What Happens At The End of Life?

hey what's up everyone today we're gonna talk about death and dying not in a morbid way but actually to help many of us who are curious about it to find some peace of mind separating fact from fiction I'm Risa Morimoto your host and you're watching modern aging where we chat about innovative and holistic ways to care for one another as we age if you want to stay in the loop about all our latest videos click on that subscribe button and that little bell you're sure to always be notified when new episodes are uploaded today's guest is dr. Chris Carter he's chief medical officer and CEO of hospice Buffalo he's interviewed thousands of patients over the years about their experiences as they approach the end of their lives you can check out his TED talk on YouTube just type in Christopher Kerr I see dead people we had an awesome conversation about the process of dying separating what is common myth to what is actual fact check out you know when we first talked or when I first saw your TED talk I was very excited to talk to you today we're going to talk about the process of dying but before we kind of get to that I'd love to hear a little bit about you and your background how you came to become a hospice doctor sure I'm born and raised in Toronto Canada I'm still Canadian uh-huh came down for a beer in the early 80s and ended up staying seriously yeah yeah I met somebody and so I'd been here ever since and I live close to Kane border in a small town called East Aurora near Buffalo I live on a horse farm I got to hospice complete by accident I trained did my residency at strong and internal medicine and then I came to Buffalo for cardiology and I needed to moonlight to support my family and one day I'm looking through the one ads an ad for a hospice doctor and I had funny because I had petitioned to actually get out of the rotation as a resident I didn't think there was anything to learn or do Wow so I went there just looking to do some weekend work to supplement my income and that's how it happened and I started working there and I just was immediately taken by how much there was to do right I know well I'm curious actually how much like what do you do as a hospice doctor you know you're really looking after the totality of the patient so from complex symptom issues to psychological distress you're caring for their practical needs you're caring for them in the context of their family the best way to describe it as other specialties of Medicine tend to be organ focused and we're focused on the larger experience of illness anything that's affecting quality of life so it's heavily predicated on a lot of communication open honest transparent communication so that includes prognostication what to expect things that may be absent upstream in the care of the patient so it's all of that Wow so you must develop kind of close relations with some of these patients no I mean and what's kind of doing normal span of time that they're there well unfortunately there's a subset of patients probably a third they're in for a week or less and then the rest may be there for several months but you do get very close because you you you get to see them as people not just patients you're you know you're caring for them in their home you're caring for them in the context their relationships their existential issues so you do health calls oh yeah yeah I'm sorry yeah the most about Hospice is home based care okay so I thought there's an institution I thought you're not actually Hospice no we have a dedicated unit a free-standing unit where people come who are in distress or can't be cared for in their home but the vast majority of patients 90-plus ninety-five percent of our patients we care for where they are right and I think I feel like most people don't want to die in a hospital right well for obvious reasons oh that's amazing though so are you also there at the last moments often yep mm-hmm and so kids so what actually happens as like when do you know that death isn't at what point it's really notable for how a traumatic it is or anti-climatic it is you know dying is really a process it's it it doesn't occur in minutes it usually occurs in months there's 10 percent of deaths are acute the rest are essentially for castable and the common denominator for all of them is a lessening you know you eat less you do less you sleep more and that's the trajectory we tend to think of it you know illness in terms of parts but this is more constitutional dying and if you think of old people you know who've died you know one month they stop going to get their mail the next month they stop going upstairs they start napping more they eat less the body has ways of telling itself that we're dwindling and that's what dying really is it's a dwindle it's a slowing down and you sleep more comfortably so there's less to do than you would think we tend to complicate dying yeah we you know an early illness it's you know if you take something like cancer where you are and the diseased is determined by you know the size or the spread and so we get very focused on quantifying illness in terms of measurables you know what our blood counts what's the size the tomb or that sort of thing but actually that becomes less of the issue so we see people who are dying even as tumors are regressing because oh yeah because it's not really the issue it's the burden of disease over time so if you had the flu for three days you'd feel one way the flu symptoms could be less but if you had to flip those symptoms for 30 days you would feel dramatically different so it's it's it's that weight of illness it's the it's it's the cost on the body and what it gradually it doesn't pay to do it pays to do less to eat less and that's why the common denominator is progressive sleep unless something's interfering with that process something being you know pain or a bad cough or breathlessness so a symptom otherwise actually a bit there's a built-in mechanism for dying that it's an 8 do you think that people know when they're dying yes yes that's the great the joke's on us you know I even know doctors who you know don't want to tell a patient that they're dying because they equate that with giving up or taking away hope right which