From Medical Memoir to CPR: A Conversation with Physician-Writer Dr. Sunita Puri

Transcript

• 00:00Seeking to articulate questions
• 00:02that are kind of right there below
• 00:05my skin that are eating at me.
• 00:07And sometimes those are questions like
• 00:10should I be doing CPR on somebody
• 00:13who's got an irreversible underlying
• 00:16condition And ABMI of 16 right?
• 00:20That was a question that really got
• 00:22under my skin when I was a resident,
• 00:25and I wasn't facile in understanding
• 00:28how you translate what you want to say
• 00:32into how you actually say it to somebody
• 00:35grappling with a decision before you.
• 00:38And I think part of what I ended up
• 00:42learning as I wrote more and more was
• 00:45that memoir and first person narrative.
• 00:49Far from being navel,
• 00:51gazing is a way to Nestle the universal
• 00:54by writing about the personal.
• 00:57And that is no easy task,
• 00:59because I think part of what makes
• 01:02writing really compelling and good,
• 01:04good writing compelling is the
• 01:06willingness to put yourself on the line.
• 01:09The willingness to be utterly
• 01:11human means that you are kind of
• 01:14turning your skin out and everything
• 01:17underneath that lining of the colon
• 01:20that has to be exposed to the world.
• 01:23And that's not an easy thing to do.
• 01:25And I was very bad at it early on
• 01:29until I started really noticing what
• 01:32are The Who are the writers and what
• 01:34are the stories that stick with me?
• 01:36That like those questions that
• 01:38I had a hard time articulating,
• 01:40the things that stayed under
• 01:42my skin like splinters.
• 01:44Who are the writers that helped
• 01:47me to do that?
• 01:48One of them, Sherwin Nuland,
• 01:52worked here,
• 01:54right?
• 01:55And so much of what he wrote and articulated
• 01:58were things that were on my mind,
• 02:01but I had no way of bringing to the
• 02:04surface until I saw some examples like his,
• 02:08where he was willing to be totally
• 02:11vulnerable.
• 02:11He was willing to be much less
• 02:14than omnipotent,
• 02:15and that's a type of humility that is
• 02:18the absolute pathway into good medical
• 02:22memoir and nonfiction narrative.
• 02:25Richard Seltzer was another
• 02:27person also here whose writing
• 02:30was incredibly inspiring to me.
• 02:33And I remember an essay of his
• 02:35where he wrote about a patient
• 02:37who was dying of pancreatic cancer
• 02:39that he had operated on years ago.
• 02:41And this patient was skin and bones,
• 02:44and his family was very ready
• 02:47to let the patient go.
• 02:50The patient was ready to let go,
• 02:52but the doctor was not ready to let go.
• 02:55And I don't know,
• 02:56I don't remember the name of the piece,
• 02:58but I do remember that he was giving
• 03:01the patient doses of morphine,
• 03:04so much so that he thought this one is
• 03:06definitely going to take the patient's life.
• 03:08And the patient stopped breathing for a
• 03:10minute but was right back up and taken.
• 03:13And I remember he went outside
• 03:16the room of the patient and the
• 03:19patient's wife and mother were there.
• 03:21And he said to them, he's not ready yet.
• 03:26And they responded, he's ready.
• 03:29You ain't. And I will never forget them.
• 03:33This is a piece I actually
• 03:35teach to my medical students
• 03:36and to my students of writing,
• 03:38because I think so much of what's
• 03:41going on there in the interior
• 03:43are things that go on for many
• 03:46of us in life and in medicine.
• 03:49But the full range of humanity that's
• 03:51in that very short piece has nothing
• 03:54to do with the heroism of this doctor.
• 03:57It has everything to do with
• 04:00the conflicts of this doctor.
• 04:03And even though in medicine I'm
• 04:05going to go out on a limb and
• 04:08say we're slightly obsessed with
• 04:10uncomplicated narratives of heroism,
• 04:12how many of you might agree with that?
• 04:15Nobody. Well, I know.
• 04:17OK, I have two people agree with me there.
• 04:20But I think what it means to be a good
• 04:23writer is to venture into that places
• 04:26with really no clear, easy answers.
• 04:29And sometimes all you have
• 04:31is the questions themselves.
• 04:34And so I wanted to start by reading from
• 04:38the piece in The New Yorker about CPR.
• 04:42And I think one of my approaches to this
• 04:44piece and to much of what I try to write,
• 04:46what I try to do.
• 04:48Not that I'm an expert.
• 04:49Not that I'm, you know,
• 04:52I'm not Shep Newland.
• 04:53But what I try to do is put myself on
• 04:57the line and hold my feet to the fire.
• 04:59Because it was only through the
• 05:01things I did wrong or the things that
• 05:04stayed under my skin like a splinter.
• 05:07All those memories of what went
• 05:09awry or what was less than ideal,
• 05:11or what I regretted,
• 05:13Those were the things from which
• 05:15the most honest writing bloomed.
• 05:18And the best writing is the honest writing,
• 05:20'cause we can all tell when somebody
• 05:23is going through a storyline that has
• 05:25been pruned like those bushes on the
• 05:28streets of outside every house in
• 05:31Beverly Hills versus the overgrown
• 05:33lush on the streets of Oakland.
• 05:37And I prefer the streets of Oakland
• 05:39because the streets of Oakland
• 05:41feel real to me.
• 05:42So before I read,
• 05:43the last thing I will say is that
• 05:45part of what it has meant for
• 05:47me as someone who is trained in
• 05:49ethics and in writing,
• 05:50is to look to the story as
• 05:52a type of narrative ethics.
• 05:55Are folks familiar with that term,
• 05:56narrative ethics.
• 05:57So it's this idea that ethical
• 06:01conflicts exist in the realm of story,
• 06:05that one way of approaching how we
• 06:08think about articulating ethical
• 06:11conflict and approaching the resolution,
• 06:13or moving closer to a mutual
• 06:16understanding of a way forward is
• 06:18through the stories and the unique
• 06:21lenses of everybody involved in the conflict.
• 06:24And so I You can be a memoirist
• 06:26or a writer of nonfiction and use
• 06:29those skills to look at very complex
• 06:33ethical issues as well.
• 06:35And that was part of my intention,
• 06:37not just with the piece, but with the book.
• 06:41So I'm going to read from my piece
• 06:44in the beginning sections.
