Podcast appearances and mentions of bob right

As a property management business owner, how do you find the best people to build an effective sales team? In this episode of the #DoorGrowShow Podcast, property management growth expert Jason Hull sits down with Bob Lachance, founder of REVA Global, to talk about how you can utilize virtual assistants for lead generation and growth. You'll Learn [01:22] Identifying a Need in the Real Estate Industry [08:53] How to Utilize VAs in Your Business [14:35] Creating a Hiring System in Your Business [19:30] Using VAs for Lead Generation  Tweetables “When marketing consistently goes out, what we find is all those leads end up piling up.” “Over 70% of all sales never happen on the first touch.” “People want to do business with people they see, feel, touch, and like.” “Property management can definitely be death by a thousand cuts.” Resources DoorGrow and Scale Mastermind DoorGrow Academy DoorGrow on YouTube DoorGrowClub DoorGrowLive TalkRoute Referral Link Transcript [00:00:00] Bob: Virtual assistants are a big part of anyone's business. In my opinion today, I think you got to start looking at that because small businesses, a lot of times, especially when we start, we are on a tight budget.  [00:00:12] Jason: Welcome DoorGrow property managers to the DoorGrow Show. If you are a property management entrepreneur that wants to add doors, make a difference, increase revenue, help others impact lives, and you are interested in growing in business and life, and you're open to doing things a bit differently, then you are a DoorGrow property manager DoorGrow property managers love the opportunities daily variety unique challenges and freedom that property management brings. Many in real estate think you're crazy for doing it. You think they're crazy for not because you realize that property management is the ultimate high trust gateway to real estate deals, relationships and residual income. At DoorGrow, we are on a mission to transform property management business owners and their businesses. We want to transform the industry, eliminate the BS, build awareness, change perception, expand the market, and help the best property management entrepreneurs win. I'm your host, property management growth expert, Jason Hull, the founder and CEO of DoorGrow. [00:01:10] Jason: Now let's get into the show. And today's guest is Bob. Do you say Lachance?  [00:01:18] Jason: Lachance. Yep. Lachance.  [00:01:20] Jason: I nailed it. All right. So Bob, great to have you on the show. And, Bob, you are helping people discover the top marketing channels that can maximize lead generation when working with VAs. And so we're going to chat a bit about that today before we get into that, tell everybody a little bit about you, how you got into entrepreneurism and what led you to what you're doing now.  [00:01:43] Bob: Yeah. So right now I'll just start right now. I have a real estate investment company as well. And I have a virtual assistant staffing company, so I use my VAs in my own business. So I have a rental portfolio as well as a buy sell fix flip company here in Connecticut, doing a couple of different states, but I started back about 20, 21 years ago now back in 2004. [00:02:06] Bob: I played professional hockey prior to that for eight years and then got into real estate. And you know, from real estate, helped start an education program while I was, you know, working on properties. I did a lot of, you know, fixed flip wholesaling, all that kind of good stuff. This is, again, I'm dating myself, but this is back in 2004. [00:02:25] Bob: And through the process, when I helped start this education company there was a huge need in the industry, just like you, right? You see a need out there. And I'm a lot like you on that side of it, helping people and figuring out, you know, where they could. Create passive income or income in general. [00:02:42] Bob: So, during the coaching program, while I was in it, I realized there was a huge need. Majority of the students that I coached didn't have the time to actually put into their real estate business because they were either working part time or full time. They just needed to, you know, they needed help. And for years, upon years, I was looking for a solution for that. [00:03:01] Bob: Whether it was a product I didn't know back then, again, this is going back from 2007 to 2013. I didn't know there was any services out there, like what virtual assistants were. And then I got introduced back in 2013 what a virtual assistant was. You know what this could help my business So I hired my first one and then light bulb went on like, you know what we could turn this into a business I could take the back end of what it helps create which is the real estate education company And our students could use it to help them grow their business help scale help, you know, get your time and freedom back. So launched it in 2014 and then fast forward today you know 10 years later i've been in business for a while and I also have like I said my real estate investment company  [00:03:45] Jason: Nice. [00:03:46] Jason: Nice. All right. And so let's get into the topic at hand. So, we're going to talk a little bit about leveraging virtual assistants. And so how did you kind of start doing this yourself?  [00:03:58] Bob: Yeah well, when I first got into this, like I said I door knocked first, we didn't have the opportunity to have, you know, virtual assistants do some outbound stuff. [00:04:07] Bob: And I didn't understand, you know, I didn't understand what outsourcing was when I first started. It was just me. I had an individual who was my business partner back in the day, but first year I door knocked. I went from door to door, individuals that were behind on payments. So it wasn't the easiest job in the world, but it allowed you to understand how to build a business from ground up. [00:04:29] Bob: I think that was very important back then. So nowadays you can have virtual assistants do that, whether it's you know, cold calling, whether it's responding to direct mail, whether it's text messaging, whether it's social media, whether it's going out to, you know, Facebook marketplace and going right direct to seller, you also have rarely used now Craigslist, of course, but there's different ways to acquire and use your virtual assistant to do that. So that's just, again, a long and short.  [00:04:54] Jason: So go ahead and tell people a little bit about your company and what you help people do. And I'm really curious because this is usually a difficult thing for business owners to outsource. [00:05:05] Jason: Usually they'll outsource some of the lowest level stuff, and it's usually not towards growth, lead generation, outreach, stuff like that. Those pieces can be really difficult to get dialed in or to do effectively. And so, tell us a little bit about REVA global? Okay. Yeah.  [00:05:22] Bob: So, you know, like I said, we started back in 2014. [00:05:26] Bob: Like I said, I've been doing this for a long time and just to fast forward to what that looks like today and working with property managers, because obviously the individuals that are on your podcast here, I'll speak to them. And I know, you know, many people that also buy and hold also probably do fix and flip or also may wholesale, but it's kind of the same concept, but there's a lot of different tasks within it that virtual assistants can do. [00:05:50] Bob: So what I did is I broke up all the stuff that our VA is doing in my own business because you know, many individuals that are listening to this will relate to a company like ours because like I said, we have a real estate investment company, but we also use our VA's which I think is pretty cool. I think Nowadays, it's very important as a service provider like myself to use it to make sure it works so I think that's a pretty unique thing that we actually have. But what we do, we have virtual assistants that acquire, we call them like a department of acquisition. So if you're looking for leads, you could do cold calling, you do text blasting, you could do lead management. You know, lead management, a lot of us, I'm just like, you will have