>> host: did you know about the paintings? >> guest: these were murals that we had to create. they were in such a bad state of disrepair before the renovation. so these were created in the studio on campus and installed here. they were not painted michael angelo style. ..

this was the first one to be brought to the united states in the mid-19 century. so it's remarkable in that way. >> host: it's on display for anyone who is walking by? >> guest: absolutely. the technology of course is what's remarkable about this. >> you are watching booktv on c-span2 with top nonfiction books and authors every weekend. booktv, television for serious readers. >> up next on booktv, "after words" with guest host dr. martin mccarry, surgeon at johns hopkins hospital and professor of health policy. this week doctor atul gawande and his newest book "being mortal: medicine and what matters in the end." in the award-winning author

argues it was all the medical science can solve in the modern era. it is still efficient any area of aging and dying. this program is about one hour. >> host: great to see you again. congratulations on the book, "being mortal." >> guest: thank you. >> host: 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 thought of walt whitman and his book leaves of grass. he has this famous quote in the poem, i bequeath myself to the dirt to grow from the grass that i love. what does the leaf of grass mean to you and why did you decide to put on the cover transferred it's a biblical reference actually. all flesh is grass. it refers to the idea that on the one hand we all come from something fertile but also the idea that grass is mortal. grass is temperate.

>> host: in the process of writing this book, "being mortal" what you think is terrific by wacom when the few times we can have an honest conversation in a public forum about our mortality and the end-of-life issues, did it eat you, did it strike you i'm not going to be around you for ever? 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 to start investigating why even in my own practice we don't do a very successful job of dealing with mortality. you know, we reach by the end of 1990s a place where 17% of the population died in on any 3% died in institutions. often hooked up on machines unaware of what was happening in the world to no chance to say goodbye, no chance to preserve

some quality of life that they came to the end. it was clear that this was not what people wanted, and that i wasn't being successful at it. i begin 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 palliative care physicians, hospice workers, nursing home workers and i learned along the way. i learned about what some of them do that easily successful process of changing care and i began trying at. and then 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: was that a tough time for you personally? >> guest: yes, it was.

aving the chance to understand what 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 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. also i wasn't asking even my own dad. and so when his condition began to deteriorate, and this is a tumor that's going to make in quadriplegic and graduate took his life, and she these options,

radiation, chemotherapy. i started asking questions that people start asking. what are your priorities? what are the trade-offs you're willing to make and not make? really hard questions to ask, and get changed every step of his care along the way. >> host: you describe your grandfather and he lived to be 110 years old? >> guest: 110. >> host: lived in a village in india. tell me a little bit about what you learned from his life. >> guest: so he is not sitting because he the kind of old age that we think we want, right? the last 20 or so this life he needed 24 hour care basically and yet he did not have to check into nursing home like he would be today. he was surrounded by family. he could sit at the head of his dinner table at home, still ahead of the family. people came to them for business

advice or advice about who they should marry. he was respected. and he really was able to live as good liv a life as possible l the way to the very end. now, what made that possible and why did we lose the? that was the lesson to be taken out of it, as a society. in other words, that was what america had in the 19 century. it's what your pet in 19 century. it's what china, korea and india are leaving right now, and why. the breakup of the extende extem taking their selection is occurring because that works only by enslaving the young. young women to provide the care, and then on top of it isn't something imagine reaching your 80s still waiting to inherit your land. having the economic future still dependent on your data. the economic progress of the world occurs because you give young people from they can work with you, live what they want and marry whom they want to be moved to the city for often they

take different lines of work. the often leave the elderly, the elders behind. we didn't have a plan in the 19 century 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 lecture turned over to the health care and they will fix and take care of and treat. >> guest: my grandfather, my dad is having trouble with memory or he's having falls in the home. let's take them to the doctor and the doctor will fix that. we say, well, we like fixing problems. we have a procedure we can do, a therapy we can offer but some problems you can't fix. some of these we can't make them go and then we throw up our hands and we say well, i can either try x, y or z or go see another specialist. that's the failure of our understanding. there are things to fight for besides just living longer or

trying to repair unrepairable problems. >> host: when we go through school, it seems like medical schools, nursing schools attract good people. these are the type of high school students who want to be a nurse is a remarkable person. sort of person who interviews for medical school is a remarkable person. then they come out in this dilemma, and is it confusion of preparedness, a sense of this is out of my league? where do things go wrong when you have such great people going into a profession and then they're faced with dealing with the problems that they may feel is out of their league? >> guest: i think there are a few things that happen. number one is i had a geriatric office, clinic. right below my click every as i walked past it without ever knowing what they did in there.