• 06:52Shortly after his 67th birthday,
• 06:55Ernesto Chavez retired from his job
• 06:58at a Los Angeles food warehouse.
• 07:01Sara, his wife of 45 years,
• 07:05told me that he meticulously
• 07:07took his medications for high
• 07:09blood pressure and cholesterol,
• 07:11hoping to enjoy his time
• 07:14with his grandchildren.
• 07:16But one morning in January 2021,
• 07:19Ernesto burned with fever,
• 07:21his chest heaving as though he were
• 07:24once again lifting heavy boxes.
• 07:27At the hospital,
• 07:28he tested positive for COVID-19.
• 07:31His oxygen levels plummeted and he
• 07:35was quickly intubated 10 days later.
• 07:38His lungs were failing,
• 07:40his face was bloated from
• 07:42liters of intravenous fluid,
• 07:44and his hands and feet had begun to cool.
• 07:48As his chances of survival waned,
• 07:51I arranged to speak with his family about
• 07:54a subject inseparable from death itself,
• 07:57Cardio pulmonary resuscitation, or CPR.
• 08:01For decades,
• 08:02physicians have debated whether CPR should
• 08:05be offered to people who suffer from
• 08:08the final blows of incurable illness,
• 08:10be it heart failure,
• 08:13advanced cancer or dementia.
• 08:15Although CPR has become
• 08:17synonymous with medical heroism,
• 08:20nearly 85% of those who receive
• 08:22it in a hospital die,
• 08:24their final moments marked by pain and chaos.
• 08:28The pandemic only deepened the risks.
• 08:31Every chest compression spewed
• 08:34contagious particles into the air,
• 08:36and intubation,
• 08:37which often follows compressions,
• 08:39exposed doctors to virus laden saliva.
• 08:43Hospitals in Michigan and
• 08:45Georgia reported that no COVID
• 08:48patients survived the procedure.
• 08:51An old question acquired new urgency.
• 08:54Why was CPR default treatment,
• 08:56even for people as sick as Ernesto?
• 09:02As a palliative care physician,
• 09:04I help people with serious,
• 09:06often terminal illness consider a
• 09:09path forward during the pandemic.
• 09:11This involved weekly ZOOM meetings with
• 09:13each family whose loved one was in the ICU.
• 09:16With COVID, we discussed how the virus
• 09:19could damage the lungs irreversibly,
• 09:22how we gauged a patient's condition,
• 09:25and what we would do if,
• 09:26despite being on life support,
• 09:28that patient died.
• 09:31On a Gray afternoon, I logged on to
• 09:33Zoom to speak with Ernesto's family.
• 09:36I would be joined by Sarah,
• 09:38her daughter Nancy, and Neil,
• 09:40an internal medicine resident
• 09:43covering the ICU.
• 09:44Before the meeting,
• 09:45I asked Neil whether he'd been
• 09:47taught to have these conversations.
• 09:49Nope, he said.
• 09:50I asked him what he might
• 09:52say to Ernesto's family.
• 09:54Unfortunately,
• 09:54he still needs the ventilator for his lungs
• 09:58and he's not showing signs of improvement.
• 10:01We want you to know that he is very sick
• 10:05because he's so sick his heart could stop.
• 10:08If that happened,
• 10:09would you want us to do CPR to revive him?
• 10:14He used his hands to simulate chest
• 10:17compressions on a phantom body.
• 10:19In my own residency,
• 10:21I'd been taught to ask patients
• 10:23whether they wanted CPR and to
• 10:25go along with their decisions.
• 10:27But an informed decision,
• 10:29I learned, required more from me.
• 10:32One night I cared for Andrew,
• 10:35a man with incurable colon cancer who'd
• 10:38stop urinating and become disoriented.
• 10:41Unable to hold a conversation,
• 10:44he needed immediate dialysis.
• 10:46So I admitted him to the ICU when
• 10:49I discussed CPR with his wife.
• 10:51I didn't explain that Andrew's cancer
• 10:54had caused his heart and kidneys to fail,
• 10:57that he was dying,
• 10:59that CPR wouldn't change, that.
• 11:01I placed the entire burden of
• 11:04the decision onto her shoulders,
• 11:06reducing what should have been in a
• 11:09conversation into highly consequential yes,
• 11:12no questions.
• 11:13If Andrew stops breathing,
• 11:16do you want a ventilator?
• 11:18If his heart stops, do you want me to do CPR?
• 11:22To Andrew's wife and to most people,
• 11:25these questions mean Do you
• 11:27want us to try and save him?
• 11:31I offered CPR as though it were
• 11:34a choice between life and death.
• 11:37On the zoom call,
• 11:39my screen split into three rectangles.
• 11:42Sarah and Nancy were huddled on a bed.
• 11:46Dark circles ringed Sarah's eyes,
• 11:48and she told me that Ernesto's last
• 11:51words to her echoed in her mind.
• 11:54He said he wants everything
• 11:56done to save his life.
• 11:57If he's going to die anyway,
• 11:59why not try the heroics?
• 12:02She disappeared, her rectangle suddenly dark.
• 12:06Sorry,
• 12:07I just don't want you to see
• 12:10me cry again in residency.
• 12:12I would have assumed that
• 12:14because Ernesto wanted,
• 12:15quote UN quote, everything done,
• 12:18he would want CPR.
• 12:20But this conversation was about
• 12:23more than resuscitation.
• 12:25It was about death and how Ernesto would
• 12:28want to be cared for as he approached it.
• 12:32Speaking with Sarah,
• 12:33I tried to be frank about a
• 12:36procedure that symbolized both
• 12:38to doctors and to patients,
• 12:40something other than its reality.
• 12:49And to read very briefly from a
• 12:52section of the book that really looks
• 12:55at how do you ask these questions,
• 12:58how do you develop a different
• 13:01relationship to language than
• 13:03that we're taught in medicine?
• 13:06Because in my training,
• 13:07the question of do you want CPR,
• 13:10do you want more chemo or hearing
• 13:12things like he's a fighter,
• 13:14he wants everything done,
• 13:16he's awaiting a miracle, these words,
• 13:20fighter, miracle, everything.
• 13:22And even the ones we use,
• 13:24like stable multi system,
• 13:26organ failure, things like that,
• 13:29protecting an airway.
• 13:31These phrases mean everything and nothing.
• 13:35They require translation.
• 13:36But we're not taught to be translators.