is absurd first of all it's the patient's life in their body in an age of autonomy and self-determination if anything you should have the right to reclaim what's happening with your life but unfortunately that actually happens people keep that from patients I've never met one didn't know they were dying even in dementia it's shocking how people have an awareness I mean if it's you're lying in bed and you can't get up anymore you look at your arm and it's half the size it was you know you have a way of self informing that defies medicines best attempt to deny dying so the tension comes when there's an incongruity and you see it all the time where patients are aware yet medicines telling them something else in terms of the actual physical process right so once they're in Hospice yeah do they get pulled off all their meds no not at all no there's there's a lot of myths with hospice first of all physical pain is way overstated it's it's it's less oh sure oh yeah far in a way I would say confusional state psychogenic distress the consequences of impairing sleep or changing sleep architecture people starts as people start to transition there those become more prominent pain is much less of the issue right that's the fear right yeah and that's one of the same that's a symptom of what's wrong in the care of sick people is that people go into it completely uninformed as to what to expect next I often tell the story that people will go to the can to hospital know where to park how much the coffee is but they actually don't know how they're gonna die let alone when they're gonna die is that just because the doctor doesn't tell them or they don't ask or is there just like this weird yeah there's a couple of soms sometimes it's hard for patients to hear it so there are doctors who are fully disclosing I think that medicine is set up to be so interventional even economics of medicine don't really recognize the dying patient they recognize the patients we do things too so all right if you think about it so you don't you don't go to the hospital because you're feeling sick and are dying you go there because something is being done to you right even if it's just an imaging so that's where we recognize the patients so we were heavily focused obviously on the treatment not the relief of suffering and so the dying patient almost falls off the assembly line of an of care in our modern healthcare system and because the primary doctor is a much different role now they're kind of they've often fade into the backdrop as subspecialty medicine takes over right but if you don't have a reason to go back to the doctor you're often left and you're left with these great questions where am I at what's going to happen to me and that's where the fear comes in yeah and you know we have a medical culture that's death-defying yeah why you know it's interesting I think that as medicines we evolved and there's more to do we've become self enamored with technology and the skills that we can bring to bear to fight illness but we've gotten more and more focused on organs and not the big picture I think there's an assumption that somebody else is telling the patient you know what's actually happening and there's some data that's really interesting the more doctors involved less the patient actually knows well you got a bunch of spot welders you know I'm coming I'm the kidney guy I know I don't know what's going on with this I'm here I'm here for your heart I don't know what's going so it's very possible to be getting world-class care multi-million dollar care be within a unit or something and the family not actually know what's transpiring right so there is a gross absence of of honest communication about what's happening and if you think about it if if your means of communicating with your doctor is because you're being evaluated or something's being done to you when there's no longer anything to do which is the worst words and you can say in medicine there's nothing more we can do for you that's when you literally go home and your your your family and you are left with what happens next and unfortunately we're in a healthcare environment where there's very little dollars towards care at home so when you need care most you receive the least amount so yeah it's tragic so in terms of the actual physical process of dying like this steps you know how do you advise families and how do you advise patients I don't know if it's the same in terms of communications so basically their doctor they're they've been in the hospital their doctor who now says we can't do anything else right so then they get transferred to Hospice right and that's where you step it yep right I think the starting point typically because there's an abundance of misinformation or a lack of information or disparate pieces of information the first thing you have to do is find out what they actually know and it's often striking so you'll see somebody who's literally days from death who doesn't know that they're actually dying that soon so there's you know the over prognostications by a factor of 2 to 3 on average so yeah so resetting things often first requires determining what somebody understands and then really what do they want to know and what you find is people wanted again because they've been having these dot this dialogue with themselves often that's in congruent to what they're hearing from the medical practitioner so yeah so you kind of reset the table and they should expect to that it's fine for them to sleep more don't bother them you know like what do you what do you tell a family like what to expect in terms of the actual process just make sure you know I know whether it's were in the hospital we're so trying to be like make sure you turn them over make sure they're not getting bed sores all that kind of yeah yeah I think what you do typically is you you go with them and and repaint the picture so Madhu this with you with somebody you've lost for example you know before they died and if we were to talk and say you know what were they like six months ago or they're like four months ago two months ago today it's seldom a falling off the cliff phenomena it's a slow slide that slope or that trajectory is the same one that's going to take them to