nice and cinematic schools don't teach geriatric skills to outwit him and said let me hang out with you for a day. geriatrician should we did. among the things he did was recognize those life-threatening thing for some of the stations over 80 was that they might fall into they fell and broke their hips, head on average only six months to survive and they were miserable. more important than getting their mammogram, more important than the colonoscopy was preventing them from falling. he knew how to examine defeat to look for ways that the toenails and the calluses could make someone unsteady and arrange for a podiatrist to help a trust those problems. >> host: see if they could reach their feet. >> guest: take off their socks and observe. let them struggle to take off their shoes because it told him something about their abilities and whether there was care they could have at home. he went further and recognized the people who are -- have a

much high risk of falling. he reduced the drug so you were having with dizziness and dehydration. >> host: the drugs were not necessary? >> guest: they weren't addressing the priority. so the priority wasn't survival. the priority was having as good a life as possible for as long as possible. when you understood that when you're making different choices and trade-offs. it didn't matter it was a pulsing body. she was like to do the thing she wanted to do and what she said was her because priority was keeping her home. now if you ask, if i asked you, do you know this for risk factors for someone, for the likelihood of falling and the three most important things that we can do? we weren't taught that. we don't know that. not part of our training. and so we didn't teach people along the way in residency come

in medical school before that. what is the science of the aging population? and have done. 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 it's for different goals. i think what has happened is that our medical valleys, our fundamentally about health, safety and survival without recognizing that well being is bigger than that for people. the second force is money. who are the lowest paid people in our profession? not as the surgeons. the geriatricians, the psychiatrist, the palliative care doctors, primary care physicians. it's because of 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 of what matters in

people's lives and then make the plans accordingly. just doesn't remotely pay as will society. we can do an operation or we can do that in colonoscopy the. >> host: i didn't know there was a field of medicine called geriatrics in medical school, did you? >> guest: no. >> host: as i understand it really grew like pediatrics group, where folks were still specializing in infectious diseases or primary care but they did that 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 are training fewer people today in geriatrics and we did a decade ago. it's reached the point to 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, don't pay

geriatricians, that we hav had o give up on you at the bnf geriatricians for the need out there and we have to train these basic skills to interests, the medical students, the students pick their right. we have to make these basic skills up, what are the checklists. my last book. what are the checklists for that have to be executed on that of the most important ones for people who are facing aging and address their particular health risks, but also stepping back even higher than that, being able to ask the key questions and get some skills and a proven along the way and have asked 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 were saying i am giving up on you. >> host: medical school seems

to be, and i may be overly reducing it but it seems to be the equivalent of learning so many foreign-language is, the only way you can memorize everything is to pare things. diagnosis treatment, diagnosis treatment. it's almost as if we can come up with this reflex. there's a diagnosis, i know the treatment. diagnosis treatment. what's good about that is you can learn all this knowledge and there's plenty of up to plenty of after doing but what's concerninconcernin g is you can miss out on a sense of what's appropriate. appropriateness. that really seems to be one of the focuses of the issues around the end of life as you described them, this sense of when is it appropriate? why are we treating high cholesterol in somebody who is life expectancy of two years when the cholesterol is not going to kill them. >> guest: and the medication makes event is unlikely to fall. >> host: enemy confuse it with an important medication.

>> guest: i think it brings up a core point which is how do we do with appropriateness? the great fear people have, the charges these about death panels, appropriate this means it's no longer that my choice about what appropriate. i think what we're seeing is an evolution of what it means to be a doctor. the last half-century it's changed. 50 years ago it was the paternalistic doctor knows best. the doctor would tell you what you're going to get, might or might not say which really going on with you. never would go to the options. >> host: yes, doctor, whatever you say. >> guest: we thought it was our job if you don't want to worry people of what might be going on. we rebuilt in the '70s, '80s and '90s. by the time you and i were trained we were taught to be doctor informed i called. almost a retail model. go through all the options, talk about the pros and cons and the risks and the benefits and make all menu of options and then you go what would you like to do? which one do you want?

