mix the two processes. . . you're i happen to get up very early for work, and then i work

on weekends, and i would write -- i would do all sorts of things for motivation. i'm a real deadline person so i tent to get things done, but it's hard to get things done when you're exhausted. so i'd work in here in the living room, upstairs, library of congress. i just kept going. and i played all sorts of tricks on myself. i would break down my increments and think, if i got used to saying to my daughter, if anything happens to me, destroy the post-its that say in this 15-minute increment you do this and that. i found if you work in those short chunks you're getting things done. i'm a great listmaker and i love to cross things off my list. so that's how i gets done.

>> up next, after words, this week, dr. atul gawande in his latest book, "being mortal." the author argues that with all that medical science can solve in the modern era it's still deficient in the area of aging and dying. this program is an hour. >> atul, great to see you again. congratulations on the book, "being mortal." >> thank you. >> the book 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 has this famous quote from

the poem, i bequeath myself to the dirt to grow from the guardrails that i love. what does the leaf of grass mean to you. >> guest: it's a biblical reference. awe flesh is grass and refers to the idea that on the one hand we all come from something fertile, and the idea that grass is mortal, grass is temporary. >> host: in the process of writing this book "being mortal" which i think is terrific. one of the few times we can have a conversation about mortality and end of life issues. did it hit you, strike you, i'm not going to be around here forever? maybe i should talk to my patients differently about their goals? what impact did writing this book and doing the research have or your own practice? >> 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. we reached by the end of the 1990s where 17% of the population died in the home and 83% died in institutions, often hooked up on machines, up aware of what was happening in the world no chance to say goodbye. no chance to preserve some quality of life as they came to the end. it was clear that this was not what people wanted, and that i wasn't being successful at it. so, 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 scores of palliative care physicians, hospital workers, nursing home workers, and i learned along the

way. about what some do that is really successful process of changing care at the en, and i began trying that, and then my father was diagnosed with a brain tumor in his brain stem and spinal cord, and unexpectedly needed to use some of what i was learning as a son instead of as a doctor. >> host: was that a tough time? >> guest: it was. having the chance to understand what people who are more effective, whether as family members or as clinicianses, what they do, made it less tough. it was very interesting. 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. and i was never taught to articulate and recognize that. the second part was that the

most reliable method of learning what people's priorities are is to ask. and i wasn't asking. and also i wasn't asking even my own dad. and so when his condition began to deteriorate, and this is a tumor that was going to make him quadriplegic as it gradually took his life, and he faced options of surgery, radiation chemotherapy. i started asking the questions that people talk about asking. so, what are your priority? and what are the tradeoffs you're willing to make and not willing to make? hard questions to ask. and yet changed every step of his care along the way. >> host: you describe your grandfather, siterum gawande.

lived to be 110. >> guest: he is fascinating. he is the kind of old age we think we want. he -- 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 could sit at the head of his dinner table at home, still the head of the family. people came to him for business advice, for advice about who they should marry. he was respected and venerated. and he really was able to live as good a life as possible all the way to the very end. now, what made that possible? and why did we lose that sunset that was the lesson. >> as a society? >> guest: in other words that is what mrs. hat in the 19th 19th century, what europe and china and korea and india are leaving right now and why. the breakup of the extended family, taking care of somebody like him, is occurring because

that it worked only by enslaving the young. young women, to provide the care, and then on top of it, his sons. national reaching your 80s, still waiting to inherit your land. having your economic future still dependent on your dad. and the economic progress of the world occurs because you give young people freedom. they, work with where they want, live where they want, marry woman they want. they move to the cities. often take different lines of work. often leave the elders behind, and we depend have a plan -- we didn't have a machine for what happens to people left behind. india, china, korea don't, either. and what we have decided, medicine will take care of it. >> host: just turn it over to the health care field and they'll fix and take care of and treat. >> guest: my dad is having trouble with memory or having falls in the home. well, let's take him to the doctor. what happens? we say, well, we like fixing

problems. we have a procedure we can do. we have a therapy we can offer. but some problems you can't fix and can't make them go away, and then we throw up our hands, and we say, you know, well, i can either try x, y, z, or see another specialist. thr understanding. there are things to fight for besides just living longer or trying to repair unrepairable problem. >> host: when we go through school, it seems like medical schools, nursing schools, attract good people. these are the type of high school student that wants to be a nurse is remarkable person. the sort of person that interviews for medical school is a remarkable person. and then they come out in this dilemma, and is it confusion,