• 13:41We're not taught to be
• 13:43interpreters of language,
• 13:44the language that we are socialized
• 13:47into when we start our medical training.
• 13:50And so how do we develop a
• 13:52different relationship to language,
• 13:54one that will enable true informed consent,
• 13:59which is the bedrock of biomedical
• 14:02ethics And everybody's right to enjoy.
• 14:05But asking somebody,
• 14:06do you want X or Y intervention
• 14:09strips the question of the context.
• 14:12And it is only within a specific
• 14:14context that we must learn to talk
• 14:17about with honesty and clarity
• 14:19that we can really ask the right
• 14:22questions and articulate the
• 14:24dilemmas that are on our minds
• 14:26and those of our patients.
• 14:28So very briefly,
• 14:36around the time that I met Joe Brown,
• 14:38I realized that I doubled
• 14:41as an accidental linguist,
• 14:42helping patients and families to
• 14:45excavate the many layers of meaning
• 14:48they assigned to a word or phrase.
• 14:51In the first few minutes of our conversation,
• 14:54Teresa would describe Joe as a fighter.
• 14:57Countless patients describe
• 14:59themselves this way to me.
• 15:01When I first met her,
• 15:03Linda described herself as a warrior
• 15:06against her failing kidneys.
• 15:08Back in fellowship,
• 15:09Dave told me he felt more like a
• 15:12soldier in his battle against emphysema
• 15:15than he did when he was in Vietnam.
• 15:19Recently, I'd seen an elderly
• 15:21patient with end stage lung cancer
• 15:24hospitalized with severe pneumonia.
• 15:26Her granddaughter superimposed an
• 15:28image of her face thinned by cancer,
• 15:32crusted over with a slowly healing
• 15:34zoster rash onto Hulk Hogan's body,
• 15:37and hung photocopies on every
• 15:40wall in her room.
• 15:42Don't be fooled by her looks.
• 15:45My grandma is every bit as tough as the Hulk,
• 15:49and there's no way she's losing
• 15:51to this wimpy old cancer,
• 15:53her granddaughter said.
• 15:54When I first met her.
• 15:56As a side note,
• 15:57I did not know who Hulk Hogan was,
• 15:59so it made for very interesting,
• 16:02just like certain cultural
• 16:04things that passed me by,
• 16:07I understood this impulse to fight when
• 16:11faced with anything life threatening.
• 16:13Our instinct to preserve our lives
• 16:15is so strong that it's practically
• 16:18A biological response or biological
• 16:21response to fight an enemy in
• 16:24every way possible.
• 16:25Our bodies want to keep living,
• 16:28which is why they have so many
• 16:30built in mechanisms to stay
• 16:33alive even when faced with life
• 16:35threatening illnesses or injury.
• 16:37But what do we fight for when,
• 16:40despite the best possible effort made
• 16:42by the body and mind and medicine,
• 16:45the disease grows stronger in residency?
• 16:49In the early months of fellowships,
• 16:51I had the impression that self-described
• 16:54fighters would be difficult patients.
• 16:56Fighters were the ones who didn't
• 16:58understand how sick they were.
• 17:00They demanded unrealistic treatments and
• 17:03berated doctors who wouldn't provide them.
• 17:07They vocalized their strength and courage
• 17:09ever more loudly as their bodies weakened,
• 17:13as though the militaristic ferocity
• 17:15of their wards alone could halt
• 17:17or reverse the territorial gains
• 17:20of their invisible enemy,
• 17:21be it cancer or heart disease
• 17:24or liver failure.
• 17:26When fighters died,
• 17:27their obituaries underscored these battles.
• 17:30Celebrities who died of cancer,
• 17:32quote UN quote,
• 17:34lost their long battles or
• 17:36succumbed despite fighting.
• 17:38But what did these fighting words
• 17:40actually mean to the people who use them?
• 17:43Their use had become so pervasive that
• 17:46they were now de rigor descriptors
• 17:49for anyone confronting mortality.
• 17:52Fighters wanted everything done.
• 17:54They hoped for miracles.
• 17:56They refused to entertain any
• 17:59discussion of quote giving up.
• 18:01Some physicians I knew interpreted
• 18:03the description fighter as an
• 18:05indication that they should
• 18:07provide all treatments possible
• 18:09regardless of their effectiveness.
• 18:13I had seen many a conversation
• 18:15stalled with the use of these
• 18:17phrases and began to wonder if
• 18:19the way to advance a challenging
• 18:21conversation was to explore these word
• 18:24choices to force clarity about what
• 18:27fighting for a miracle might mean in
• 18:30a very specific context or set of
• 18:33unfortunate circumstances. After all,
• 18:37didn't the word fight imply a conflict?
• 18:40Did the fighter grasp the complexity
• 18:42and nuance of the battle?
• 18:44What did the fighter know about
• 18:47his or her enemy?
• 18:49How, specifically,
• 18:50did they understand the consequences
• 18:52of the fight and what they were fighting for?
• 18:56What was worth fighting for with what
• 19:00consequences for the battleground,
• 19:02which was inevitably one's body and life?
• 19:06Could there be miracles aside
• 19:09from curing a disease,
• 19:11especially if that wasn't possible?
• 19:17All right. Thank you so much.
• 19:29So,
• 19:37so we're going to, I'm just
• 19:38going to ask a couple questions,
• 19:4410 or 12 minutes and then we'll
• 19:48open it up to your questions.
• 19:50OK. I'm going to converse and then
• 19:52we'll open it up. We'll converse.
• 19:53I'm not going to converse,
• 19:56OK. As you're talking,
• 19:57I was like looking through all like my
• 20:0050 questions that I came up with and
• 20:02I talked for a little too, no, no, no,
• 20:04not at all. That was really wonderful.
• 20:06So I wouldn't, I think I'm going to
• 20:08just come back to the CPR article.
• 20:09So first. When I saw that you
• 20:12had written about CPRI thought,
• 20:14is there anything new to say about CPR?
• 20:17It's been like literally
• 20:19like beaten to death.
• 20:22But you did and
• 20:23you you explained I think I think
• 20:25your combination of personal history
• 20:27and and the history of the the
• 20:30practice itself at least for me.
• 20:32Kenneth gave me a a new way of looking
• 20:34at it which I thought was really
• 20:36great and I wanted to just kind of
• 20:38pick apart 11 thing that goes along
• 20:42with CPR which is DNR and ask you
• 20:45about I think people everybody knows
• 20:47what that means in this audience.