invariably you find is, right? they say, i don't know. what would you do, doctor? 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 decide. what is evolving is the recognition that i began to see when i followed the geriatricians and the palliative care doctors. they play the role of the counselor and the counselor says here are the options i need to ask a few questions to understand your life. >> host: to give guidance. they want options. >> guest: and the guide says to, from your understanding of what their priorities are in life. you have to be good at eliciting a short conversation to a are good at it, like a 20 minute conversation they will ask was your understanding of your health? what are your fears and worries for the future? what are the goals that you have if you're health worsens? what are the outcomes that would be unacceptable to you?

based on that, option a., that doesn't work. option b. doesn't work. option c. might be way to go. or none o of the work. we'll have to almost make up a solution here. a heavy woman who said she had ovarian cancer. she said my priority is there's a wedding i want to get to this weekend. on saturday. she was admitted to the emergency room with a bowel obstruction from her tumor making it so she couldn't eat, really sick. what we focus on then was how do we get her to the wedding? medical technology not to put in the icu or into surgery, but together to that wedding. that's what is cool again to be a doctor. >> host: that's great. the first time you had to break the news to a patient, you remember that time? what was it like? >> guest: i would never end because, as an intern you the past come you'll probably asked

as welcome to go and get the informed consent to or go can send them. and you would inevitably be explaining the operations and talk about the risk and benefits. but when you're writing done, you have this risk of death and justice risk of terrible bleeding and you might have an infection, and invariably they raised their eyebrows and say, no one said anything about that. oh, w we all have or learn to be getting it. you learn can you watch the chief resident at what did they do? they end up saying, oh, these are just forms. don't worry about. just legalese. >> host: alco even possibly know what the complications are like? we read about them but how can we cancel people. >> guest: when i met the people who really good at walking through a conversation about whether you want a do not resuscitate order or not, or a consent discussion, they treat

it, that conversation, the same way that people treated teaching us how to do an operation. they broke it down, they studied how come with the component parts are, and he recognized like there are certain questions that are more effective than others that you need to use questions. for example, one questions. for example, one of them explained to me you need to track yourself, and you should be talking less than 50% of the time that you're in the room with a patient. i began tracking the. i was talking 90% of the time. the patient would not have engaged in and say to you understand? yeah, you understand. that was our conversation. that set of skills but how do you break bad news to someone? there are good ways and bad ways. the bad what is give all the facts. none of the meaning. >> host: treat to the medical vocabulary. >> guest: exactly. diagnosis of this compares the chances of that.

the effective conversation is here's what i know, and i'm worried. i'm worried about these kinds of complications but i'm not worried about these other ones. they talk about i worry, i hope, i wish. i wish it were true that you could cure this. i hope that we will be able to buy you more time. i'm worried you may end up in the hospital again. at the same two people here's the data, here's your understanding, and i'm on your side on this. of all been fooled. i tell the story of even my dad. i thought he was, towards the very end, that this is it, the

moment he was gone, and then he woke up. had 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 medical school mentors told me to ask patients, are you taking your medications because they will get defensive, but ask them, a lot of people have a tough time taking their medications as they showed. how have you been doing with the? it is amazing. with one set of vocabulary there's almost a huge disconnect or an alienation, and then when you phrase things a certain way, when you talk about end-of-life issues as you are, it's almost inviting a conversation. >> guest: the are two things i think we're missing. words matter. words matter, and the stories matter. part of even writing a book like

this and doing the kind of investigation i did, it was deliberately a dualistic 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 remove all of 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 study, is recognize that the stories are really powerful and they tell you a lot about your experiences of the body, experiences of illness. and in this case the experience of mortality. i think we are increasingly willing to recognize in medicine that those are just as important contributions to knowledge and our skills and professions as the straightforward quantitative one. >> host: i think of the time i was in the trauma bay and a

patient died and i was told the mother is next door. you need to talk to her. i walked in there, the mother is happy and looks at me said, how is my son doing? instantly this mess 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 me be completely missed this part. to what extent when you were researching the issue with end-of-life care did you look back and feel like, how could this be missing? >> guest: i mean, all along the way. i am a cancer surgeon like you are. you're a pancreatic -- pancreatic cancer surgeon. you are dealing with every patient having had this discussion to only some of mine are folks with whom i'm worried that their potential at the end of life. and it was a striking all of him. one of the first essays i wrote

even as a resident was about a 23 year-old who died from lymphoma. and that the subsequent times i've written about family members to have a serious illness and the struggles of how are we supposed to cope in this situation. i'm curious for you. reading this book, you break bad news all the time. yet seen a lot of them died. was this mostly from it or did you feel like you saw things that were new to you that were helpful? >> guest:helpful? >> host: you've done a tremendous amount of research. you use a lot of observations. to really encourage myself to ask, what are your goals as a patient? just last week i had a patient who is 81, frail, and needed a hand crisp surgery in order to remove the campus but instead i stopped and said wait a minute, what are your goals? tell me about -- they said i would want to spend time with my husband here, and it we can get another year i will be happy.

