know what the conversations are like. the fascinating thing is, when i met the people who are really good at walking through a conversation about whether you want a do not resuscitate order or not, they treat it as, that conversation, the same way that people treated teaching us how to do an operation. from a broken down, study the component parts and recognize there were certain questions more effective than others. you need to use questions. need to check yourself. and you should be talking less than 50 percent of the time that you are in the room with the question -- patient. ninety plus percent of the time the patient would not and you get to the end and say, do you understand? and that was the

conversation. that set of skills, they're good lawyers and bad ways. the bad way is to give all the facts and none of the meaning, retreat to the medical books -- medical vocabulary. here is the data. the effective conversation is here is what i know, and i'm worried. i am worried about these kind of complications. and now word about these other ones. i'm very hopeful certain things. i wish that -- they talk about i worry, i hope my wish. i wish it were true then we could cure this i hope that we will be able to buy the more time. the more you may end up back in hospital again.

here's the data, here is the understanding. i am on your side on this. uni have been fooled. tell a story of my dad. i thought he was sick towards the very end. this is etched on of the moment. and then he woke up. more days. >> host: you know, as you say some of those phrases, i am concerned. reminds me of the importance of the art of language as a doctor. remember in school mentor's told me, don't ask patients, are you taking your medication because they will get defensive. a lot of people have a tough time taking their medications as they should. how have you been doing with it. and it is amazing. with one set of vocabulary there is almost a huge disconnect or alienation,

and then when you phrased things a certain way, when you talk about end-of-life issues, it is almost inviting a conversation. >> guest: to the things we are missing. the words matter, and the stories matter. and part of writing a book like this and doing the investigation i did was deliberately a journalistic investigation, less interested in taking out the details and the nuances and complexities and make it so that, you know, when you do a randomized trial he removed all the detail and look at what everyone has in common. and what we do in a careful case study or a bunch of case studies is to recognize that stories are powerful and tell you a lot about the experiences of the body, the experiences of illness, and in this case experience with mortality.

i think, you know, we are increasingly willing to recognize in madison that those are just as important contributions to knowledge and our skills and professions. >> host: i think of a time i was in a trough of day and a patient died and i was told by mother's next door. you need to talk. the mother looks to me and says, how is my son doing. instantly this mass of emotions, mad at myself for not thinking through this ahead of time, what should i tell her, matt a little bit at my training for having made the completely misses part. to what extent when you were researching -- researching issues with end-of-life gear did you look back and see and feel like, how could this be missing? >> guest: all along the way. i am a cancer surgeon, like

yourself. you are a pancreatic cancer surgeon, sir you deal with every patient having to have this kind of discussion. only some of mine are folks with whom i am worried that day are potentially at the end of life. one of the first as as i rode even as a resident was a 23 year-old to die from lymphoma. i have had subsequent times, written about family members in a struggle. how are we supposed to cope in a situation? and i am curious for you. in this book. you break bad news all the time, pancreatic cancer patients, have seen a lot of them died. was this mostly familiar, or did you feel like you saw things that were new to you? >> host: i saw things that were new in this book because you have done a tremendous amount of research and used observations.

has encouraged myself to ask, my goals. a patient was 81, frail, and needed a pancreatic surgery to remove the pancreas. instead i said, wait a minute. tommy. he said, i want to spend time with my husband, and if we can get another year i will be happy. it was clear to me that she would outlive this cancer. >> guest: one of the things, words matter a lot and people, one of their goals, a lot of times, that question is hard. they do not necessarily have clear goals, but we ask questions that get at priorities, and a couple of them did you. one of the outcomes that he would not -- that you would find unacceptable and the outcomes that you hope for. another set of words i have not really recognized was, you know, whether -- what are the goals is your

treatment does not work or if -- a harder task sometimes. another one is just a, what are your fears and worries for the future. but it is soliciting guidance so that then when things are not going the way that you hope you have got some understanding as a doctor about where to help them walk, you know, and sometimes make a turn. >> host: great points. we want to take a quick break and continue the conversation. >> the 2015 c-span students camera video competition is under way open to all middle and high school students to create a 5-7 minute documentary on the theme, the three branches and you, showing l8 power, lock, or action by a french of the government has affected you or your community. 200 cash prizes for students