all these leads in your database, but if you don't get ahold of them the first time, your marketing is going to consistently go out. So when marketing consistently goes out, what we find is all those leads end up piling up. And if you try to reach out to them the first time, you know you have a very small percentage that are actually going to pick up the phone. Right? So you need somebody then that will continue to follow up on those leads. [00:06:57] Bob: And a national statistic is over 70% of all sales never happen on the first touch, right? So you have to continue. And I think that's probably 90 or 95 percent nowadays. So that's what we find in our office. And I know a lot of our clients say the same thing. So that number could change a little bit depending on what you read, but our experience in our office is over 90%. [00:07:21] Bob: So what I mean by that is the first touch, whether it's direct mail call or a cold call, whatever you do for direct mail or whatever you do for marketing, that first touch will not equate to a contract, so you're going to have somebody that's continuing to follow up with those individuals. Very important. [00:07:39] Bob: I wish I would have understood that stat when I first started real estate. But again, you know, you learn over time. Another stuff. If you look at other tasks as well, that works very well is marketing. Right social media management because you look at any type of business if you don't have marketing It's very difficult brand awareness, right people want to do business with people they see, feel, touch, and like so you need to make sure that you're out there You're out in the public's eye. [00:08:05] Bob: I think that's very important. I know you guys do a great job of that Jason on the marketing side of always being out there because I see in a lot of different places everywhere I'm looking online. So whoever's doing your stuff man, great job. So you're doing a fantastic job on that side of it. And then you go into leasing so if we look at property management you know driving leads is one thing, but you also have to, you know, close them. [00:08:27] Bob: So if it's you, me, or whoever's the one on the phone locking up those deals, it then goes to once you own them, you got leasing, you got move in, move out, you have collection, you have evictions, you have maintenance, you have accounts receivable, you have accounts payable, bookkeeping, accounting etc that fall underneath that property management umbrella, that virtual assistants are phenomenal to actually take on those tasks for you.  [00:08:52] Jason: Got it. Yeah. Yeah. So what's the typical process for somebody that could use some help from a company like yours? How do you engage them? [00:09:01] Jason: What's onboarding like? How does that work?  [00:09:03] Bob: I think for anybody who's looking to scale or looking to just get help in their business. You know, here in Connecticut, it's pretty interesting because if you're looking to hire someone in house, you start looking at what's going on with the world and what's going on with the economy in state of Connecticut, minimum wage is up to $15.69. [00:09:24] Bob: So when you start looking at that I know in my area, if I try to hire someone at minimum wage, they don't have a four year college degree. That's just not the highest level individual that you'd want working in your office. And so now you start looking at those things and what's happening around the country. [00:09:42] Bob: Virtual assistants are very are a big part of anyone's business. In my opinion today, I think you got to start looking at that because small businesses, a lot of times, especially when we start, we are on a tight budget. Right. And so for us to start to scale or start to grow or start to hire, we really need to look at what's going out, meaning out of our pocket. [00:10:04] Bob: So it's very important. So they first look at number one, what can we afford as small business owners? If we look at that number, now we start looking at what tasks in our business do not put money in our pocket. Right? And if you look in your world, meaning the property management world, it is a lot of the tasks like leasing, like taking calls from tenants, move in, move outs, eviction process when you're calling attorneys back and forth. What does that look like? There's just a lot of back and forth, right? Maintenance concerns. You get those all the time and those are the things that burn up your time. Your phone doesn't stop ringing. [00:10:44] Bob: So if your husband or wife wants to go on vacation with you and your phone doesn't stop ringing. That's going to put a lot of stress and a lot of challenges in your personal life to where, especially when you continue to grow. You have to put more systems and processes in your business. You know, if you had one house, that's one headache. [00:11:02] Bob: You had two, that's two headaches. You have a hundred, you have a hundred potential headaches that if you don't want to take those headaches on yourself, it's always good to have somebody else take those headaches before it gets to you.  [00:11:15] Jason: Yeah. Property management can definitely be death by a thousand cuts. [00:11:18] Bob: Yep.  [00:11:18] Jason: Yep. And if you get it really well dialed in though, yeah, it can be a really great residual income business model.  [00:11:25] Bob: So Very good. Very good. Well, two sides of it, right? You buy, right? You have an equity play there, right? And if you don't have to deal with the headache, you get the positive income, you get tax advantages, things like that. [00:11:36] Bob: So, I mean, I'm a huge advocate of buying and holding and property management because over time, the more, like you said, the more properties you actually hold, the bigger your income grows.  [00:11:48] Jason: Nice. Yeah. Cool. So, so I love this. There's lots of low level tasks. It does get really expensive trying to afford staff and team members and you don't want the cheapest or lowest level or worst people. [00:12:02] Jason: You know, in the United States representing your business. And so, sometimes you can get people at a fraction of the price point that have a lot more education that are a lot better. And so when you, any of the roles that are able to be done virtually, you open yourself up to a global marketplace rather than just your local city. [00:12:22] Jason: And so, yeah, so there's definitely advantages. So my entire team are virtual and I've got team members in various areas, Canada, Philippines. Egypt gosh, I don't know where else like all over the place and I've hired people over the past and just about everywhere. So yeah. And so, and so I'm not limited, so I'm able to just go find the best and I'm able to figure out, okay what can kind of fit into our budget and what can we afford in order to do that. [00:12:49] Bob: Right. And to your point, to get back to what that looks like, I mean, anyone in this world could go out and go source for their own candidates. You know, we set up a very unique system process. We have a whole sourcing and recruiting team. All my virtual assistants are in the Philippines. We set up a sourcing and recruiting team out of the Philippines, so they're Looking through, you know, thousands of resumes every single month sifting through and we're getting the best of those Resumes that come in as soon as they pass then they go through an interview process. [00:13:22] Bob: They pass the interview process They go to our training team and they train for about a month on various tasks property management tasks lead generation tasks, etc And then once they actually get to the end of that stage, they do another test and a lot of individuals do not pass our testing phase. And that's a positive thing because, you know, that's a way to kind of weed out the individuals that wouldn't make it, yeah, very good. [00:13:48] Bob: So, after that goes to our placements team and our placements team, it's kind of like match. com. They look at exactly what you're, you know, what the tasks are. And we do DISC profiling, things like that, and predictive index. And we look at the tasks that they're good at, and we match them exactly up with the client and the tasks that they're looking for. [00:14:05] Bob: So for instance, if someone's looking for a bookkeeper, you're not going to give them a profile that's a sales profile, right? You're going to, you're going to give them the correct profile. You put them together, they go through an interview process, and they pick the best candidate that fits within them so after that, it goes to our operations team. We have what we call a client service manager that helps manage the relationship between you and your va, so it's very streamlined. [00:14:27] Bob: You know, we tried every different business model there is out there and the model that we have right now seems to be the best model.  [00:14:34] Jason: Nice. Yeah, I always recommend if you're a property manager like watching this or listening if you don't have a really solid hiring process you have not like tested embedded and experimented with, then the best initial way to do hiring is to leverage other companies' hiring processes. Go and work with a company and there's lots of different companies I've worked with over the years to get people on my team, and then eventually we've built a really good process internally, but In the beginning, I do think every business eventually needs their own hiring system, but if you don't have a great robust hiring system that you can get candidates consistently, that you know are a good culture fit, a good skill fit for the role, a good personality fit for the role then you need to go leverage somebody else's hiring system. [00:15:20] Jason: So I would highly recommend, especially if you're going to dabble with VAs, especially in the Philippines or any other area, that you want to not be dealing with all the riff raff and the challenges and everything else. You want to have some help with this. So I highly recommend you leverage somebody else's hiring system. And they're going to help you not waste as much time and money for sure.  [00:15:46] Bob: And that's one of the things that's a great very great point because when you're first starting out or you're smaller. The best thing to do is learn off of others, right? [00:15:55] Bob: It's you'll walk through a company like mine. You say, "wow, what a great system." You know what? Document what we do and then implement it in your own business if you start growing. I think that is a fantastic idea, Jason, for that. Because, you know, you look at the biggest companies in the world. [00:16:09] Bob: They didn't just, you know, start being the biggest companies in the world or that, you know, it doesn't, you don't have to be the biggest, but they learned from somebody and they started implementing and they tested, you don't always get it right the first time. But after a while you will hone in and get that right. [00:16:24] Bob: So I 100 percent agree whether it's with our company or anybody else. Like I said, anyone could do anything themselves. It all depends on what you need help with at the beginning.  [00:16:34] Jason: Yeah. And it also depends on how long do you want to suck until you figure it out.  [00:16:40] Bob: That's true.  [00:16:41] Jason: Like so if you want to collapse time, I highly recommend. Because I know when I started experimenting with hiring in the Philippines. Like there's just things you don't even think to ask like we had to ask like where are you accessing the internet? [00:16:53] Jason: Is this like at a cafe at your home? Is it reliable? What kind of computer do you have? You know, we needed to be able to you know there's just so many little quality controls we had to implement in order to figure out if they would be a good candidate, I mean, I've had team members in the Philippines with chickens going off constantly in the background and roosters crowing and like all sorts of stuff and their internet going up and down and so you know, there's there's a lot of quality controls that I think need to be put in place because it's not America. We have a little bit more stability in our infrastructure and in our internet connections and everything else. [00:17:29] Jason: And so, and then, you know, it helps to have somebody that manages the relationship like your company, because a lot of times, in that culture, they can be a little bit shy, I think at times, or a little bit nervous about displeasing their employer or giving honest feedback. And so they tend to ghost or disappear. [00:17:49] Jason: People have talked about people in the Philippines doing this. And so having somebody manage that relationship as a liaison can help improve the results that you're getting from team members. And but the cost savings are awesome. I mean, it's like a third to a half of what you would get and you can get college educated people, you get people that have like lots and lots of experience and skill, and they are able to be paid very well for their area. [00:18:14] Jason: And for you, it's seems like a steal. So.  [00:18:17] Bob: And that's one of the things that we pride ourselves on. I mean, you nailed it. You touched upon all of that. You know, we make sure there's backup. We make sure there's the right internet connection, the right computer system, etc. So to your point that is definitely something for everyone listening to this to look at because the vetting process, that's what I found the most tiring. When I first hired my first VA, I got it wrong a lot, to be honest with you. And I didn't ask any of those questions. And then it's kind of funny to talk about the rooster. That happened to me. And that was before I actually owned the company. And then I started my company. That's one of the things I'm like, all right, we have to listen for, right? [00:18:52] Bob: What's your background, what's your surrounding, right to your point. And then you start learning over time. And then the more interviews you go on, the more stuff you learn, right? Like you said, you don't learn or you don't know all this stuff until you actually go through the process. And I think it's important for you to understand if you're going to do this, know that you're going to have a lot of pain up front when you hire at the beginning, right? And then you work with a company like mine and you'll realize you didn't go through that pain, but then you want to go hire someone. And then you decide to then throw your hat in the ring and do this yourself. [00:19:25] Bob: 100%. The questions to ask, just like Jason said up front, those are some of the things to look at.  [00:19:30] Jason: You know, based on the stuff that you said, I there's a lot of. Property management targeted, you know, VA companies leveraging talent in the Philippines, but it seems like one of the things you brought up that seems to be unique to what you guys do that's different than most of the others, or maybe all of them is the focus on client acquisition, lead gen, and on the sales side of things. [00:19:53] Jason: Most are usually focused on trying to find VAs that are more like executive assistants or that are going to do tasks and be told what to do rather than people that you can trust to be the initial connection and face of your business.  [00:20:08] Bob: You know what it's interesting, again, it's interesting you say that because I've been in this business for about 21 years, real estate investing. [00:20:14] Bob: And we realized over time that If you don't have, you talk about acquisition and lead generation, if you don't have leads for any of our businesses, we are going to struggle to make ends meet, right? So you have to figure out a way that's going to drive in leads to your business. I mean, I know for me, I'll just give you a perfect example. [00:20:32] Bob: When I door knocked, I went door to door to door every day from 10 a. m. to 3 p. m. But when I go home, I'd get that list and I would skip trace it back in the day You'd use 401. com white pages, and I would look for the best possible phone number for that individual then I would call. So when I got home, I would skip trace then I'll call until seven at night until I had to eat dinner with the family. But over time, I was beat up. [00:20:55] Bob: I don't recommend doing that anymore. You don't have to do that anymore because you can hand over those tasks over to a virtual assistant. And they're the ones that are going to be doing the outreach for you. And again, I do recommend you should try it because you'll realize you know, open your mind and understand that outsourcing that task will really give your energy back and bring your success up. [00:21:16] Bob: You may feel, well, I don't think anyone could do that task better than me. We all said, I know you said it before, Jason, I've said it. We all feel that way. And if you think about it, if they do 80 percent as good as you, that's a huge win. Now you get to do other tasks. That's going to drive business and revenue to your business. [00:21:36] Jason: Even if they do it half as well as you, but they're getting. You know, half the result and you're able to hire two or three of them and not do that work. Like it's easily time and money well spent. So it's consistency, right?  [00:21:48] Bob: It's all the consistency. If you have something, a task that gets on a consistent manner, consistent basis every single day, you will get results by the end of the week. [00:21:58] Jason: Yeah. So what are kind of SLA you know, you know, what do you sort of think are the metrics or KPIs for as an appointment setter or somebody trying to help, you know, maybe reaching out directly to owners or maybe reaching out to schedule, I don't know, appointments with real estate agents to build referral relationships. [00:22:17] Jason: How many calls should they make a day? If this is their full time gig and how many appointments do you think they should be booking?  [00:22:22] Bob: Well, it depends. So if you have, so for instance, if you have a, you know, triple line dialer, as an example, it depends if you're, you know, calling just on a, you know, on your phone and just dial like this, but there's a lot of very good technology out there. [00:22:36] Bob: You got mojo dialer, you have things like that actually are very good. You may have a company that you refer, Jason, that you could tell everyone but you're probably calling if you're full time, anywhere between 400 and 600 dials using that dialer, not manual dialing. You're probably going to hit about a hundred, 150 if you're manually dialing. [00:22:57] Bob: And that's a day. Yeah. But if you have a triple line dialer, you're going to hit on average 400 to 600 and this is just what I've seen through the years that I've been doing this. You may have a technology that burns through a thousand calls and then you're going to be listening to me saying, well, Bob, you're a hundred percent wrong. [00:23:13] Bob: I'm just telling you what I see on a daily basis and what comes out of, you know, mine and my client's offices.  [00:23:19] Jason: I think yeah, even if they're doing it manually, if they can get a hundred to two hundred calls a day and get two appointments booked a day, like, so they're getting roughly about 10 a week. [00:23:27] Jason: Like that's a solid result for an appointment setter.  [00:23:31] Bob: That's a win. That's a win. You're looking at, if you're looking for, so we call them ITS's in our office, interested to sell. I know other people call it different, but that's what we look for. Same exact thing. One to two per day per VA. [00:23:44] Jason: Nice. Yeah, very cool. And those listening, I'm sure all of you would love to have one or two appointments booked for you per day, and that would fill up a nice little chunk of your time and help you close some deals. So, yeah.  [00:23:57] Bob: Especially on the buy and hold side Jason. It's a lot easier to look at your numbers. [00:24:03] Bob: And I know you have a formula that you guys look at to make sure the rent and you know, what the interest rates are today, et cetera, et cetera, whatever financing you have, but it is easier on the buy and hold side to fit within your buy box, right? Rather than having to go at, you know, 30 or 40 or 50 or 60 percent of the value. [00:24:20] Bob: When you fund it out and then try to resell it. So it's a different kind of mindset. So you're very fortunate if you're going to buy and hold your buy box is usually different than somebody who's either trying to wholesale or fix and flip.  [00:24:32] Jason: Got it. So we've probably got some property management business owners listening to this. [00:24:37] Jason: And for some reason, maybe they're just crazy and they have not yet worked with DoorGrow yet, but they're like, Hey, I would like to grow, add some doors and maybe have somebody do some calls and reach out to Bob. How could they get in touch with you and how can they initiate a conversation?  [00:24:54] Bob: Well, you can check us out on our all of our social, of course, but REVA Global. R-E-V-A Global. com. If you have any specific questions, obviously for you, you could just reach me direct at bob@revaglobal.com.  [00:25:07] Jason: Awesome. Hey Bob, thanks for coming on the show. Any parting words for entrepreneurs that are struggling, they've never hired an assistant yet they, even if they've built out part of their team or an entire team already, which is ludicrous to me, but what would you say to them? [00:25:22] Bob: Well, I would say number one, get started, of course, but number two, I would say you got to set up your processes and systems and get them done consistently because if you just get success here. And then you stop doing it. Real estate's a long game. You know, like I said, I started this 21 years ago and I wish I knew what I knew now back then. [00:25:43] Bob: I would start buying properties back then because right now I'd be retired with thousands of doors and rental income of a thousand doors. But I started a little bit later.  [00:25:54] Jason: Hey, Bob, we appreciate you coming and hanging out with me on the DoorGrow show today. And I'm excited to see if you helped maybe some of our clients listening or some of the people let me know what results they get and maybe we'll have you come back on. [00:26:07] Bob: Thanks for having me. Appreciate it.  [00:26:08] Jason: All right. So if you are a property management entrepreneur, you're struggling to add doors, you're struggling to figure out how to grow your business. We want to help you. We want to support you. Reach out to us at DoorGrow. com. You can also join our free community at DoorGrow club. com. Go there. Answer the questions. We reject 60 to 70 percent of applicants. It's just for property management business owners And if you get inside, we'll give you some free stuff that'll help you out and help out your business. So that's it for today until next time to our mutual growth I'm, Jason Hull, and I hope you crush it. [00:26:40] Jason: Bye, everybody. [00:26:40] Jason: You just listened to the DoorGrowShow We are building a community of the savviest property management entrepreneurs on the planet in the DoorGrowClub Join your fellow DoorGrow Hackers at doorgrowclub.com Listen everyone is doing the same stuff SEO PPC pay-per-lead content social direct mail and they still struggle to grow at DoorGrow We solve your biggest challenge getting deals and growing your business Find out more at doorgrow.com Find any show notes or links from today's episode on our blog doorgrow.com and to get notified of future events and news subscribe to our newsletter at doorgrow.com/subscribe until next time take what you learn and start DoorGrow hacking your business and your life.