it was clear to me that she will outlive this cancer, and the congress the goals she wanted to accomplish. >> guest: one of the things i do think that the words matter a lot and asking people but what are the goals, a lot of times that question is hard for people. they don't necessarily have clear goals but when you ask questions that get at your partners and a couple of them get you there, one is what are the outcomes that you wouldn't, that you would find unacceptable, and what are the outcomes you really hope for? or another set of words that i hadn't really recognize is what are the goals if your treatment doesn't work or if you're health worsens? these are harder to ask sometimes. another one is just what are your fears and worries of the future? but it's the listening, the guidance so when things aren't going the way you hope, you've got some understanding, about where to help them walk.

sometimes make a turn on the pathway. >> host: great point. we will take a quick break and continue the conversation. >> host: atul, cdc came out with a report just this month updating the numbers on a life expectancy, and now the 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're a woman. as a matter oas a matter fact me health 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 endemic 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 actually have, they are happier as they get older. this is a little counterintuitive. people in all this study, comparing 30 year-old and a 70 year old in the 70 year old is likely to be happy, have lower rates of depression. they are likely to have more complex emotions. they can have poignancy which is the sak site of a negative and positive emotion at the same time, into you incarcerate and use those words deliberately. put people into nursing homes over into housing situations where they will feel they are at

home. what's the most, then you're sometimes people in nursing homes? when do i get to go home a? those other groups who are, have much lower levels of happiness. and i think that's the crucial find income is that win, we have become a society that has made it real possible to have a great life because we have pensions and also security for when you retire. people are able to sustain themselves. they can live independently. we get knee replacement and other things that keep us going for longer. there is no better time to be elderly in history, but when you become dependent, when you know longer can take care of yourself when you are having trouble with false and amendment is going and you need help, that is when it suddenly turns the tide and we are put into institutions that no longer on are what we have,

we get to have a tone which are choices, autonomy. >> guest >> host: even with small things catholic institutions, their top goal is health and safety. they will tell you, bring someone, we are an accredited safe place for your parent. but we don't talk about whether, can the parents go, can the ugly person cenpeco to the refrigerator and get what they want to eat whenever they want? will they be allowed to wake up whenever they want? no. what happens is there's a scandal time to wake up. there is a pale line to get ready for, and you get just a certain time because it's all on the stats schedule that's required. they look more and more like hospitals, and in the hospitals they are all built around the nursing station. in some of these interesting pioneering places they build them around the kitchen and move the nurses out and decided because it's not about the

nurses. it's about being in a home, in the kitchen. .. less than half the cookies. the ability to offer choices and in ways it's not only important to have the cookie but with the sacrifice is the idea that these are people that live for something more than bingo and

safety and just being alive today. these are people that have history, they were teachers, policemen, doctors and they care about the connections to the outside world and the church and other places that they were part of and they care about being able to live for larger purposes. one of the fascinating experiments to talk about is a pioneer. they had something to care for in the world and a purpose and a reason to live. they became active in life. they ended up needing less medication and they even lived longer. >> host: is the autonomy really symbolic to people in that they are given some of the

dignity back? is that part of the happiness when you described your own mother-in-law i think it was, whether she liked to wear certain shoes as part of her identity and she wore them proudly in the nursing home for safety reasons they relegated her to some -- have we taken the dignity later in life in certain contexts in the united states as you describe the people are incarcerated? >> guest: people are getting the idea that this has to change command the culture of change its nursing homes and an 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 is a revolution of how this kind of care is

provided into the other major things are small. it's allowing people to have a lock on their door and it's expecting privacy, moving away from the double rooms to single rooms. the plan in our licensed college will we have to live with an unknown within unknown roommate who might be up all night. people care about the israeli fundamental things. why has this happened? the homes that exist today understand the people they market to are not parents. they marketed to kids because they are often the decision-makers. someone i spoke to set up this great quote. they said safety is what we want for those that 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 how lonely our people. how do we ensure people have a purpose in their day and 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 in their life? the places i visit and write about have done that and it has changed the experience. i describe a 94-year-old man who was having some trouble with his memory, he didn't have all of his teeth but then you describe some of the things he was beginning to do and so for the first time in my life, i was not afraid. >> host: you pointed out how it is a sense of autonomy and company or companionship that contributes to happiness. do you think the seeds of