ill-preparedness, a sense of, this is out of my league. where do things go wrong when you have great people going into a profession, and then they're faced with dealing with a problem they may feel is out of their league. >> guest: there's a few things that happen. number one is -- i had a geriatric office, a clinic, right below my clinic, and forrize walked past without ever knowing what they did there. 97% of medical schools don't teach jeeratric skills -- geriatric skills. i asked if i could hang out, and he recognized that the most life-threatening things for patients over 80 is they might fall, and i they fell and broke their hip, they had on average only six months they survived and they were miserable. so more important than getting their mammogram, more important than the colonoscopy, was preventing them from falling, and he knew how to do that. how to examine the feet to look

for ways the toenails and the calluses could make someone unsteady and arrange for a podiatrist to help address the problems. >> host: even see if they could reach their feet. >> guest: make them take off their socks and observe, sit back and let them struggle to take off their shoes but is told him something about their abilities and whether there was care they could have at home. he wasn't further and recognized that people who are on drugs have a higher riecks of fallingg and he reduced the drug so he wasn't having trouble with dizziness and dehydration. >> host: that was because the drugs weren't necessary? >> guest: they warrant addressing the priority. the priority wasn't survival. the priority was having as good a life as possible for as long as possible, and when you used it that way you were making different choices and tradeoffs. didn't matter it was just a pulsing body. it was that she was alive to do the things she wanted to do, and what she said was her biggest

priority was keeping her home, and so if you ask -- if i asked you, do you know that four risk factors for someone to -- for their likelihood of falling and the three most important things we can do? we weren't taught that. we don't know that. and so we didn't teach people along the way in residency, in medical school before that, what ills the science of the aging body? and of dying? what are the skills required to help people achieve the best possible outcomes. it actually is often something that requires the deployment of medical technology but for different goals. i think that what has happened is that our medical values, our fundamentally about health-based on survival, all recognizing that well-being is bigger than that. the second force is money. who are the lowest paid people

in our profession? not us as surgeons. the ge -- the 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 make -- get an understanding what matters in in people's lives and then make plans accordingly. just pay as well as deciding, we can do an operation or we can do that colonoscopy. >> guest: i didn't know there was a field of medicine called geriatrics in medical school. >> guest: i didn't. >> host: it grew like speed pediatrics grew, where folks still specialized in diseases or primary care but for older patients, and as i think about these issues you're talking about, i wonder, what is

happening to geriatrics today. >> guest: it's in decline.+] at a time when we have more elderly people than ever, we're training fewer people in geriatrics than a decade ago. it's reached the point the geriatrics profession says we're so far behind the eight ball can the country has been ignoring the fact we don't train geriatrics doctors and we have to give up the idea there will be enough for the need and we have to train these basic skills to enterrists to medical students to residents. and they're right. we have to make these basic skills of -- what are the checklifts -- my last book -- the checklift for -- that have to be executed on that are the most important one for people who are facing aging, and addressqp their particular healh

risks. also, stepping back, even higher than that, being able to ask the key questions and get some skills and improvement along the way in how to ask people about their priorities in life effectively, while helping them understand, you still care, just because you're talking about the worst-case scenario, does not mean that you're saying, you know, i'm giving up on you. >> host: medical school seems to be -- i may be overly reducing it but seems to be the equivalent of learning so many foreign languages-the only way to memorize everything is to pair things. diagnosis, treatment, diagnosis, treatment. and it's almost as if we can come out with this reflex. diagnosis, treatment, diagnosis, treatment. you can learn all this knowledge and there's plenty to learn, but what is concerning is you what

is appropriate, and that seems to be a focus of the issues around in the end of life as you describe them, the sense of, when is it appropriate? why are weá3 treating high cholesterol in somebody who has life expectancy of two years when the cholesterol is not going to kill them -- >> guest: and the medication makes them dizzy and likely to fall. >> host: and may confuse it with an important medication. >> guest: brings up a core point. how do we deal with appropriateness. the great fear people have, the charge these are about death panel is that dealing with appropriateness means it's no longer about my choice about what is appropriate. i think what we're seeing is an evolution of what it means to be a governor in the last half century it's changed. 50 years ago, the doctor knows best. the doctor would tell you what you're going to get, might or might not tell you what is really going on with you, never would go through the options.