How can you, as a dentist, truly make a difference in your profession through organized advocacy? In this episode, Dr. Bob Dee shares vital insights into the inner workings of the American Dental Association (ADA), emphasizing the power of active participation over passive membership. Dive into a comprehensive discussion on the strides the ADA is making in political advocacy for the profession. Discover how influencing legislation, like dental loss ratio and Medicaid laws, directly shapes the dental industry and enhances patient care quality.Dr. Dee also tackles big topics such as corporate intrusion into healthcare, offering a vigorous defense of the dentist-patient relationship's personal nature that corporate entities can't replicate. While concerns exist about the efficacy of membership and communication within ADA, Dr. Dee reveals a determined vision for positive organizational change. Don't miss out on practical advice on joining advocacy coalitions and learn about the exciting upcoming Digapalooza event that promises valuable insights from industry leaders.What You'll Learn in This Episode:The benefits and importance of actively joining the ADA.The ADA's role in critical legislative changes such as dental loss ratio and Medicaid laws.Dr. Dee's perspective on the unique gifted relationship between dentists and their patients in comparison to corporate healthcare.Practical steps on becoming more involved in dental advocacy.Upcoming industry trends and why it's crucial to stay informed via events like Digapalooza.A deep dive into the real impacts of your active participation in organizations like the ADA.Take action and tune in to understand how your dedicated involvement today can create a thriving future for the entire dental profession.‍Sponsors:‍‍For high quality AND affordable dental supply options, visit The Dentists Supply Company(TDSC) website today! Our listeners get a special deal - 25% off on orders over $500 - Just type in the special code: TDM25 at checkout for your exclusive offer. AND if you're a member of your state's Dental Association, you may be eligible for additional savings upon providing your ADA number. Click or copy and paste the link here to save today! https://www.tdsc.com/‍You can reach out to Dr. Bob Dee here:Website: https://dentistryingeneral.com/YouTube: https://www.youtube.com/@dentistryingeneralFacebook Group: https://www.facebook.com/share/L5bCmGf8oKHcH3yH/?mibextid=A7sQZpDigapalooza Event: https://pay.dentistryingeneral.com/MondayMorning ($400 Off for Our Listeners!)‍Mentions and Links: ‍Events:Digapalooza‍Organizations:ADA‍Videos:Dr. Dee's Video on Medicaid Laws‍If you want your questions answered on Monday Morning Episodes, ask me on these platforms:My Newsletter: https://thedentalmarketer.lpages.co/newsletter/The Dental Marketer Society Facebook Group: https://www.facebook.com/groups/2031814726927041‍Episode Transcript (Auto-Generated - Please Excuse Errors)‍Michael: Hey, Bob. So talk to us. What's one piece of advice you can give us this Monday morning? Bob: As we discussed off the air, the one advice I can give you definitively is to join the American Dental Association. And that comes from someone who criticizes them on a regular basis. Michael: So let me ask you this why join them and what do you criticize them about Bob: first of all, let's talk about the positives I don't like to talk about Negativity first, everybody can improve things, right?so why should you join the American Dental Association because for a hundred and sixty three years dentists like myself have contributed to building this huge organizations. We are the fourth largest lobbying power in Washington, DC. Think about it. Hospitals, physicians, all these physical therapists, all these health care organizations.We are the fourth largest. Representatives and senators and politicians know our lobbyists by name. So it is important for us to have proper representation. The government will bring different, ideas to the table. There are a couple of them going on right now that we should be opposing. And we need to have a voice there.So if you do not join the American Dental Association, and if you do not contribute, do not just write a check and go to your offices and say they don't do anything. We need to get involved. We need to have a voice within organized dentistry. It's basically for advocacy. Michael: We're advocating for our patients first. and then the profession. Our oath is to the,patients and then the profession. So that's basically why we should, join. Why do I criticize them? I don't criticize them to weaken them. I criticize them to make them better.Bob: Every, time we, as an advocacy coalition, criticize them is an opportunity for them to correct things and be stronger and attract more people. For me, lack of communication between what the American Dental Association does and the members, that'sbeen an issue. Also lack of focus. To what is important, for the benefit of our patients and the benefit of the profession.I feel like we need to reiterate to them what is important so they can concentrate better. Michael: So you mentioned that we need to participate more and not just cut a check and then, you know what I mean? go back to practicing, but then you also mentioned there's a lack of communication. So do they even listen?Bob: If we participate.They are listening. I guarantee you that they are listening. I have this facebook group dentistry in general. They are part of it. I have heard that they are listening and they are making some changes. Is it fast enough for most people? I don't know. That's why I have created this advocacy coalition that includes 30 people past present American Dental Association leaders and well known people within the dental community to help guide them.We have a platform, a six pillar platform that we have presented to them, and we're going to be at the House of Delegates Trying to contribute positively. I want everybody to understand we're not here to weaken the American Dental Association. This is all for making them stronger. Michael: Gotcha. Okay. So it's more like we're just sometimes, downhearted because it's not moving at the speed of our expectations.Bob: there is a, myth that the ADA can do everything. This is a capitalistic system that we live in, right? Michael: There Bob: are laws and there are rules that when a dentist Criticizes them that oh, why can't we have the insurance companies pay more? That's not the job of the American Dental Association That's illegal.We cannot to have Another company pay us more. These are things that we cannot control. A lot of times dentists criticize the ADA for things that's out of their control. Obviously they're struggling and they see their patients being affected. So we naturally want these things to happen, but we need to be realistic.The way we can affect all the things they want is by making sure we know what legislation to support. what issues we can push through the politicians through legal ways to make a positive effect. Michael: Gotcha. So then what can they control in simple terms and what issues right now do you see most trying to push?Bob: Right now two of the most important things is the dental loss ratio, which is identical to the concept of medical loss ratio that the Affordable Care Act brought for medicine. We want the DLR for dentistry. Unfortunately, ADA, in my opinion, agreed to a plan that is not What we should have agreed to so we need to be outspoken and we need to be involved in creating the better than a loss ratio one that was passed in massachusetts Called question two a lot of this information is on my youtube channel on my facebook group So if people need to find out more and educate themselves contact me educate yourself These are the most important things You that are affecting our profession and our patients.That should be the number one thing. We advocate for patients first, not for ourselves. And the second thing is Medicaid laws are being ignored in every state and people will say, why should I even worry about Medicaid? I'm fee for service. I'm a PPO. I don't take Medicaid. Medicaid laws dictate.every insurance law that there is. As Medicaid goes, so does the private insurance. Michael: Gotcha. So we should be focused more, especially if we're heavily insurance, but like Medicaid. Bob: We shouldn't be focused on it, but we should look at states to enforce Medicaid laws that are there. I have a YouTube video on this subject that goes into details of what it means.All we want is to prove to politicians that this is good for the patients and let's enforce it. Michael: Okay. And so doing this. The first steps, if we're like, ah, should we join? Should we not join is joining, right? Continue to join, continue to be a part of it. And then now, if we wanted to start having our input into it, we do what?Bob: The alternative is what? Sitting on social media complaining about