further meanness are increasingly starting earlier in life with a personalized society that we live in and this is the first time in civilization where folks need to go to college and live with some folks or they may live alone and soon after they have their personal this and that and devices and personals of scripture into movies such a personal individualist society. do you think that's why we are seeing an emergence of the shared culture businesses and the sort of businesses that try to say we are a community, retirement community trying to create more of a community rather than a facility or trying to create more of a sense of shared activities and shared

participation. >> guest: given the choice many people will choose the pathway that provides less contact with the human being. i don't want to have to, you know, connect with a human being if i don't have to. and its manifest and 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 is they moved out. they would rather live alone and live in the family of their kids and the under their rules in the house. they didn't want to live by their son or daughter's rules and they don't want to live by their rules so we live increasingly at an intimate distance company or one another but not too near. i think where we are hungry though is that we do still want a contact that friendships,

relationships are taken they sometimes involve hard conversations and people don't always get along. retreat to your own space is necessary to navigate those kind of freedoms. the hard part of that becomes when you can no longer be independent and just hang out in your code retreat to your own corner because you need human beings to help you manage anything from how do i change the light bulb to getting where you want to go and the frustration of a have to wait and how do i navigate and negotiate that world. the crucial part about it though is it's completely assumed that just because you're an independent you don't have a life worth living anymore. you know, what achievements, what growth would there be.

and in fact there is a there's a huge amount that's possible. and that is reigniting the desire for the connection into the world because you can still make contributions along the way or just have some connection to people who you love or are close to. >> host: nursing homes are an amazing institution in america today. serves the function you point out what they are not doing well in terms of getting people sort of institutional life and not giving them the autonomy they may need for happiness were the companionship or things like the patch program pic program but you also point out in the book it has a lot of positive things in it and you talk about the ways that you've been inspired. >> i do think that it is coming

from upside down you would have thought when we started researching the book that the reason nursing homes would come to exist as people were living longer and would come up with a rational way that makes sense for how to we take people different through the phases of their life. we don't have hospitals in the 1950s. we -- >> host: as a law that pastor of the time. >> guest: that's right. they have technological capabilities and the law allowed every community to build a hospital in finance the hospital and they filled it with elderly people whose problems could be fixed. and at the and at the hospital said what do we do with these folks and so as medicare got created they were allowing people to go for about 90 days and it was called a nursing home, the idea is to you would be nursing people back to health

and not to acknowledge you might not be able to get back to health. and so they were built around the priorities of health and safety. safety is really important. many of these places people were neglected. there is a basic level that has to be there but they were not created out of an understanding that this is about a well-being. nursing people back to health may not happen that it can happen regardless of what prevails and the idea that people prefer to give a priorities and what are the lines that we do not cross the picket feel like i'm at home. those are the things we are now discovering. they are starting to hit the age that they are thinking about those issues and we have parents that are starting to think about those issues and this generation

isn't going to put up with being the wards of the state. >> host: it is a tough subject to talk about because it is polarizing to folks. that is people have had individual experiences where they have seen somebody on a ventilator far longer than that person would have wanted or vice versa. you seem to have discussed the difficult issues and end of life care but also by focusing on life and achieving what you want to achieve during the end of life. what inspired you to take a positive approach to what otherwise is a very polarizing subject which from my understanding hasn't really even look to the polarized reaction that you would normally think from this book.

>> guest: the discussion is that it is going to be all about what you take away. it's trying to guide people to give up sooner because you're not giving up soon enough. what i thought as it is about fighting for a set of goals that are different than what we've understood and i realized that the goal isn't good. it is messy and it isn't entirely in our control. but second, that is just a tiny moment i towards the end about life and living even as you face tremendous constraints.

it's what came out of looking closely at what the field was already discovering. now it also gets us out of the box of this incredibly polarized >> host: what our death panels so people know what you are referring to. >> guest: it is a little unclear. it's a very specific notion of the possibility of not allowing and encouraging the discussions about people's priorities at the end of life that we were looking for ways to just hasten people's end. crash and care. there are a number of studies that show this but the powerful one looks at terminal ill cancer patients with months to live.