• 20:49But you know and it's simplest terms
• 20:53it means just don't do CPR and do
• 20:55do comfort care and let people be.
• 20:58But of course it's it's it's taken
• 21:00on this meaning of ignoring people
• 21:02and letting them suffer and just not
• 21:05even not even stopping by the room.
• 21:06So how did that happen and what
• 21:08how can we change that.
• 21:11So that's that's a great question. No.
• 21:16This is on but can people hear me even.
• 21:19OK. So I'm just going to project.
• 21:23So I think there is this
• 21:26binary that is in our lives.
• 21:29Oh, OK Is this on? Is this on?
• 21:32OK, this is on. OK.
• 21:33A second ago it was not on So OK.
• 21:38So I think there's this binary
• 21:40in medicine and that consists
• 21:43of do everything or do nothing.
• 21:46And I think the practice of
• 21:49resuscitation falls into that binary.
• 21:52Because when we think about just in popular
• 21:56culture or on ER or any of these other shows,
• 22:00what it means to do everything for
• 22:03someone inevitably includes CPR, right?
• 22:06Without the understanding that CPR
• 22:08is not there to reverse a debt.
• 22:11What, sorry,
• 22:12CPR is not there necessarily to save a life.
• 22:15It's about reversing a death.
• 22:17And those are not the same thing.
• 22:19And reversing a death is not
• 22:21the same as restoring a life.
• 22:23And so I think when we get into this,
• 22:26do everything or do nothing,
• 22:28we don't actually know what we're
• 22:31talking about with respect to what
• 22:33CPR symbolizes versus what it is
• 22:36and what its intent actually was.
• 22:38And so DNR evolved in the 80s,
• 22:42really as a corollary to CPR,
• 22:46especially as people were kind of saying,
• 22:48I don't know,
• 22:49that I want my life prolonged at all costs,
• 22:52including the cost of bodily integrity
• 22:55and suffering writ large in the many
• 22:58definitions of suffering that exist.
• 23:00I don't know that I want that,
• 23:01but I also don't know what else to say.
• 23:04And so the DNR order evolved specifically to
• 23:09say when someone's heart stop and they die,
• 23:14do not perform any part of ACLS,
• 23:17right.
• 23:18But that's all it meant.
• 23:20It didn't mean that it,
• 23:21let's say somebody was in the ICU with
• 23:26terrible sepsis who and they need
• 23:28antibiotics and they need pressors.
• 23:30You can still be DNR and have all of that,
• 23:36but because of that thinking of it's
• 23:38either everything or nothing DNR
• 23:41which literally stands for Do not do
• 23:45something people began to fear and
• 23:48with good reason because this played
• 23:50out in practice and sometimes still
• 23:54does that do not perform CPR sometimes
• 23:58becomes do not provide pressors,
• 24:00do not provide BIPAP,
• 24:02do not provide these other life
• 24:04extending things that may actually
• 24:06be within someone's goals of care.
• 24:09I like the term allow natural death better.
• 24:12Have has anyone heard this term
• 24:14because I think this is actually the
• 24:16way we should be talking about this.
• 24:18Not do not resuscitate,
• 24:20but allow natural death,
• 24:22which I think to my mind #1
• 24:25doesn't imply A withholding,
• 24:27it implies A stepping out of the
• 24:29way for an unfolding to happen.
• 24:32That's natural.
• 24:33But you can still have a whole
• 24:35lot of other interventions up
• 24:38to that point of arrest.
• 24:40I
• 24:43just thank you. I I just worry
• 24:46that allow natural death,
• 24:47which is now kind of I I guess a
• 24:49newer phrase, 'cause I haven't
• 24:50heard it other than from what I
• 24:52read in your piece that soon like
• 24:54in two years it'll be another like
• 24:56allow natural death ignore. Yeah.
• 25:00And I think you know and I hear this
• 25:03a lot that well the person's DNR,
• 25:05so why are we doing XY and Z.
• 25:08And it's like a constant process of
• 25:11education and re education to say I
• 25:14understand why you might feel that way
• 25:17but a do not resuscitate only applies
• 25:19to the point of cardiac arrest and
• 25:22it's like a continual reminding people
• 25:25that that's not giving up on somebody
• 25:28that's respecting their dignity if
• 25:30indeed that is not only their choice but
• 25:33what's appropriate in a given circumstance.
• 25:38So in during COVID a family
• 25:41member was hospitalized with
• 25:44in early COVID and pre vaccine when
• 25:48we were doing all the zoom stuff
• 25:50that you were you were talking about
• 25:52and there was a great pressure from
• 25:56this person's PCP to make them DNR
• 26:03and it felt really pushy and it was
• 26:06very aggressive and horrible and of
• 26:08course we thought DNR would just meant
• 26:12ignore and let die and this person
• 26:14was not intubated like it wasn't.
• 26:16It wasn't like a situation where allow
• 26:19natural death would have been the
• 26:20right thing to do because natural death
• 26:22may have been years later post COVID.
• 26:24So I don't know if you have
• 26:26something to say about that kind of.
• 26:27I'm sure you experienced that also.
• 26:30I think sometimes,
• 26:32especially some of what I have
• 26:35seen in the palliative world,
• 26:38but also in just like the general
• 26:41world of medical practices,
• 26:43there can be an overzealousness to
• 26:46jump to certain recommendations that
• 26:50are coming from well meaning people
• 26:52who may not be listening to what the
• 26:55patient or the family or even some
• 26:58of the other providers are saying.
• 27:00So I've definitely been in situations
• 27:04where some family member to usually
• 27:06with someone who can't speak for
• 27:09themselves but somebody speaking on
• 27:11their behalf will be very insistent.
• 27:13No, we should not be doing this.
• 27:15We need to take them home on
• 27:17Hospice and I'm thinking,
• 27:19well actually they don't have like
• 27:21a Hospice admitting diagnosis.
• 27:23They're just 90 years old.
• 27:25But that doesn't mean they've
• 27:26no reason to be on.
• 27:28I cannot certify them to be on Hospice.
• 27:31They were well, 90 year old.
• 27:33And so some of that we never really
• 27:36know what's where these intentions and
• 27:39conversations are really coming from,
• 27:41right.
• 27:41We are a privileged part of our
• 27:44patients lives for a brief snapshot
• 27:46but as much digging and trying
• 27:48to get people to articulate.