>> host: yes, doctor, whatever you say. >> guest: we thought it was our job-don't want to worry people's pretty little heads what might be going on. we rebelled in the '70s, '80s, and '90s we were taught to be doctor informative, i call ill. almost a retail model. go through the options, option a, b., c., talk that the pros and cons and risks and benefits and make the whole menu of options and go, what would you like to do? which one do you want in and invariably you find this, right? they say, i don't know. what would you do, doctor? some what are we taught to say? it's not my decision. this is your decision to make. i'm not deciding for me. you have to be the one to decide. and what is evolving is the recognition -- i saw it when i followed the geriatric doctors and the pal yative care doctors they play the role of counselor and the counselor says these are the options but i need to ask you questions to dish.

>> people want guidance. >> guest: the guidance has to come from what your understanding is of their priorities and you have to be good at eliciting in a short conversation. a 20-minute conversation they will ask, what is your understanding of your health? what are your fears and worries for the future? what are the goals that you have if your health worsens? what are the outcomes that would be unacceptable to you? option a., that doesn't work, and option b. doesn't work. option c. might be the way to good or none of them work. we have to almost make up a solution here. i had a woman who said, you know what? -- she had ovarian cancer. she said my priority, there's a wedding i want to get to this weekend, on saturday. she was admitted into the emergency room with a bowel obstruction from her tumor so she couldn't eat, really sick. we focused on how to get her to the wedding?

put her in the icu or surgery, but to get her to that wedding. that's what -- that's when it gets cool again to be a doctor. >> host: that's great. the first time you had to break bad news to a patient, do you remember that time? what was it like? >> guest: i remember it mainly because as an intern, you would be asked -- you probably were asked as well -- tog ho in and get the informed -- as we -- go consent them, turn it into a verb. and you would invariably be explaining this operation and talking about risks and benefits get sayf death and terrible bleeding andf might have an infection, and invariably they raise their eyebrows and say, no one said anything about that. and you say, oh, we all have our way of evading it. you watch the chief resident. they end up saying, oh, oh, oh,

this is just -- these are just the forever. don't worry about it. just legalees, and what -- how can. >> host: how can we know what the complicationses are like? how do we counsel people? >> guest: the fascinating thing is when i met the people who are really good at walking through a conversation about whether you want to do a do not re -- re sunday tate order or not. they treat it, that conversation, the same way that people treated teaching us how to do an praying. the broke it down, study the component parts, and recognize, there are certain questions that are more effective than others that you need to use. one of the explained to me, you need to track yourself and you should be talking less than 50% of the time you're in the room with the patient. i tracked myself. i was talk can 90% of the time

and the patient would nod and then you say, do you understand? and they say, i understand, and that was the conversation. how do you break bad news to someone? there are good ways and bad bays. the bad way is give all the fact and none of the meeting. >> host: retreat to the medical vocabulary. >> guest: exactly. the prognosis of this, the chances of that. the effective conversation ises, here isñ what i know and i'm worried. i'm worried about these kinds of complications in you. 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 is saying to people, here's the data. here's your understanding. and i'm on your side on this. and i admit i have some uncertainty. i'm worried is, i am positive. you and i have all been fooled. i tell the temperature of my dad. -- the story of my dad. i thought he was towards the very end, that this was it, the moment he was gone, and then he woke up. what are you guys doing? had three more days. >> host: as you say 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 method indications? because they'll get defensive. ask them, a lot of people have a tough time taking their medications as they should. have how you been doing with it?

it is amazing. with one set of vocabulary there's a huge disconnect or alienation, and then when you phrase things a certaino2j] wa, talk about end of life issues, it's almost inviting a conversation. >> guest: there's two things we're missing. words matter. the words matter. and the stories matter. and part of even writing a book like this and doing the kind of investigation i did, it was deliberately a journalistic investigation. i was less interested in taking out the details and the nuances and complexities and make so it you -- when you do a randomized trial you remove all the detail and look at only what everybody has in common and what we do in a careful case study, or in a bunch of case studies, recognize that the stories are really powerful and they tell you a lot about the experiences of the body, theyí experiences of