our problems, right? And what's going to happen? Nothing. Zero is accomplished by not joining, So joining and getting involved is important, and then support the coalition. Dentistry in General Advocacy Coalition will be out there presenting ideas.It's not a, organization that collects money. I'm covering all the costs because I don't want people to think that this is a profit generating organization. This is to help younger dentists. For years to come. We want to make sure the profession is protected and our patients are protected.Michael: Gotcha. So right now, Bob, me a percentage from one to a hundred? How much of a percentage do you feel protected and your patients protected? Bob: Listen, we are fighting different wars on different fronts. The corporate intrusion into healthcare is something that everybody knows about, We have insurance companies. That's another corporation intruding into our profession and into our patients well being. So for me, to put a percentage on it, I'm an optimist, right? I'm a, Glass half full. I say something that a lot of dentists rolled their eyes at me. We are a lot like. Hairstylist, Then doctors. Why? Because you will drive two hours to see your hairstylist The personal relationship dentists form with their patients is very important to them. So I still believe we have a chance. of keeping corporate intrusion at bay.We can't prevent it. It's there, However, if you create this professional and compassionate relationship with your patients, they will travel to come to you, but they also pay out of pocket to be out of network with a lot of these insurances. So it's important to understand that. So I would say We are still 80 percent strong, my friend.Some people may be less optimistic as I am, but we want to make sure we keep it at 80 percent and we're not going to go down the road medicine took. Michael: Gotcha. Okay. Awesome, Bob. I appreciate your time. And if anyone has further questions, you can definitely find them in the dental marketer society, Facebook group, but where can they reach out to you directly?Bob: The easiest way to reach out to me or join my Facebook group is to go to my website, dentistryingeneral. com. There are two buttons, you can join the Facebook group, you can look at our event, and there is a chat button there that whatever you want to ask or comment, it comes right to my phone and we can talk.Michael: Gotcha. And then you also have I Bob: call it the Digapalooza, I try to bring speakers that are well known and are all stars. It's October 25th and 26th in the Chicago area. I say Chicago area because it's not downtown. It's 20 minutes away from downtown in a upscale mall. we have a very attractive lineup of speakers for two days and for your listeners, as I told you I still offer the early bird, which is 400 off and I can give you the link that you can share with your audience.Michael: Oh, we appreciate that, man. Thank you. So that's going to be in the show notes below the information for Digapalooza and at the same time, the early bird special So thank you so much, Bob, for that. And I appreciate you coming by and thank you for being with me on this Monday morning episode.Bob: Thank you for having me.

Get ready to dive deep into the future of Vocational Rehabilitation (VR) with Dr. Joe Ashley and Dr. Bob Schmidt in our latest episode! Joe, the dynamic Project Director of the VR-ROI initiative at George Washington University, teams up with Bob, one of the leading economists and the Project Research Coordinator, to bring you insider knowledge on revamping return on investment models for VR programs. They're on a mission to streamline and elevate how VR agencies operate, helping them become more efficient, effective, and impactful. Their discussion is packed with actionable insights that will empower your agency to sharpen its data collection strategies, ensuring the true value of your services shines through. Plus, learn how to better communicate the VR success story to policymakers and stakeholders! Tune in to discover how you can maximize your VR impact with the latest advancements from the VR-ROI project. Don't miss out!   Listen Here   Full Transcript:   {Music} Joe: We're trying to make sure we have information that the director can use with policymakers, and something for clients and counselors to use to say, yes, this is the kind of services we're looking for.   Bob: The model we develop is based on readily available administrative data.   Joe: It's built on the individual customers and how well they do and what their outcomes are.   Bob: The human capital development, that's what it's all about a lot. Some things just aren't measurable. So when you mentioned financial return on investment, that's what we're talking about.   Joe: If you can't capture it, you're not able to tell the story.   Carol: Yep, if it isn't documented, it didn't happen.   Bob: That's right.   Joe: Yeah.   Intro Voice: Manager Minute brought to you by the VRTAC for Quality Management, Conversations powered by VR, one manager at a time, one minute at a time. Here is your host Carol Pankow.   Carol: Well, welcome to the manager minute. Joining me in the studio today are Dr. Joe Ashley, the project director for the VR Return on Investment project based at the George Washington University, and Dr. Bob Schmidt, one of the five economists working on the project and the project research coordinator. So, Joe, how are things going for you today?   Joe:  Today they are doing really well. Thanks for asking, Carol.   Carol: Nice to hear it, Joe. and Bob, how are you doing?   Bob: I'm doing well as well, at least, as well as Joe is doing.   Carol: That's awesome. Alright, glad to have it guys. Okay, so for our listeners, Joe is my colleague and we got him out of retirement to serve as the project director for this important initiative. And this project is funded by the National Institute on Disability, Independent Living and Rehabilitation Research, also known as NIDILRR. Now, this is the federal government's primary disability research organization and is part of the Administration for Community Living. Now, NIDILRR's mission is to generate new knowledge and to promote its effective use to improve the abilities of individuals with disabilities to perform activities of their choice in the community and to expand society's capacity to provide full opportunities and accommodations for its citizens with disabilities. NIDILRR achieves this mission by funding research, demonstration, training, technical assistance, and related activities to maximize the full inclusion and integration into society, employment, independent living, family support, and economic and social self-sufficiency of individuals with disabilities of all ages. They also promote the transfer of, and use and adoption of rehab technology for individuals with disabilities in a timely manner, and also ensure the widespread distribution and usable formats of practical, scientific and technological information. And they do address a wide range of disabilities and impairments across populations of all ages. Now, Joe, I know you have a little disclaimer you wanted to make.   Joe: Yeah, I just want to be sure that people understand that what Bob and I are going to talk about today is our opinion of what return on investment should be, and is not necessarily reflect what NIDILRR is looking at.   Carol: Excellent. Well thanks Joe. Let's dig in. So, Joe, why don't you kick us off and tell us a little bit about yourself and your journey in vocational rehabilitation?   