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

March 27, 2024

Information

3/20/24

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

Thomas P. Duffy Lecture

Cohen Auditorium

Cosponsored by the Program for Biomedical Ethics

Sunita Puri, MD, MS

ID11515

To CiteDCA Citation Guide

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&amp;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&amp;R&amp;A&amp;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.