illness, and, in this case, the experience of mortality. and i think we are increasingly willing to recognize in medicine that those are just as important contributions to knowledge and our skills and profession, as the straightforward quantitative work. >> host: i think of a time i was in a trauma bay and a patient died, and i was told the mother's next door, for you to talk to. i walk in there the mother is happy and looks at me and says, how is my son doing? and instantly this mass of emotions, mad at myself for not thinking through this ahead of time, what should i tell her? mad a little bit at my training for having maybe completely extend when you were 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 cancer surgeon, like you're a cancer surgeon. i don't even -- you're a pan treeatic cancer surgeon so your dealing with every patient having to have this discussion. only some of mine are folks with whom i'm worried they're potentially at the end of life. i have written about family members with serious illness and the struggles of just, what are we -- how are we supposed to cope in these situations? i'm curious for you, like, reading this book, you break bad news all the time, pancreatic pan -- cancer patients. seeing them die. was this mostly familiar or did you see things that were knew to you that were able? >> host: thinks that were new in

this book because you have done a lot of research and observations to encourage myself to ask, what are your goals as a patient? last week i had a patient who was 81, frail, and needed a pan careeras surgery in order to remove the pancreas. but i said, wait a minute. what are your goals? tell me. they said i really want to spend time with my husband here and if we can get another year, i would be happy. it was clear to me that she'll outlive this cancer and accomplish the goal she wanted to accomplish. >> guest: one thing i think that the words mif#uju a lot, and asking people about their goals, a lot of time that question is hard for people. they don't necessarily have clear goals but when you ask questions about your priorities and a couple of them get you there one is, one of the outcomes you would find unseasonnability and the outcomes you hope for here? another set of words i had not

recognized was whether the -- what are the goals if your treatment doesn't work or if your health worsens? these are harder to ask sometimes. another one is, what are your fears and worries for the future? but it's eliciting the guidance so that when things going the way you hope, you've got some understanding as a doctor about where to help them walk, and sometimes make a turn on the pathway. >> host: we'll take a quick break and continue the conversation.

iatul. cdc came out with a report updating life expectancy and now it's up to 9 and if you make it to age 65, on average, you'll live to 83 if you're a man and 86 if you're a woman. matter of fact most of the health statistics arenk better except for one, the suicide rate has gone up by a few percentage points. do you think that depression is one of the underappreciated, underrecognized endem mick problems and how does it connect to the issues of older people? >> guest: i do think it is. what you see is very interesting, which is that as people age, they actually have -- they're happier as they get older. this is a little counterintuitive. people in all of these study -- you compare a 30-year-old and a

70-year-old and the 70-year-olds are more likely to be happy, lower rates of depressions, likely to have more complex emotions. they can have poignancy, this idea of negative and positive emotion at the same time, until you incarcerate them. and i use those words deliberately. put people into nursing homes or housing situations where they don't feel they are at home. what's the most common thing you hear sometimes from people in nursing homes? when do i get to go home? and those are the groups who are -- have much lower levels of happiness. and i think that is the crucial finding, is that when -- we have become a society that made it really possible to have a great life as we have pensions and social security when you retire. people are able to sustain themselves, can live independently.

we get knee replacements to keep us going longer. there's no better time to be but when you become dependent, when you no longer can take care of yourself, having trouble with falls or your memory is going and you need help, that is when it suddenly turns the tide and we're put into institutions that no longer honor what we have to -- get to have in the home, which are choices, autonomy. >> host: even with small things. >> guest: so, in institutions, their top goal is health and safety. we are an incredibly safe place for your parent. but we don't talk about whether-can the parent go -- can 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 i they want? no. what happens is there's a scheduled time to wake up.

there's the pill line. to get ready for, and you get dressed at a certain time because it's all on the staff schedule. but they look more and more like hospitals, and in the hospitals, they're all built around a nursing station. you -- some of these interesting pioneering places they built them around the kitchen, and move the nurses out into a side area because it's not about the nurses. it's about being in a home. in the kitchen, people are allowed to go open the door and get what they want. do you know how controversial that is? >> host: just a little bit of autonomy. >> guest: the argument is a diabetic might get a soda out of the refrigerator, it's not safe. an alzheimers patient is supposed to beiñ eating on a pue poureed diet might get a cookie. you see writeups for violating rules. you can get written up.