• 27:50So tell me what you understand
• 27:52about what's going on?
• 27:53What is worrying you about
• 27:56the situation to make,
• 27:58to have you be very insistent on Hospice?
• 28:02Like,
• 28:03could we imagine another way that
• 28:05we could care for your mother given
• 28:07that right now she doesn't qualify
• 28:10for Hospice and you just almost need
• 28:12to keep digging and digging and
• 28:14digging to kind of get a sense of
• 28:17where is this conflict coming from?
• 28:19And can you help people see
• 28:21it a different way,
• 28:22especially if it's overzealous and
• 28:24pushy and disempowering and weird,
• 28:29Totally agree. Thank you.
• 28:30I'll ask one more question
• 28:32and then I'll open it up.
• 28:33Just thinking about training.
• 28:35And so the what the example that you
• 28:38just gave was so well articulated and
• 28:41like that should be what everybody
• 28:43is capable of doing and having
• 28:45these conversations not just the
• 28:47palliative care doctors and team.
• 28:49And so you wrote I,
• 28:51I I can't remember where I read it
• 28:53but you wrote about how we received
• 28:55so much training in procedures.
• 28:56We're watched as we learn how to do an
• 29:00ABG or whatever and G tube and even,
• 29:04like drawing blood and you know,
• 29:05the simplest to the most complicated
• 29:07procedure where we have to be watched and
• 29:09we have to do it a certain number of times.
• 29:11And yet with learning how
• 29:13to have these conversations,
• 29:15it's just kind of expected that we're smart.
• 29:17So we could just do that.
• 29:19It's just talking to people.
• 29:20Do you really need to be
• 29:21watched and taught how to do it?
• 29:22And I know in palliative care,
• 29:23you guys spend time doing that.
• 29:25But on the rest of medicine,
• 29:27Yep.
• 29:29And I think, you know,
• 29:30in palliative care, words are our tools
• 29:33and communication is our procedure.
• 29:35Really, that's kind of how I
• 29:37think about it, that you know,
• 29:39you go in as a cardiologist and
• 29:41you learn to do a cardiac Cath and
• 29:44you do it and you do it and you do
• 29:46it and sometimes things go South.
• 29:48And so part of it is not just the
• 29:51scripts we teach, which I mean,
• 29:55I'm all for the scripts as the basics,
• 30:00but it's not just about knowing
• 30:04what questions to ask.
• 30:05It's about learning how to navigate
• 30:08the answers people give 'cause
• 30:10that's where things can go South.
• 30:13You can ask things like tell me what you
• 30:15understand about your illness, right?
• 30:17We teach these questions,
• 30:19but someone can say something
• 30:21that if you're so busy thinking
• 30:23ahead to the next question,
• 30:25you're not present with their
• 30:27answer or with the emotion in
• 30:29the room or trying to decipher.
• 30:32Here's the text. What is the subtext?
• 30:35What are they really trying to say?
• 30:38Is there a discrepancy between what they're
• 30:41saying and what you can feel in the room?
• 30:44And that's where I think this
• 30:46becomes a true procedure.
• 30:48Someone goes to the OR and you think
• 30:50it's gonna be a straightforward
• 30:51Whipple and you get in there
• 30:53and there's Mets in the liver.
• 30:55It is not what you anticipated
• 30:56and your plan has to change.
• 30:58Or somebody has a very tortuous femoral
• 31:02artery and you're up there trying
• 31:03to do a cap and it is not working.
• 31:06Now what are you gonna do?
• 31:07And in that way,
• 31:08the analogy is really apartment that how
• 31:11we think about a structure of a conversation,
• 31:13troubleshooting,
• 31:14really excavating the meaning
• 31:16of the words that we're using,
• 31:19not just what someone else is
• 31:21using and asking them to help
• 31:23you understand what they mean
• 31:25when they say they're a fighter.
• 31:27But what do you mean when you say
• 31:29the patient is stable, right.
• 31:31I've heard that a million times.
• 31:33And like,
• 31:34I don't know what stayed stable in what way,
• 31:36right? Like stable to in whose eyes?
• 31:39And they're better, OK.
• 31:40I don't know what that means either.
• 31:42And so being helping people to
• 31:45articulate what's happening and
• 31:47helping yourself to be clear,
• 31:50that's the only way that that procedure
• 31:52of a conversation is gonna work.
• 31:55But we do not.
• 31:56And I wrote about this in the book many
• 31:59different places that no one watched me.
• 32:01I was just sent in as an intern to
• 32:04go talk to somebody and I was well
• 32:06meaning and I wanted to do it well.
• 32:08And I screwed up a million times,
• 32:10even knowing that this is something
• 32:12I should be good at.
• 32:13And so for those of us who don't
• 32:15care or who are kind of like,
• 32:17well, I'm a normal person.
• 32:19I'm a nice person.
• 32:20I can just go talk to this family
• 32:23like that's you, Nick.
• 32:25You may be normal and nice,
• 32:27but that's not a normal circumstance
• 32:31that you're walking into.
• 32:33That's a conversation someone's going
• 32:35to remember for the rest of their lives.
• 32:38And we need to take it as seriously as if
• 32:40we're going to the operating room and opening
• 32:43someone up for the first time in their lives.
• 32:46Because for me, it's never lost on me that
• 32:49I walk in A room and I talk about CPR.
• 32:53For me, that I do that many times a day,
• 32:55for the people listening to me,
• 32:58that will be something.
• 32:59They will remember.
• 33:00They will remember what I said.
• 33:02But more importantly, they're going
• 33:03to remember how I made them feel.
• 33:05We are not teaching that in medical
• 33:08school across the board.
• 33:09If you get it,
• 33:11you're lucky I did not get that.
• 33:13I screwed up a bunch of times and
• 33:16was super hard on myself and cried
• 33:18and didn't feel like I could go to
• 33:21my supervisors and say I need you to
• 33:23come in here with me because I want
• 33:26to do this well and I don't think
• 33:29I'm doing it well and I need help.
• 33:32And it just was not the sort
• 33:34of place where I could do that.
• 33:37And I hope that that's changing more.
• 33:42I have a lot of opinions also.
• 33:45We love your opinions. OK, I'm going
• 33:47to open it up first to students.
• 33:49Any questions from our students?
• 33:56Student,
• 34:00students of life?
• 34:03First of all, thank you very much.