and teachers totaling $100,000. for a list of rules and how to get started, go to students camped out of work. >> host: atul gawanda, the cdc came out with a report this month updating numbers on life expectancy, and now is up to 79. if you make it to age 65, on average you will live to 83 if you are a man and 86 if you're a woman. it sounds like most of the health statistics are better, except for one, the suicide rate has gone up by a few percentage points. do you think that depression is one of the under appreciated, under recognized endemic problems, and how does it connect to the issues of older people? >> guest: i do think that it is, and what you see is very interesting, which is that as people age they actually have -- they are happier as they get older. this is a little counter

intuitive. in all of these studies, if you compare a 30-year-old and a 70-year-old, the 70-year-old is more likely to be happy, have lower rates of depression, more complex emotions, can have poignancy, the idea of negative and positive emotions at the same time. intel you incarcerate them. and i use those words fervently. put people into housing situations where they do not feel that there are at home, that is the most common thing you hear from people in nursing homes. they say, when do i get to go home. and those other groups who are -- have much lower levels of happiness. and i think that that is the crucial finding. 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, can live independently, candid knee replacements and other things that can keep us going longer. there is no better time to be elderly in history, but when you become dependent, when you no longer can take care of yourself and they're having trouble with false, your memory is going and you need help, that is when it turns the tide and we are put in as -- put into institutions that no longer honor what we had in the home, which is choices come on autonomy. >> host: even small things >> guest: so as -- in institutions their top goal is health and safety. in fact, they will tell you, we are an incredibly safe place for your parent, but we do not talk about whether , you know, can the elderly person simply go to the refrigerator and get what they want to eat whenever they want? will they be allowed to break up whenever they want?

no. what happens is there's a schedule time to wake up, there is the po line you ready and stressed that a certain time because it is all on the staff schedule. but they look more and more like hospitals. and in gospels they are all built around the nursing station. in some of these interesting , pioneering places they have built them around the kitchen and moved the nurses out into a site area because it is not about the nurses but it is about being in a home. in the kitchen people are allowed to open the door and did what they want. two-year know how controversial that is? >> host: that little bit of autonomy. >> guest: the document was a diabetic may get a soda. it is not safe. an alzheimer's patient who is supposed to be eating all the pureed diet might go and get a cookie. you know, it is fascinating. you see the write ups of patients for violating

rules, and you can get written up, by the way. of that idea. the most common reason people will get written up is because they violated food rules. alzheimer's patients according cookies, for example. you know, let them have a cookie. the ability to offer choices in ways that is not only important about the turkey. what we have sacrificed is the idea that these are people lives for something more than being go and safety and just being alive today. these are people who have histories, they were teachers, policemen, doctors. and they care about the connections to the outside world, to the church, to other places they were a part of, and they care about being able to live for larger purposes. one of the fascinating experiment that i talk about is this pioneer who brought

pets into nursing homes and had to battle all kinds of regulations to make it possible, but when people had pets, even people with dementia, they suddenly had something to care for, purpose and reason to live. and those folks will come out and became active in life. they end up needing less medication and even live longer. ..

>>

>> why does this happen? they understand that people that they market to are not apparent that the kids in their awful decision makers. someone is boat two's said safety is what we want for those with loved but autonomy is what we want for ourselves but we ask what is the safety record we don't ask how old the hour people? and had you insurer people have purpose in their day and how to engage our people able to be with what is important to them? and it has changed the experience i describe a 94

year-old man who is having trouble with memory then he described some of the things he was getting to do for the first time in my life i was not afraid. >> host: new nicely point out it is a sense of autonomy with companionship that contributes to happiness or increasingly starting earlier in life with a personalized society this is the first time in a civilization and soon after they have personal this and that but it is that why we