the most common reason people get written up is because they violated food rules. hoarding cookies, and you know what and let them have the damn cookie. the ability to offer choices and ways that not only -- it's not only important to have the cookie. what we have sacrificed is the idea that these are people who lived for something more than bingo and safety and just being alive today. these are people who had histories, they were teachers. they were policeman, doctors, and they care about the connections to the outside world, to the church, to other places they were part of, and they care about being able to live for larger purposes. one of the fascinating experiments i talk about is a$5 pioneer who brought pets into nursing homes and had to battle regulations to make it possible,

but when people had pets -- even people with dementia, they suddenly had something to care for in the world, a purpose and reason to live and those folks woke up. they became active in life. they had -- ended up needs less medications and even lived longer. >> host: is the autonomy really symbolic to people in that they are given some of their dignity back? is that really what is a part of the happiness when you describe your own mother-in-law issue think it was, she liked to wear certain shoes. that was part of her identity, and she wore them proudly, and the nursing home, for safety reasons, relegated her to some -- >> guest: she wasn't allowed to wear the shoes. >> host: have we taken away dignity in later in life in certain contexts in the united states, in places as you described, where people are in a sense incarcerated?

>> guest: yes. i think there are places that are getting the idea this has to change, and that the culture of change in nursing homes and in assisted living and even in making home healthcare change, has become one of the most amazing sources of innovation in the country. we talk about the technology innovation. right now in this country in every state, there's a revolution in how this kind of care is provided, and the major things are small. it's allowing people to have a lock on their door, which means wok on the door to have permission to come in. it's respecting privacy. moving from double rooms to single rooms. when a licensed college, where roommate who might be up all night, crazy -- >> host: sounds and noises. >> guest: people care about

these really fundamental things. why does this happen? the homes that exist, they understand that the people who they market to are not the parents. they market to the kids because the kids are often the decisionmakers. we -- 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. and we may go in and ask, what is the safety record? we don't ask, hoe lonely are people? how do you ensure people have purpose in their days? how engaged are people able to be with the world and with what is important to them? are people even getting to learn and pursue new things? the places i visit and write about have done that. and it has changed the experience. i described meeting a 94-year-old man who had -- having trouble with his memory.

he didn't have all of his teeth. but they then you describe the things he was getting to do and for the first time in my life i was not afraid of being 94 years old. >> host: you nicely point out it's both y and company or companionshipth y that contributes to happiness. do you think the seeds, though, for loneliness, are increasingly starting earlier in life with the personalized society we live in? this is the first time in civilization where folks leave to go to college, may live alone, and they have their personal this and that and phone and devices and personal subscription to movies. it's such a person, individualized society. do you think that is why we're

seeing an emergence of the shared culture businesses, things like uber, or zip car, this businesses that try to say, hey, we're a community? retirement communities. trying to create more of a community rather than a facility. trying to create more a sense of shared activities, shared participation. >> guest: it's really interesting because given a choice many people with choose the pathway that provides the lease contact with a human being. i don't want to have to connect with a human being if i don't have to. and it's manifest in lots of interesting ways over the last century that when people got pensions and social security, the first thing that the elderly did was they moved out. they'd rather live alone than live in the family of their kids.m:

and be under their rules in the house. they didn't want to live by their son or daughter's rules. the son and daughter don't want to live by their rules and live in their house. so we live increasingly at what the sociologists call an intimate distance. near one another but not too near. and i think where we are hungry, though, is that we do still want contact, the intimate relationships, friendships, relationships over time, they sometimes involve hard conversations and people don't always get along. the freedom to retreat to your own space is absolutely necessary in order to navigate those freedoms. 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 my light bulb, to getting to where you want to go, and the frustration then of, i have to wait, i don't understand my needs and how die navigate and -- how do i navigate and negotiate that world? we assumed just because you're dependent, don't have a life worth living anymore. what purpose -- what achievements, what growth could there be? and in fact, there's a huge amount that is possible, and that is re-igniting the desire for connection into the world because you can still make contributions along the way, or just have some joy with the connection to people>g you lovr are close to. >> host: how did we get nursing home inside it's an amazing institution today in america. serves a function. you point out what they're not doing well in terms of giving people sort of institutional

life and not giving them the autonomy they may need for happiness or the companionship with things like the pet program. but you also point out -- the book, despite the title "being mortal" has a lot of positive things in it and you talk about what you have seen out there, individuals and changes in the way things are done. >> guest: i do think it's coming from turning upside-down the reasons we created these places. you would have thought -- i thought when i started researching the book, that the reason nursing homes would have come into existence is because people were living longer and and we were go come up with a rational way that makes sense for how to take people through8: the different phases of their life. no. we built a ton of hospitals in the 1950s. >> host: as a result of a law that passed around that time. >> guest: that's right. hospitals suddenly had technological capabilities, a law allowed every community to

