and then went further to recognize people have a much higher risk of falling and then would reduce the drug. >> host: and he could do that because they were not necessary? >> guest: there were not addressing the prior day's their priority was to have as good a life as possible for as long as possible and once you understand it that way it was just she was alive to do what she wanted to do in her biggest priority was to keep her home. you know, the four risk factors are the likelihood of falling in the most important thing we can do?

so we did not teach people along the way the science of the aging body. that is the skills required to achieve the best possible outcome and what has happened is our medical values but the second course to are the lowest paid people in our profession? not us surgeon but the psychiatrist in geriatricians and palliative and primary care physicians but if they take time to talk to people to allow

people to have the time to talk and get an understanding of what matters in people's lives and then plan accordingly but we could do an operation or colonoscopy. >> i did not even know there was a field call geriatrics. did you in school? it grew like pediatrics crew where folks are so specialized with infectious diseases or primary care that they do for older patients and as i think about these issues what is happening to geriatrics today? >> guest: it is in decline with more elderly people than ever we're treating fewer people than we did one decade ago actually the geriatrics profession says we're so far behind the

eightball the country is ignoring the fact we don't tray or page geriatricians that we have to give up on the idea there will be about their behalf to train basic skills to the internist and residents and their right. we have to make these basic skills. >> host: and what has to be executed for those that are facing aging and address their health risk? >> but even stepping back to last the key questions for skills and improvement along a the way effectively while helping them understand talking about the worst-case scenario does not mean you

say i give up by new. >> host: i may be overly reducing medical school with is the equivalent of learning so many foreign languages is to pare it diagnosis treatment. diagnosis treatment. and you can learn all this knowledge finding no a sense of what is appropriate to end those issues around the end of life why are we treating high cholesterol with a life expectancy of two years?

and then the medication makes them dizzy and they fall. >> guest: it brings up the core point and talk about the death panels that it is no longer about my choice. what we see is the evolution remains to be a doctor. 50 years ago it was paternalistic doctor knows best they would tell you what you would get maybe might not tell you what was going on with you but never the options. and we thought it was our job but no one to worry their head. but by the time we were trained three were taught to be almost retail to go through all the options and talk about the pros and cons

and risks and benefits and what would you like to do? which you want? and they say i don't know what would you do? we are taught to say it is not my decision this is your decision and would devolving is the recognition of the palliative doctors have to ask a question to a understand your life people went options but guidance it comes from your understanding of your priorities and to have to be good at eliciting a 20 minute conversation they will ask what is your understanding of your health? what are your fears a and

worries? what are the goals? what are the outcomes that are unacceptable? based on that option a does not work and option b does not work abc. we will have to make up a solution she said my priority is a wedding at one to get to one saturday. she was in the emergency room with the bowel obstruction from her tumor so we focused on using medical technology not to put her into surgery or icu but to get her to that wedding. that is when it gets cool to be a doctor. >> host: that's great. the first time you have to break bad news to a patient.

day remember that time? >> guest: and vividly as an interview be asked to get to informed consent it would be explaining the operation and talk about risks and benefits. you have the risk of death and terrible pleading in they would raise their eyebrows nobody said anything about that. we have our way to be vague but then you say this is just the form. don't worry about a. how could we possibly know what the complications are like? meeting those ever good at walking through a

conversation but they treat that conversation the same way they would teach us how to do it operation. they would break it down, as steady that component parts and recognize there are certain questions more effective than others. for example, you need to track yourself and you should be talking less than 50 percent of the time. i was talking 90% the patient would nod. deal understand? yes. that was our conversation. but how do you break that? there are good ways and bad ways. the bad way is to give the facts but not the meaning.

>> host: entry to the vocabulary. >> guest: exactly. prognosis, chances of this. but here's what i know and i am worried. i am worried these publications for you but not these other ones. i very hopeful about certain things. i wish, but i worry, i hope, i wish. i wish it were true. i hope that we will be able to buy you more time. i am worried you may end up back in the hospital again. here's your understanding and i am on your side. and i have uncertainty. i am worried.

i tell the story of my dad that to the and this is the moment then he woke up. would you guys doing? [laughter] he lived three more days. [laughter] >> host: the just reminds me of the importance of the art of language as a doctor i remember in a school of mentor said don't ask patients a taking your medications but ask them a lot of people have a tough time taking their medications how have you been doing with it? it is amazing with one says there is a disconnected alienation but when you phrased things a certain way with the end of life issues it is almost as if you invite a conversation. >> guest: what we're missing is words matter.

words matter. writing a book like this that was deliberately a journalistic investigation with the nuances and complexities that when you do randomized trial would get would only everybody has in common with the careful case study is to recognize the stories are powerful with the experiences of the body a and the elvis and in this case mortality. and we are increasingly willing to recognize those are just as important contributions to knowledge and skills and professions.

