our lives, then we focus on getting, having in achieving. when we are near, when we become

aware of the finiteness and the limitations of our health and uncertainty of the political atmosphere for any variety of reasons. like ebola. we sadly want to focus on people we are closer with and being connected to others. i think that wisdom is really just a manifestation of having perspective on where we are in life. >> host: it's interesting. i've had patients tell me they wish they would have spent more time with their family but i've never heard anybody say i wish i would have spent more time working. >> host: i had two kids go off to college and if they said that's me right now i don't want to focus on work, it's want to be with family i was sam not sure that's a good idea. >> host: she showed that people they think they have 20 years or so we behave as though we are mortal and we sacrifice now and we are willing to delay

gratification. that makes no since when you become more aware of there being a finiteness of time. really it's just a matter of perspective to have the proper perspective for where you are in your place and time. >> host: our guest is good to see you again and congratulations on your book "being mortal" i love it and thank you for the conversation. >> guest: thank you. >> that was "after words" booktv's signature program in which authors of the latest nonfiction books are interviewed by journalists public policymakers and others familiar with their material. "after words" airs every weekend on booktv at 10:00 p.m. on saturday, 12 and 9:00 p.m. on sunday and 12:00 a.m. on monday. and you can also watch "after words" on line great go to booktv.org and click on "after words" in the booktv series and topics list on the upper right side of the page.

>> as barbara explained this is a book about scaring new emerging diseases and where they emerge from and where they emerge from generally is wildlife. it's from other species, nonhuman animals and in particular nonhuman animals other than our domesticated animals. if you have been following certain stories in the news over the last few months you know that one point of entry into this object is the daily newspaper itself. you have probably heard about until virus killing three people that visited yosemite this

summer. people have been dying in war north texas of west nile fever. i think in the dallas area alone dallas area longer than 15 people who died of west nile fever just since july. there has been an ebola outbreak again in central africa. the democratic republic of the, has an ebola outbreak that has killed three dozen people i think by now and still going on. there was another ebola outbreak across the border in uganda unrelated to the spillover that it caused the outbreak in the democratic republic of. that one has ended so these things are happening. this is like a drumbeat of disease outbreaks and small crises. there is another on the arabian peninsula. there is a virus that emerged that closely resembles the sars virus.

belongs to the same family, the coronavirus, the sars virus that really scared experts. this new stars like virus out of the arabian peninsula has only killed one person and put another man in the hospital in britain but scientists all over the world are watching it carefully. why are they watching it carefully? because they know the next big one could look something like that. so as i say there is a drumbeat of these things. those diseases that i mentioned all have two things in common. they all come out of wildlife. they emerge from nonhuman animals and among those that i mentioned they are all caused by viruses and that is a particular profile of the scariest of the exemplars of this phenomenon. the scientists have a fancy name for it. as barbara mentioned they call

these animal infections that pass into humans zoonoses, a virus or can be other forms of an infectious bug. it can be a bacterium. it can be to produce on like the creatures that cause malaria. it could be a fungus. it could be a worm. could be something called a prion which causes mad cow disease. usually it's a virus. viruses more than anything cause these. and they passed from animals and humans. they don't always cause disease. sometimes they become harmless passengers in humans. there is a virus that i talk about in the book and i couldn't resist it because it's got such a wonderfully gruesome name and you have to find a light side of this subject where you can find it.

[laughter] and with all due respect to the people who suffer, the people who die and there are a lot of depth in this book. there are a lot of depth and i respect that but still i didn't want this book to be just a painful gruesome duty, just an important scary book. i also wanted to be pleasurable reading experiences. i wanted to be a page-turner and i wanted it to have moments of suspense and moments of heroism by some of the scientists studying this sort of thing and yes we look at some moments of humor. it's not a very funny book but i hope it might be the funniest book about ebola that you ever read. [laughter] you can watch this and other programs on line at booktv.org. ..

>> >> >> of the transportation and logistics sector that is why to're generally interested