• 34:04I appreciated the way
• 34:06that you kind of brought
• 34:07the conversation around
• 34:08to like, what are your
• 34:09goals? What are your understandings?
• 34:10What's important to you and
• 34:12approach the conversation
• 34:13a little bit more that way
• 34:15versus this is what I see medically etcetera.
• 34:20You were talking about language
• 34:22and the shift from like DNR to
• 34:24A&D or allow natural death.
• 34:26And I'm curious about how the the
• 34:28pulse or the most forms depending
• 34:30on which coast you're on have
• 34:33changed these conversations.
• 34:35So kind of giving more information about,
• 34:38you know, the difference between DNR,
• 34:39but still comfort measures or
• 34:41comfort measures only.
• 34:43And if you're seeing kind of that
• 34:45narrative and those conversations
• 34:46shifting and getting a little bit
• 34:48more approachable for people who
• 34:50aren't maybe super palliative inclined,
• 34:52that makes sense, Yeah.
• 34:54So I think that pulsed and
• 34:56most forms definitely give a
• 34:59structure to a conversation.
• 35:01And I'm all for conversation aids
• 35:04or documents that give people some
• 35:07language to use with each other and
• 35:11with their doctors about what they want,
• 35:13what they don't want,
• 35:14what they understand and don't understand.
• 35:17And I think that last point
• 35:19is the potential danger.
• 35:21Because if we hand people a
• 35:23form or an advanced directive,
• 35:25and I think this happened
• 35:26a lot during the pandemic,
• 35:28like go home and fill this out,
• 35:30the thing that's missing is the context,
• 35:32right?
• 35:33And the context in which we help
• 35:36people understand what's going
• 35:37on that I think can't be divorced
• 35:40from the content of the forms.
• 35:42So if I give you a form and you
• 35:45are relatively healthy and you're
• 35:4765 and maybe you've got some CAD
• 35:50and I say go take this form and
• 35:52think about these questions and
• 35:54what you might want,
• 35:56that's very different than if
• 35:58someone has metastatic pancreatic
• 36:00cancer and they've had three
• 36:02lines of chemotherapy and the
• 36:04cancer has spread regardless.
• 36:06And I give them a form like that
• 36:08because the consequences of the choices
• 36:11they will make are not the same.
• 36:14The form is the same,
• 36:15but not the consequence.
• 36:17And so I think the danger is
• 36:19that we give people a form
• 36:22and don't give them guidance.
• 36:24We don't help flesh out what
• 36:27is the situation in which I'm
• 36:30asking you to fill this out.
• 36:32I do think the forms are very helpful,
• 36:34and I actually have a mentor who is
• 36:38part of the pulsed writing committee
• 36:42who has talked to me a little bit
• 36:44about just even coming up with like
• 36:47the phrase comfort measures only, right?
• 36:50Like every word was something.
• 36:52Not every word,
• 36:53but many words and phrasings were
• 36:56things that were the subject of debate.
• 36:59So there's a whole interesting
• 37:00history here and I wish he were here.
• 37:02I would invite him to comment
• 37:04further on that.
• 37:05But yeah,
• 37:06but I do think they're helpful,
• 37:07but I think they need to be used in a,
• 37:10in a way that they're not always used.
• 37:11I guess.
• 37:12I think I'm conversation
• 37:17guy versus. Yeah, exactly.
• 37:20Any other students questions in the back?
• 37:31Hi, I'm a first year student.
• 37:35I want to thank you
• 37:35for your talk.
• 37:37I my question is
• 37:38more you know in terms of learning
• 37:41how to have these conversations and
• 37:44acknowledging that you are going to mess
• 37:46up when you have these conversations.
• 37:48What do you recommend that we do
• 37:50as we learn how to have better
• 37:54conversations around E&R&A&D and
• 37:57stuff like that?
• 38:01So I think having the intention
• 38:04to do them well and understanding
• 38:07that they're just as important,
• 38:10if not foundational in your
• 38:12interactions with patients,
• 38:14I think knowing that and really
• 38:17believing that is the first step.
• 38:20I think also finding mentors who
• 38:24do it well and making an effort to
• 38:27learn from them is really important.
• 38:30And I think also watching people who do it
• 38:34in a way that you don't think is effective,
• 38:37they also have something to teach you, right?
• 38:41So I think you want to have the intention.
• 38:44You want to learn from those around you
• 38:46who give you a variety of examples.
• 38:48And then the thing I tell my students
• 38:51and my trainees and my fellow is that
• 38:55bringing her own personality to it.
• 38:57I think it sounds very stiff.
• 38:59When we read from scripts,
• 39:01the scripts are a place to start.
• 39:02I feel like I'm bashing the scripts.
• 39:04I don't mean to,
• 39:06but I want to complicate them and I
• 39:09want to complicate the way we inhabit
• 39:12ourselves when we're with patients.
• 39:14There isn't one way to be a doctor.
• 39:17There isn't one way to have a
• 39:19conversation with somebody.
• 39:20So if anything,
• 39:22one of the biggest pieces of feedback
• 39:25I tell my trainees is relax,
• 39:29take a deep breath and go in there
• 39:32and bring your authentic heart
• 39:35to these conversations,
• 39:37because people can tell when you're
• 39:40there as a performance versus when you're
• 39:43there with the full force of your humanity.
• 39:46So I think there's a couple different
• 39:48elements to it that you don't have
• 39:50to phrase things the way I would
• 39:52phrase them or the way anyone
• 39:54else would phrase them.
• 39:55Find your own way around your words,
• 39:59but have the intention be that
• 40:02you're there to listen 1st and
• 40:05to really try to understand.
• 40:08And you won't always understand
• 40:09where someone's coming from,
• 40:11but if you speak to them human to human,
• 40:14sometimes getting our own medical
• 40:16jargon in the ways we've learned
• 40:19to be with patients out of the way,
• 40:22that helps us to have the most
• 40:24authentic goals of care conversations.
• 40:29That is my non evidence based to
• 40:31bring your authentic heart.
• 40:34Next question.
• 40:40So my question is a little
• 40:41more specific to CPR. And
• 40:47in your opinion, what is the lowest
• 40:49level of care where we should
• 40:52start having these discussions?