>> host: i think at the time i was in a trauma day i was told the mother was next door she was happy and says how was my son doing? and instantly the massive a motion that it myself not think intrusiveness ahead of time and mad at my trading to complete leavis this part. to what extent we researching with the end of life care did you feel how could this be missing? >> guest: we are cancer surgeons to your pancreatic so you deal with every patient having these discussions but only some are mine that are

potentially at the end of life. but one of the first essays i wrote as a resident was a 23 year-old who'd died in writing about family members and the struggles but how are we supposed to cope? you break bad news of the time. it was mostly familiar. i saw things that were new in this book used a lot of research and observation. so what your goals as a patient? just last week a have a patient 81 who needed pancreas surgery but instead i said wait. what are your goals?

they said i really want to spend time with my husband and if we can get another year i will be happy. is clear she would accomplish the goal she would accomplish. >> lot of times that question is hard for people is not necessarily clear but what are your priorities? one is what is the outcome you find unacceptable? and one that i did not recognize is what are the goals is the treatment doesn't work? and others your fears and worries for the future but

things and not going away that you hoped about where to help them walk. >> host: we will take a quick break and continue the conversation>> host: the cdc cap with a report updating the

numbers on life expectancy now it is 79. if you make it to age on 65 yielded to 83 as a man or 86 if you are a woman. most of the health statistics are better except the suicide rate has gone up by two percentage points per producing depression is one of the under appreciated your under recognized problems? how does it connect to the issues? >> what you see is very interesting they are happier as they get older. it is counter intuitive to compare the 30 year-old and seven year-old they're more likely to be happy, lower rates of depression, a more complex emotions they could

have poignancy but until you incarcerate them and i use those words deliberately. and put people into nursing homes or housing situations where they don't feel they are at home. that is what you hear when do i get to go home? those of the group's fifth have much lower levels of happiness. that is the crucial finding that makes it possible to have a great life with intentions to live independently and those that keeps us going for longer there is no better time in history when you become

dependent is no longer can take care of yourself. that is when it turns the tide and we are put into institutions that no longer honor what we have been the home that his choices of autonomy. >> so the top goal was health and safety. >> but we don't talk about and the elderly person goes to the refrigerator to get something to eat whenever they want or wake up? no. there is a schedule time to wake up, the pill line to get ready for. get dressed at a certain time because it is on the staff schedule but they

looked like hospitals. they're all built around the nursing station and with these pioneering places they build them around the kitchen to move the nurses out of this side area is not about the nurses but being in the home and in the kitchen people can get what they want to know how controversial that is? the argument is a diabetic may get a soda so it is not safe an alzheimer's patient who eats only pureed die it they get a cookie for greasy patient ride ups for violating rules and they could be written up. the most common reason people get written up is because they violated a food rule you will see

alzheimer's patients according cookies. let them have the dam could keep. the ability to offer choices but we sacrifice the idea that these are people who live for something more than just being alive today they were a policeman and teachers and doctors and care about connections to the outside world, two's the church and other places and they care about living for larger purposes a fascinating experience is a pioneer who brought pets in two's nursing homes and had to battle all kinds of regulations but suddenly they had something to care for with a purpose and reason to live and they woke

up. they became active is life in and using less medication and even lived longer. >> host: isn't the autonomy? isn't that part of happiness when you describe your own mother-in-law? she liked to wear certain shoes. that was part of her identity and she wore them proudly but the nursing home delegated person of different ones. [laughter] have we taken away dignity in the united states where people are incarcerated in a sense? >> guest: yes. but people are getting the idea this past changes and that culture of change with

nursing homes and assisted living and even making health care is the most amazing source of innovation when we talk about technology right now in every state there is a revolution how this care is provided. and allows people to have a lock on their door. the workers have to talk to have permission to come and. respecting privacy from a double room down act a single room. with an inner life since college degree have to live with the unknown roommates who may be up all night? making crazy sounds and breezes. >> people care about these fundamental things. the homes that exist the people that they market to run not the parent they

market to the kids because they're the decision makers. there is a great quotation safety is what we want for those we love but autonomy is what we want for ourselves. we may ask what is the safety record? we don't ask how lonely are the people? saudi rancher people have a purpose in their day? how to engage our people able to be with though world and with what is important to them? are people getting to learn and pursue new things? places have done that and it has changed the experience like the 94 year-old man who was having trouble with every bit then he described you as getting to do for the first died in my life i was

not afraid. >> host: denies they point out a sense of autonomy of company and companionship using the proceeds of loneliness are starting earlier in life with a personalized society? this is the first time in civilization where they live alone then they have their own personal this or that or their personal subscription it is a personal and individualized that is why we see the emergence of a shared culture businesses like uber or these

businesses that try to say we are a community, retirement community to create a community rather than a facility but shared activities and shared participation. >> many people will two's the pathway to the least contact with a human being. i don't want to have to connect with a human being if i don't have to. manifestly it shows itself and when people got pensions and social security the first in the elderly did is that they rather with out said to be under rules they did not want to live by the son and daughters rules.

they don't want to live by their rules so it is increasingly but we still want that intimate relationship but to go two's base was absolute necessary to navigate. the hardness pareos when you just hang out because you need human beings to you where you want to go.

>> i chrysalises said to be assumed just because you are an independent -- to depend even have a life worth living. what gross could there be? in fact,, there is a huge amount that is because you can still make cuts to be shan's along though with a. >> host: how did we kid and dash get jesse helms.

>> again that if the weather started that that makes sense of and make it people in their life? no. we've built a ton of hospitals but the law allows every community to build and finance a hospital. they would fill up with elderly people whose problems could not be fixed.