build a hospital and finance building the hospital, and he hospitals filled up with elderly people whose problems could not be fixed, and the hospital said, what do we do with these folks? and so as medicare got created, there was financing for allowing people to go to a nursing home for about 60 days and it was called a nursing home. the idea was that you would be nursing people back to health. we were not creating these places to knowledge you might not be able to get folks back to hasn't. so they were built around the priorities of health and safety. now, safety is really important. many of these places in the 60s were fire tripes. people died in them, neglected. there's some basic level that has to be there but they weren't created out of an understanding that this is really about a well-being home. nursing people back to health may not happen. nursing people to well-being can

have and the idea that people articulate priorities for the lines that you do not cross that make it -- make me feel i'm at home. those are the things we're now discovering and no coincidence, the baby-boomers are hitting the age where they're starting to think about that set of issues. we hav parents who are starting to think about those sets of issues, and this generation is to put up with being simply wards of a 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. people have had individual experiences or they've seen somebody on a ventilator far longer than the person would have ever wanted, or vice versa, undertreated. you seem to have nicely discussed the difficult issues

and end of life care by also folk ku cussing on life, not just a good death. focusing on achieving what you want to achieve during the end of life. what inspired you to take that positive approach to what otherwise is a very polarizing subject which, from my understanding, is not really evoked the polarized reactions you normally think from this book. >> guest: i even talk about assisted out suicide and the -- here's the fear that people have. that the discussion of end of life orç discussion about whats going to happen as i age, it's all about what you take away. that it's just trying to guide people to give up sooner because you're not giving up soon enough. and what i saw from meeting people and watching what happens is that it's really about fighting for a set of goals that are different than what we understood. and i realized the goal is not a good death. that is not -- number one, it

is -- death is messy. and it is not entirely in our control. but second, that is just thewk tiny moment towards the end, and it is about life and living even as you face tremendous constraints, as we all face tremendous constrains, and beginning to recognize that it what people were doing, is really what came out of looking closely at what the field was already discovering. now, i do think it also gets us out of the box of this incredibly polarized set of debates about, are you really talk about death panel. >> host: what are death panel inside other. >> guest: it's a little unclear. on one level it's a specific notion that we, by allowing for the possibilities there would be discussions -- not just allowing -- encouraging the

possibilityñ

time. it's that failure to recognize the truth in that there have ban number of zoo -- studies. people who are in hospice sooner live equally long or longer.

so, i think it just reflects lack of knowledge, even in our own profession, about what the evidence is showing. a lack of understanding about why this might be. and then we have them listen to our own patients about what priorities they have and why that might be. >> host: is a positive attitude part of the ron you think people may have lived longer in the arm of patients in that study that got let chemotherapy but lived better. >> guest: i don't think so. do pessimists live less long, and they don't. i think the major difference is that when you try that last ditch operation, or chemotherapy or other kinds of aggressive treatments, putting them on the ventilator, giving people a feeding tube, you think a feeding tubes if people can't east -- when you give the

process, you have the complications, pain, suffering, and often very little benefit. to the point that the complications and the harm you have done as you have begun to do it, outweigh any potential benefit there. and so people end up doing worse. >> host: people get beaten down. >> guest: physically beat down by the toxicity and less about the psychology and more -- we did a study. the week you're most likely to have surgery in your life is the last week of your life, and the day you're most likely to have surgery is the last day of that week. now, when we go into surgery, we don't know whether things are going to turn out well at the end or not in those kinds of things, but when you're doing it with people who are facing terminal illness, this is your last ditch effort, have not discussed priorities, we're often sacrificing not just the quality of their life. their chance of survival.

and more often than not we're getting it wrong at that very last stage. and so i think it's a wakeup call for us in medicine, and for our patients who -- if your clinicians aren't willing to recognize your priorities, discuss them with your family and pushing on your clinicianses to make them understand what your priorities are besides living longer, what are the things you do not want to sacrifice as part of your care. it's important we communicate that. >> host: does longevity run in families? you hear patients say, i get fears after surgery but there's no infection. my mom had that and her mother had that to what extent can we explore more the un -- genetics? when i teal people my grandfather died another 100 they say, you're so lucky, but my grandmother died at 30 from

malaria. they've say, that didn't count. there's really interesting studies about the contribution of genetics and the contribution is very weak. how tall you are, 90%, is determined jeanette click and we know that be comparing the height of identical twins. but the average difference in the length of time -- length of survival for identical twins is 15 years. they differ by 15 yours in how long they live. >> host: people have a lot of wisdom later in life. older patients can disclose things to their doctor they wouldn't tell their own spouse, lets you put a knife to their skin within minutes of meeting them because you're a surgeon: what wisdom do patients share -- what have they shared with you about accumulating money or about time spent with family?