Joe: Carol, I've been in rehabilitation for quite a while. I worked with the Virginia Department for Aging and Rehabilitative Services, the general agency in Virginia, for over 25-27 years, most of the time as an assistant commissioner in a variety of roles. I have a master's in rehabilitation counseling from the University of South Carolina. That sort of got me focused on vocational rehabilitation. And then later I had a Doctorate in rehabilitation from SIU at Carbondale that took me on a path of looking at program evaluation and program development. When I got to Virginia, I was working out of the Woodrow Wilson Rehab Center, now called Wilson Rehabilitation Center, and was working in a program that was collaborative across, it was one of the early transition grants, 1985,and it looked at vocational evaluation as a part of a process to help kids learn what they needed to do. And we were working with students from special education and vocational education in the schools, and vocational rehabilitation, and getting these systems to collaborate to help kids find out what they want to do and to be successful in employment and in life. And I got to where I really enjoyed that kind of collaborative work, and I ended up as an assistant commissioner in the agency, looking at developing innovative new programs as a part of my responsibilities and looking at a lot of the ancillary support services like rehabilitation, engineering and other kinds of things. Through a series of circumstances, I ended up as the director of the field services for four years, where I began to get a good sense of what disabilities needed to be in terms of supports to be successful in employment and being able to live successfully in their communities. In addition to that, what counselors and other staff needed to be able to provide those services to them. And then I got into the job that was my favorite, which was something called grants and special programs, where I did a lot of the Social Security stuff, cost reimbursement, work, incentives specialist advocates. We created a new system there to do fee for service for the work incentive services. We did a lot of work with the workforce agencies. I did all the agreements with that, and then I got to do grants and any of the grants that helped people with disabilities be able to live and work and thrive in their communities were things that we were willing to support. And I got to work with a lot of different funding systems and across a lot of different systems, you know, Special Ed workforce systems, behavioral health, a lot of different groups to help people with disabilities have opportunities. So that's what I really enjoyed. And that's where I came across the late doctor David Dean and then Bob Schmidt as a part of that package with Dean. And it was about telling the VR story. And I got real passionate about how do you tell this story in a way that is going to get people like GAO to pay attention, as well as help directors with policymakers and individuals and counselors help make decisions about what's a good choice for them. So that's really how I got to where we are today with this new grant.   Carol: Very cool Joe. I know we all look to your program in Virginia for kind of the cutting edge stuff that was happening, because you all seem to always have just something cooking.   Joe: Yes.   Carol: It didn't matter what. And especially like the disability work incentive stuff that you were talking about and all of that. Oh gosh. I just think you've done a lot of stellar things there.   Joe: Well thank you. It was fun.   Carol: It's awesome. So, Bob, tell us a little bit about yourself.   Bob: Sure. Happy to. Joe mentioned Doctor David Dean. He was a colleague of mine in the Department of Economics at the University of Richmond. He worked on what he called economics of disability, and he started working on that in graduate school at Rutgers with a faculty member there. And he worked on that. So that was in the 1980s. He came to the University of Richmond, and he got me interested in it because he was an outgoing, gregarious, very bright guy and made friends easily. So he got me involved in this probably early 1990s, and we started working with DARS and several other things at the time with Joe, but also Kirsten Roe. I don't know how many people remember her, but she was instrumental in all the work we did. So this is actually our third grant with NIDILRR. The first one was a demonstration grant. So it's a kind of a proof of concept. Second was implementing it. Now this one is refining it and taking it to the next step. That's what we're trying to do with that. So David got me excited about it. Joe keeps me excited and he keeps me honest.   Carol: That is awesome. Well, I know just being around the director ranks for years and folks talking about return on initiative, it's been a, you know, a hot topic. People chat about it, but I don't know that everybody always really understands it. And I think sometimes people think maybe it's something that it isn't and they aren't very good at explaining it, but everybody wants to do it. So you guys are going to unpack all this for us. Joe, why don't you tell us a little bit about the project and what you're trying to accomplish?   Joe: Well, with this current iteration. It's what NIDILRR calls a field initiated project on their development side, and it's got a ridiculously long title. So I'm just going to say it is about updating and simplifying our return on investment model. That's its main purpose, and it's about helping our agencies understand what they can do to be more efficient and more effective, and take a look at the mix of services that they provide, to be sure that they are getting the most out of the resources they have to help people with disabilities obtain, you know, that probability of employment and upon employment, their earnings. And we're trying to make sure we have information that the director can use with policy makers, that agencies can take a look inside their own services to say, maybe I need more of a particular type of service because I'm getting good outcomes, or maybe I need to tweak a service because it's not getting what I want it to do, and then something for clients and counselors to use to say, yes, this is the kind of services we're looking for. We got four goals, and the first one is just really to update the model. Our previous model was prior to WIOA implementation, so what we hope to be able to do is take a look at the data systems and take a look at the performance indicators that WIOA requires. And we can do a correlation, perhaps with the long term employment to see how well they're correlated. Also take a look at Covid impact. The second goal is about intensity. Our other model is you either got a service or you didn't. And if you got the service then how did it affect employment and earnings? Well, the next logical step according to The Economist and we have five on the project as you mentioned earlier, was what is the intensity of the service. Does that make a difference. So that intensity measure could be hours of work. It could be what it costs to do something. It could be units of service. And taking a look at if that is related to the propensity for employment. The other piece that goes with that is how about internals provided services, what we had before in the system, nobody had good measures of the services their own staff provided. So we're hoping with what we're seeing now and we're working with the two agencies in North Carolina, and they've been extremely helpful and collaborative with us on this process is take a look at the internally provided services and see what impact they have on the employment and earnings side of things. And then we've been told many times our third goal is simplify the model. Right now it takes economists to run it. Well that's not always a good idea for some people. So what we're trying to do is see what econometric models could we put in place to simplify this process so that it's more available to rehab agencies. But you want to make sure it's still rigorous enough to give you a reliable estimate of return on investment. So one of the things we're having with that is many of the folks on the who are listening to the podcast may be aware that we did a data analysis and management capacity survey that CSVRA sent out. Our advisory committee supported, and with that, we got 54 agencies to provide us information on what their data capacity is and what this capacity of their staff is. And then what kind of training they might be interested in. We're still looking at the data from that and we'll have some information on that later. But what we find in this may make a big difference on how simplified the model can be, or whether we need to take a different track to help people be able to implement a new model. And then finally, it's about knowledge translation. And part of that is coming to us like we did a consumer and stakeholder forum with the North Carolina State Rehab councils and some other stakeholders to get input on what they'd like to see, what kinds of information and would this information be helpful to them. And then we're going to have another consumer and stakeholder forum probably next spring to say, here's the model as we have it so far. Does this make sense to you and would this be valuable to you? So those are the big overriding goals that we have for the project.   