half of them got the usual oncology care and the other half were given oncology care plus having meetings with the specialists that discover the priorities for a person. the group that had the discussions ended up choosing to stop their chemotherapy earlier. they had fewer days in the hospital less likely to die and less hospice of sooner and suffering at the end of life. they lived 25% longer to get >> host: even though they got less chemotherapy they lived longer. what does this tell us we are doing? >> guest: we are making fundamental mistakes even in our core decision-making. when we added had the fourth or fifth round of chemotherapy or try the last-ditch operation it is out of an unwillingness to recognize we might be sacrificing quality of life for

people fighting just to have a good day now instead of more time is ironically not worrying about how much time there might be ironically doesn't shorten the time and often would lengthen the time and i think it's a failure to recognize the truth and there've been a number of studies. on average they live equally long or longer. so it just reflects lack of knowledge even in our own profession about what the evidence is showing a lack of understanding of why this might be and then we have them listen about what priorities they have and why that might be and it's a positive attitude the reason people may have lived longer in

that study that got less chemotherapy but did better? >> guest: they don't. i think the major difference is that when you try the last-ditch operation were chemotherapy or other kind of aggressive treatment putting them on the ventilator giving people the feeding tube when you give these approaches you get all of the toxicities and complications and pain and suffering and often very little benefit to to the point that the complications in the harm that you've done outweigh any potential benefit so people end up doing worse by the toxicity of what you've done and it's less about the psychology and more about the

week that you're most likely to have surgery in your life is the last week of your life. when we go into surgery, we don't know whether things are going to turn out well at the end or not but when you're dealing with people facing terminal illness at the last-ditch effort we are often sacrificing not just the quality of life but the chance of survival and more often than not we are getting it wrong at the very last stage and so i think it is a wake-up call for us in medicine and for our patients who if your clinicians are not willing to recognize your priorities and discuss them with your families, push them to take them understand what your priorities are besides living

longer what are the things you do not want to sacrifice as part of your care. >> guest: you will have people say there's no fear of infection i've had my moms mom had a. >> guest: when i took people my grandfather died at 110 they say he's so lucky that my grandmother died at 30 from malaria. there's interesting studies of the contributions of genetics of longevity into the contribution. helpful you are 90% is determined genetically and we know that by comparing the height of identical twins. but the average distance in the length of time and length of survival for identical twins is

15 years but there is on average a difference by 15 years and how long they live. >> host: her patients disclose things to the doctor they might not even told their own spouse during a debate lets you put a knife to their skid within minutes of meeting them just because you are the surgeon. what wisdom do patients share about accumulating money or about of time spent with family? >> guest: i think that you are referring to a great set of research by laura carson and she's been studying by asking people 18 to 94 and a study that's now going on for two decades her team will page then periodically and ask them to record with their emotions are

and experiences are and she's done studies asking them if you have an have in our time an hour of time would you rather spend it with your sister or another family member or this movie star the younger tend to choose one signature which is that they want to take options that lead to achieving more and getting more, accumulating more, having more stuff, they want to meet more people, babe of the above the possibility of going to a loud bar at 2 a.m. in the hopes of yelling out to one another in conversation and hopefully you might meet someone new and it is an older signature that says there's nothing more of a nightmare than that. i would rather spend time with my people. they have a narrow number of people to focus on and they want deeper relationships and connections to the people they love. they are more focused on being and wanting to make sure they

have contributions that can be anonymous and small and some observations to the world. the fascination about it is that as people age our brains are changing to make you more why is that way and then she discovered they had a terminal illness and especially this was done in the west coast in the early days of hiv-aids and they would suddenly shift to having the older signature than then she did the study during 9/11 and the world became uncertain and fragile and you were not sure about what was happening everybody move to the signature saying i want to be with family and connected to those i love and make sure that i am making a difference for them.

that was the revealing thing as time goes on when we are unaware of our mortality which we are most of our lives than we focus on achieving. when we become aware of the limitations because of the uncertainty of the political atmosphere in any variety of reasons we suddenly want to focus on people that we are closer with and be connected with others and i think that wisdom is just a manifestation of having some perspective on where we are in life. >> guest: i've had patients told me they wish they would wished they would have spent more time with their family but i've never heard anybody say i wish i would have spent more time at work. >> guest: i had two kids go off to college and if they said that to me right now i don't want to focus on what i just want tbe