cv and merchants of these cultures like uber? the sort of businesses like retirement communities in trying to have shared participation. >> given the choice they will provide which has the least contact with the human being and did not want to if they don't have to. but when people of that pensions and social security

they would rather live alone been in the family of their kids under their rule. fell one to live by there seven daughters rules they don't want to live by their rules but we live increasingly in into the distance. close but not too close. but where we're hungry is we want that into relationships to take investment to involve conversations the freedom to retreat to your own space in order to navigate those areas. the hard part about aging and as the retreat to their own corner you need human

beings to help you from how do i change that labeled to getting to where you want to go? and then to understand my needs to navigate that world but the crucial part to be completely assumed they don't have a life worth living anymore. what sort of achievements or growth could there be? and actually that is reigniting the desire for connection the you can still make contributions along the way. >> how do we get nursing homes as the amazing institution as the function not doing well in terms of

giving the institutional life the autonomy for companionship for the pet program but you point out despite the title "being mortal" there are a lot of possible things ways you have been inspired with the changes in the way things are done. >> things are turning upside down. because people are living longer and it is a rational way how we take people through the different phases of their life rebuild the town of hospitals in the '50s there was a law that passed around that time

hospitals had technological capabilities and allowed every community to build a hospital and they filled up with elderly people whose problems could not be fixed and they said what do we do? as medicare got created there was financing allowing people to go to a nursing home for about 60 days it was called a nursing home the idea you would nurse people back to health we're not treating these places stearic knowledge to get them back to health so they were built around the priorities and no safety is important people are at that basic level added the understanding this is out of the of well-being.

>> that day articulate pierides that make me feel like i am at home. those of the things that we're now discovering. no coincidence no baby boomers think that we as parents are starting to think about those and this generation will not put up with to be wards of a nursing state. [laughter] >> host: end of life is a tough subject to talk about because it is polarizing if people had individual experiences or have seen someone on a ventilator for logger and someone would ever have wanted.

you seem to nicely discuss the issues of the end of life care by focusing on life not just deaf to to achieve we will achieve. what inspired you to take the positive approach to the polarizing subject? >> i even talk about assisted suicide. here is the fear that people have that the discussion of the end of life will all about what you take away. that people learn not giving up soon enough but it is really fighting for goal setter different and i

realized the goal is not a good death number one death is messy and is not entirely in our control. but second that is a tiny moment to the and if that is about life and living in beginning to recognize to what the field was already discovering with that incredible a polarized but you talk about the death panel. >> it is a little bit unclear so on one level it is a specific notion that by allowing for the possibility

for there to be discussions about priorities for end of life to ration care. but one powerful one looked at terminal lung cancer patients who only have 11 months to live on average at the time of the steady half of them at the hospital the other half were having meetings with day care specialist for the remaining time. and those ended up choosing to stop chemotherapy earlier and less days in the

hospital is started hospice earlier without suffering and they've lived 25 percent longer. >> host: even with less chemotherapy? >> guest: it indicates we making fundamental mistakes with court decision making. and when we try that last-ditch operation it is out of the unwillingness to recognize we might be sacrificing quality of life in fighting just to have a good day now instead of more time it is ironic please send a to have a good day now and not worry about how much time there might be ironically does not shorten the time and often in lincoln said. and it is a failure to recognize the truth in that. before the start of hospice

sooner don't live shorter on average they live equally long or longer. it reflects the lack of knowledge even in our own profession or why this might be and have him listen to what priorities they have then why that might be. >> host: his attitude the reason that they have less chemotherapy? so do pessimist live less long? >> the major difference is when you try that last-ditch operation or chemotherapy or aggressive treatments like a ventilator and a feeding tube so you get all the

toxicity and complications and suffering and often very little benefit that the complications and the harm outweigh any potential benefit. people end up doing worse they are beaten down by the toxicity and less about the psychology but we did a steady. the week you're most likely to have surgery in your life is the last week of life the day is the last day of that week. when we go into surgery we don't know if things will turn out well or not. that is what you're doing with a terminal illness the last-ditch effort