• 40:55So I'm about to be an EMT and so
• 41:00obviously we have DNRS, we do CPR
• 41:03which would be our main resuscitation
• 41:07a what? And if
• 41:08we start from you know, EMT basic
• 41:10up to like Level 1 trauma center
• 41:12center like here at Yale, at what level do
• 41:16you think that we should start having
• 41:19these discussions And do you think it
• 41:21would be useful to have several levels
• 41:23of DNR depending on what level of
• 41:26measures people are comfortable with?
• 41:30So I think there's in my mind,
• 41:33there's not really levels of DNR.
• 41:36If someone goes down in the field,
• 41:38you either start CPR or you don't,
• 41:41based on documentation that's
• 41:44there or or not there, right?
• 41:48So if someone has a pulse that says
• 41:50DNR and you get called to the house,
• 41:52that's something that you respect, right?
• 41:54If there's no documentation,
• 41:56in the absence of that, you usually
• 41:58have to start CPR in between there.
• 42:02There's not a whole lot if
• 42:04you're coming in as an EMT,
• 42:05if you have a pulsed form that
• 42:08shows they don't want CPR.
• 42:09But for example,
• 42:10they would want selective measures,
• 42:12which is what is a is not
• 42:14a choice on a pulsed form.
• 42:16That might mean they would want BIPAP, right?
• 42:19Or they would want other types of
• 42:21respiratory support or that they would
• 42:23even want to go to the hospital,
• 42:24but the line would be around CPR.
• 42:27So in the absence of that, though,
• 42:30I don't know that there's levels of DNR,
• 42:33right?
• 42:34There's levels of intervention,
• 42:35but intervention is not the same as CPR deal.
• 42:40I think this is where you know
• 42:42in some states they're trying to
• 42:45build pulsed registries so that if
• 42:48somebody doesn't have documentation,
• 42:50there may be a way to pull it up
• 42:53and don't know if that's only
• 42:55hospital based or whether that's
• 42:57something EMTs would have access to.
• 42:59In my opinion,
• 43:01I think that anybody with any
• 43:03sort of serious illness or strong
• 43:06feelings about whether they would
• 43:08want to go through CPR,
• 43:10that those conversations
• 43:12should happen whenever.
• 43:14A lot of times,
• 43:15like if I'm taking care of somebody
• 43:19and they tell me that they lost a loved one,
• 43:24like within the last year,
• 43:26something I will ask is tell me what your
• 43:29experience was of losing that person.
• 43:32What was their death like?
• 43:34And they may say to me it was horrible.
• 43:38She was in an ICU,
• 43:40she was traked and then they did
• 43:42CPR and there was blood everywhere.
• 43:45And you know, something like that.
• 43:47That's a way in, right?
• 43:49So talking about the minute,
• 43:51like what you're asking about,
• 43:53when should this conversation start
• 43:55with the minimum requirement for this.
• 43:58Honestly, I think whenever we lose anybody,
• 44:00it's an opportunity to talk to each other
• 44:03and to have a conversations within us about,
• 44:06would I want my last moments
• 44:09to look like that?
• 44:11If I would want to make a different choice,
• 44:14then I need to tell the people I
• 44:17love and I need to write it down.
• 44:18And I need to tell the doctors
• 44:20taking care of me,
• 44:24buddy, on this, I'd
• 44:25like to ask. Yes, somebody in the back row,
• 44:28Thank you so much for this conversation.
• 44:31I'm. I'm really passionate about this.
• 44:33So I'm not a physician.
• 44:35I'm a chaplain and I've been
• 44:37having conversations with
• 44:39patients and families for many,
• 44:41many years about this.
• 44:43And I have something that's troubling
• 44:46me and it has been for years and I
• 44:48would love to hear your thoughts on it.
• 44:51When I support providers,
• 44:53when we have just done a ACPR attempt,
• 44:57we all tell each other we would
• 45:00never want that for ourselves.
• 45:02We're going to be DNRD and I.
• 45:05When we're older, you know,
• 45:06our family members are going to be D and Rd.
• 45:08and I, we would never go
• 45:10through that ourselves.
• 45:13And you began the talk this evening,
• 45:15reminding us that we're so influenced by
• 45:18our culture of these medical shows like
• 45:21ER and movies and these types of things.
• 45:25And what is deeply troubling to me is the
• 45:28huge disconnect between medicine and culture.
• 45:33And one of my passions is to help patients
• 45:37and families experience a good death.
• 45:40And what I'm wondering is,
• 45:42how do you think we can begin to change
• 45:47our culture around resuscitation
• 45:49so that people are more open
• 45:54to having these conversations,
• 45:56seeing them for what they are?
• 45:59We're not necessarily like,
• 46:00I didn't know that resuscitation
• 46:02was someone's already dead and
• 46:04we're trying to bring them back.
• 46:06And I'm an educated person
• 46:09and I had no clue.
• 46:11So I'm like a lot of other people
• 46:13probably don't know this either.
• 46:15So what are your thoughts about
• 46:19changing our culture to be more
• 46:22amenable to these conversations?
• 46:26So I think George Clooney needs
• 46:29to do an infomercial saying
• 46:31everything I did was false.
• 46:35That would be pretty great though, right?
• 46:37If he and forget the guy who played
• 46:40the name of the guy who played Mark.
• 46:43But I really liked Mark.
• 46:44I feel Anthony Edwards,
• 46:47he was so great, right?
• 46:50He was actually my favorite.
• 46:53But if they were to come forward,
• 46:55I feel like it would be a lot of fun.
• 46:58So, but in all seriousness,
• 47:00I think that there's a couple
• 47:01different ways to think about this.
• 47:03One, I will say hands down of
• 47:07the emails I got about my piece,
• 47:09the far and above biggest comment was I did
• 47:12not know you had to die first to get CPR.
• 47:16People do not know this and they don't
• 47:19know that it's about death reversal.
• 47:22And I think that so much of the cultural
• 47:28component to this writ large is the
• 47:31expectations we have of doctors and medicine,
• 47:35right, This idea that we
• 47:37should be able to do anything.
• 47:40I think that's a big part of the cultural
• 47:44expectations of medicine that are very,
• 47:47I don't know where that came from because
• 47:50in the words of Doctor Cox from Scrubs,
• 47:54which I'm just gonna go with this now,
• 47:56I love Doctor Cox.
• 47:58He's a personal hero of mine.
• 48:01I'm not able to really enact Doctor
• 48:04Cox in this current day and age,
• 48:07but I wish that I could.
• 48:08But he told Zach Braff's character once.