the end they've often been in the process of dying but nobody's inform them it's functional it's practical it's eating and sleeping it's activity level it's talking less it's it's being different and once you can can recontextualize what somebody's experience and then they can usually understand what's going just going to continue in the same trajectory do you bring it in social workers yeah so a hospice was brilliantly framed and that it was was a number of things it was really an antithesis of the medical model so it's mandated volunteer mandated spiritual Claire Social Work nursing you know the physicians there but they're their part they're really truly are part of a team I find that within treatment there's a lot of times like a cultural gap you know for examines Japanese right so it took us a while to figure out have aides and doctors and stuff to understand her cultural background how she likes to be treated how she likes to eat how she likes you know what I mean it's like all these different things that are subtle yet important yeah especially when one sick so I'm just wondering at the end of life is that taken into account or is there kind of like kind of a standard thing that happens yeah I know it's it's it's not templated at all again imagine your your your mom or your father now is taken care of in their home and your present it can't help but become personalized and specific to that individual it's very very much about your choices and your perspectives yeah I mean your you've come out of a sterile institutionalized form of care right and processed to really work we're coming to you we're meeting you where you are psychologically spiritually in terms of your wishes all those sorts of things I feel like the fear of death it's probably one of the number one things right that people it creates anxiety for them what do you say to patients who are fearful of yeah again it's remarkable for the fact that it's really less more anti-climatic than climatic it's quieter it's gentler it's more peaceful it requires less intervention than you would think you've essentially been doing it you know on your own and and and well it's a lessening and it's it's more peaceful than imagined and you just go describe it I again it goes to this issue in the absence of conversations in the absence of knowledge people presume fears you've already done it you made an assumption about pain that it's going to be if you know if I told you you were dying that's probably the first thing is you am I going to suffer so people need to be reassured what Dyne looks like it's actually hard to die in a sufferable state because you need to sleep in to sleep you need to be comfortable they need to be comfortable not only physically but psychologically so gradually that comes over you and people generally die peacefully I would do a whole thing on Hospice I would start with looking at the myth so people live longer with hospice you don't live short you know you don't deny care if you have heart failure the way you manage symptoms of heart failure at end of life is by managing the heart failure so it's not a lesser care model in fact it's a richer care model so you know it's it's it's not like oh you flicked a switch and now you're in hospice you stop all your medical right now I mean you stop the absurdities you know that cholesterol-lowering medicines you know that are meant to treat end organ disease over many years you know but you manage diabetes it doesn't feel good to have a high blood sugar so you know all the things that make you feel more comfortable need to be kept in place so it's it's actually a aggressive medicine yeah it's not passive medicine does that physically fight with the body that's trying to die no not at all no yeah you know people talk about these last moments right you that hearing is the last to go that you see a light know how there's like these no light things [ __ ] they you're confusing near-death friend of life experience so the near-death phenomena is universally I've never seen it because there that's folks who clinically die and come back right the universal experience apparently is that you see a white light and the tunnel and all that sort of things that's not what happens no no no no no and there's all sorts of things like they they say that you know the occipital lobe of your brain being deoxygenated and you know there's a medical explanation for why that may or may not be occurring people who are genuinely dying and not coming back from it don't experience the the tunnel of white light thing you know we I think maybe the odd time I've heard of a light but but not like you do that's what NDA's are near-death experiences are right these folks aren't near-death they're dying yeah but they do say that the hearing yes the last thing to go and talk to people really at their last moments yeah and you know it's one of the things is dying people don't want to be treated like dying people they want to be treated like the people they were in life so sometimes the most comfortable deaths you know like if they're a kitchen family where everyone hangs around and it's vibrant and a lot of open communication that's how they like their room you know they don't nobody wants to be treated like they're frail and need to be put on a shelf you know there are people who certainly are uncomfortable you know that matriarchal person doesn't want to be seen in her nightgown now maybe that's different but generally people want to be treated they it becomes really profoundly a human experience and they don't want to be sterilized they don't want to be put on a shelf they don't want to be treated as though something is makes them less so they want to be touched they want to be talked to they want to be regarded yeah and they hear we would love to hear your thoughts so feel free to leave a comment in the section below if you found the video helpful share it with a 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Channel: Modern Aging - Holistic Health & Wellness After 50

Views: 149,672

Keywords: Death process, Hospice, Will, Death, Die, Terminal illness, End of life, End of life stages, Signs of imminent death

Id: v1juGV5PByI

Length: 21min 22sec (1282 seconds)

Published: Thu Jul 25 2019