>> guest: there is -- i think you're referring to this great set of research done by a stanford psychologist named laura carsonston, and she has been struggling -- asking people ages 18 to 94 in this study going on for two decades, her team will page them periodically and ask them to record what their emotions are, what their experiences are. she has done studied asking them 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, having more stuff, that they want to meet more people, that they love the possibility of going to a

loud bar at 2:00 a.m. in the hoped of yelling to one another in conversation and the hopes you might meet someone knew and there's an older signature that says, there's nothing more of a nightmare than that. i'd rather spend time with my sister. people narrow the number of people they focus on and want more connections to the people they love. they are more focused on being and wanting to make sure they have some ways in which they have some contributions that can be anonymous and small but some contributions to 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. and then she discovered -- this is laura -- discovered some of the folks she was following had a terminal illness. this was in the age of h.i.v.

age, and the h.i.v. a.i.d.s. patients would shift to having the older signature. then she did the study after 9/11 and the world became fraternal jill and you weren't sure what was happening, everybody moved to a signature of saying i'd rather be with family. i want to be connected to those i love. i want to make sure i'm making a difference for them. and that was the revealing thing. as time goes on, when we are really unaware of our mortality, which we are most of our lives, then we focus on getting, having, achieving. when we're nearer the -- when we become aware of the finiteness, the limitations of our life because of our health, the uncertainty of a political atmosphere, for any variety of reasons, could be ebola, we suddenly want to focus in on people we're closing with and be connected to others, and i think

that that wisdom is really just a manifestation of have something perspective on where we are in life. >> host: i've had patients tell me they wish they would have spent more time with their family but never heard anybody say i wish i would have spent more time at work. >> guest: right. if you're a child, i had two kids going off to college and if they said that to me right now issue don't wanting to focus on working gist want to be with family. i'd say, you know, i'm not sure it's a good idea, because it's perspective. she showed that people, think they have 20 years or more, they behave like they're immortal and -- they're willing to delay satisfaction. that makes since when you're more aware it's a finite period of time. so it's a matter of perspective and the wisdom is to have the proper perspective for where you are in your place and time.

>> host: it's great to see you again, congratulations on the book, "be mortal." i loved it and look forward to continuing the conversation. >> guest: thank you. >> as barbara explained this is a book about scary new emerging diseases and where they emerge from, and where they emerge from generally is wildlife, from

other species, nonhuman animals, and in particular nonhuman animals other than our domestic indicated animals. -- domestic indicated animals. i if you have been following certain stories in the news over the last few months, you know that one point of entry into this subject is the daily newspaper itself. you have probably heard about hunta virus killing three people who visited yosemite this summer. people have been dying in north texas of west nile fever. i think in the dallas area alone there have been 15 people who died of west nile fever, just since july. there have been an ebola outbreak again in central africa, the democratic republic of the congo has an ebola outbreak that's killed three dozen people, i think by now,

and it's still going on. there was another ebola outbreak across the border in uganda, unrelated to the spillover caused the outbreak in democratic'm republic of the congo. that ended. so these are happening. this is like a drum beat of disease outbreaks and small crises. there's another on the arabian peninsula, there is a virus that emerged that closely resembles the sars virus, that really scared the disease experts back in 2003. this new sars-like virus out of the arabian peninsula has only killed one person, put another man in the hospital in britain, but scientist all over the world are watching carefully. why? because they knowó

s of this phenomenon. the scientists have a fancy name. they call these animal infections that pass into humans zoanoces. a virus or other form of infectious bug, bacterium, could be a proto -- could be the creatures that cause malaria, a fungus or worm, something which

causes mad cow disease. but usually it's a virus. viruses more than anything cause these. ...c >>

>> and moments of heroism from those who study this sort of thing and even this humor. it is not a very funny book but i hope it might be the funniest book about ebola you might read the. [laughter]