• 48:13Everything that we do is a stall, right?
• 48:17And he's right.
• 48:19But I don't know that.
• 48:21Even though the the general
• 48:23public and all of us get that,
• 48:25I don't know that we really get that.
• 48:27And I think that gets in the way when
• 48:29we think about what medicine should
• 48:31be able to do versus what we can do.
• 48:34And I think speaking more realistically
• 48:37about medicine's limits is something that
• 48:39cannot just be the realm of palliative care.
• 48:43That expectation setting has to happen
• 48:46whenever somebody comes into the ICU,
• 48:48whenever somebody gets a serious
• 48:51illness that I understand,
• 48:53who I've just told you of
• 48:54metastatic lung cancer.
• 48:55I understand there's a lot of info out
• 48:58there about what clinical trials are,
• 49:00but a lot of clinical trials
• 49:02will not benefit you.
• 49:04They will benefit someone in the future.
• 49:07But people expect that if I'm
• 49:09on an experimental therapy
• 49:11that that may work for me.
• 49:12And I think part of dispelling
• 49:15the cultural myths we have is
• 49:17confronting them and saying this
• 49:20is what's achievable in medicine,
• 49:22but this is the realm of ER and fantasy.
• 49:27I also just think,
• 49:30being somebody who is from a culture,
• 49:33again writ large,
• 49:35where conversations about this stuff,
• 49:39we don't have the language for it,
• 49:42like in Hindi.
• 49:44When I try to have a goals
• 49:47of care conversation,
• 49:48there's a lot that just doesn't
• 49:50make sense or translate,
• 49:51in part because some of the
• 49:55actual concepts aren't there.
• 49:57And I think it would be a miss for me
• 50:00not to acknowledge the diversity of
• 50:04perspectives and communication styles
• 50:07that come into talking about death
• 50:09and dying and and suffering and loss.
• 50:11We have a million ways of talking
• 50:14about suffering because that is
• 50:16the inescapable fact of human life.
• 50:18And that's kind of how you deal
• 50:20with that is enshrined in many
• 50:22of the religions in South Asia.
• 50:25So we have vocabulary and ways of
• 50:28thinking and talking about that,
• 50:30but I literally have no way
• 50:31to say goals of care.
• 50:33Like talking directly about death
• 50:37is not something that it would be
• 50:41almost disrespectful sometimes.
• 50:43So there's a lot of indirect
• 50:44communication around it,
• 50:45and I think that's a part of the culture too.
• 50:48And I don't think you have to be Asian
• 50:50or South Asian for that to be the case.
• 50:52I think in families of all backgrounds,
• 50:54there's indirect and direct communication.
• 50:56There's the text and the subtext and
• 51:00raising the subtext into the text,
• 51:03really getting into what is our culture
• 51:07around talking about hard topics,
• 51:09let alone talking about death.
• 51:11I think that's a part of the conversation
• 51:14around how can we evolve cultures within
• 51:17a family, within a group, whatever,
• 51:21within a hospital, within medicine.
• 51:24I think those are all part of the
• 51:26way I would answer your question.
• 51:28Right. And also George Clooney.
• 51:34I love George Clooney. OK,
• 51:35we started, I know we
• 51:36started about 3 minutes late.
• 51:38So we have time for one more
• 51:39question and then we will stop. I'm
• 51:43good. So we need it for the
• 51:50zoo. I am not a doctor.
• 51:52I'm not a nurse.
• 51:53I'm a writer and I write a lot
• 51:56about Connecticut Hospice,
• 51:57and I know that it was nurses
• 51:59that recognize the need for
• 52:01palliative care back in the
• 52:0370s in this very city.
• 52:05So I wonder, given doctors,
• 52:09seeming like doctors are trained
• 52:12intensively to heal, to fix, to repair,
• 52:16I wonder if the conversation could be,
• 52:18could include nurses.
• 52:21Oh, certainly, yeah, absolutely.
• 52:23I mean, I think that obviously
• 52:27like the backbone of a lot
• 52:29of Hospice groups is nurses.
• 52:31Some of our biggest fans in the hospital are
• 52:35nurses and social workers and chaplains.
• 52:37Some of the hardest people to bring around,
• 52:40though, can also be nurses
• 52:41and social workers, right?
• 52:43I think to deny everybody their
• 52:47complexity means not to say doctors
• 52:49are the only ones that have things
• 52:52to learn and come around to.
• 52:54I've certainly met nurses who are the
• 52:56angels that got me through residency,
• 52:58who taught me how to sit there and not
• 53:01do anything but just be with a person.
• 53:04And I've met nurses who asked me,
• 53:07you know, why are you here?
• 53:08We're going balls to the wall
• 53:11for this patient.
• 53:12And so I think it's medicine and nursing.
• 53:15In both of our schooling.
• 53:17I don't know that we teach
• 53:20these concepts well, right?
• 53:22It's not to diminish the very
• 53:24important role nurses have played and
• 53:27continue to play in seeing things
• 53:29before the physicians do sometimes.
• 53:32But there's many combinations
• 53:34of discomfort and comfort with
• 53:37these subjects that arise,
• 53:39at least in my experience, in the hospital.
• 53:41So I think to not acknowledge
• 53:44nursing would be a huge mistake,
• 53:46'cause they're incredible and
• 53:47they do things I could not do.
• 53:50But I've also seen that it's not
• 53:54a straightforward embrace in
• 53:56every single health profession.
• 53:59In fact,
• 54:00who I actually want to shout out are the PTS.
• 54:03Physical therapists are on it.
• 54:07They will come to me and be like,
• 54:09are you following this person?
• 54:11And I'm like,
• 54:12I don't know who that person is,
• 54:13but they will say,
• 54:15I have no idea why we're giving
• 54:18chemo to this person.
• 54:19He cannot stand up,
• 54:21but we're going to do cytotoxic chemo.
• 54:24So the physical therapists,
• 54:25I think,
• 54:26don't get enough recognition for
• 54:29everything that they see him do.
• 54:33So I just would like everybody to
• 54:37acknowledge your physical therapists
• 54:39and your nurses and your social
• 54:41workers and chaplains and doctors,
• 54:43everybody,
• 54:46all so much for being here.
• 54:47Thank you Sunita Puri,
• 54:49and have a good night everybody.
• 54:51And medical students.
• 54:53And other students.
• 54:54If you would like a book,
• 54:56we have plenty.