Carol: I really like that you guys are digging into the capacity that agencies have, you know, with that data analysis, because I'm just thinking definitely, as I've been out across the country that you've got to have and the have nots. I mean, there for sure. are folks, I think of our friends in Texas and they have a lovely team there. Just they have like an amazing...   Joe: Oh yeah, they do.   Carol: ...resource team. And then you've got other folks trying to scrape together kind of a half of a position that can maybe do a little smidge of a little something around the 911.   Joe: they may have a resource like a data system, but they don't have anybody that can run it, or they may have staff with the capacity to do the data system, but they don't have the system. I mean, it's a lot of different variables there.   Bob: I'd like to jump in here just on one thing, which was on the simplified VR model. So the model we've developed, thank God it was by economists, is we're trying to address the question here. The goal of the program is to get people into competitive employment or keep them in competitive employment. If they already came into the program with it, maybe build on that. So there are a lot of things that are correlated with how well you do in the labor market, gender, race, Age, education level. All things are correlated, right? And maybe service provision in the VR program. But we'd like to take it from well, it's correlated, but we don't know exactly how or why. In the same way you can say, well, provision of this specific type of service leads to improvement in the labor market, leads to a greater likelihood of obtaining competitive employment. Now that's a different issue. Now the way you normally do that, the gold standard is a randomized clinical trial, right? Where you take people and you randomly select them and it's double blind. So neither the researcher nor the individual involved in the experiment know who's receiving the treatment, or  who isn't. Well, that's clearly impossible in VR. First of all, it's illegal to deny service to someone who is eligible and for whom you have the money. But secondly, it's impossible. So what you have to do is you have to impose statistical controls somehow. You have to do it through some sort of statistical model. And we've developed one which is state of the science. What state of the science inherently means that not everybody can implement it. So even at some universities, they aren't able to implement this particular model. And so we wanted to ask the question, could we come up with a simplified version of this model, a simpler model that can be used possibly in a VR agency or possibly at a local community college or university, something like that. And they could get similar results. So we wanted to see how could we do it? Is that a possible goal? What do you lose when you do it? Does it do a good enough job, or what kind of qualifiers do you have on it?   Joe: Where are the tradeoffs?   Bob: Yeah, what are the tradeoffs? That's a simpler model we're trying to do.   Carol: Should we talk about the model you developed now? Do you want to talk about it?   Bob: That'd be fine. Sure.   Carol: Let's do it.   Bob: Okay. One of the things is that the model we developed is based on readily available administrative data. What that means is you don't have to run a survey. You don't have to go out and do a very expensive sort of research project to find out what's going on. Instead, we use data from agency's own data system, which they collect to report to the Rehabilitation Services Administration, (RSA). they have really, really very good data. The RSA forces them to collect very good data. In fact, for some of our economists, their eyes just lit up when David told them the kind of data that he was able to access it. Whoa. That's great. So there are two levels. One is you get data from the agency itself, and then they will provide data to us that they provide through the quarterly RSA and nine over 11 report to the RSA. And more than that. So we get much greater detail than that if we know how to use it. If we can identify and know how to learn how to use it. And then secondly, all the agencies have given us access, been able to give us access to unemployment insurance sort of data. So quarterly data on that and what the RSA collects upon closure. They're mandated to follow employment and earnings for four quarters after closure, but we don't think that's long enough, especially since WIOA was passed Workforce Innovation Opportunities Act and changed the mandate to work on transition age, transitioning students with disabilities or providing those sorts of services. Well, if you're going to start working with young people who are just entering the workforce, or you're providing college level education or skilled training services to any age. You can't just follow them for four quarters. I mean, if you're just entering the workforce, you're not going to enter it at the highest levels of the workforce, right? So if you want to know what the real impact is, you have to follow them longer. So with the unemployment insurance agencies, we've been able to get quarterly employment and earnings data from 2 to 3 years before they even applied to the program. That's kind of a baseline. But what are the services do to you? How do things change? Well, that's your baseline three years before application. Then we try to follow them for at least five years after application at least. Now the current one starts in 2018. So the earliest applicants we have from 2018, and then we collect all applicants between 2018 and 2021. So already it's a stretch to get five years of data. But we had to start that recent because we all wasn't fully implemented effectively until 2017, 1819. In fact, the fellow North County says preferably 19 or 2021. But then you don't have, you know, this thing ends in 2025 and you don't have enough data, enough tracking. So that's the first thing, is readily administrative tracking earnings over a long period of time, as long as possible. Another thing is generally the way these things are done or have been looked at is you look at the VR program as a whole. You don't look at by discipline, you look at the agency. These are people who apply for services, and these are people who got to the point where they got a plan or plan for employment services. And then how do they do? We look a little differently. We look at by disability type. First of all, we look at for broad based disabilities folks with a cognitive impairment. And that could be an intellectual disability or a learning disability. Folks with a mental illness. And then also we try to find out how severe that mental illness is. Folks who have a physical impairment and folks who are blind or visually impaired or otherwise visually impaired. So we look at and we estimate those all separately because we think services are assigned differently by disability type on average. And also the disability type affects how you will do in the marketplace, for example. What we found out was for folks with physical impairment, unlike folks who have a cognitive impairment, cognitive impairment might be with you since birth, perhaps. And so therefore you kind of have a steady level of earnings at a certain level. But if you have a physical impairment that often comes on very quickly, very acutely, very quickly. So all of a sudden you see their preapplication Application for earnings pretty good. And then boom there's a big plummet, right? And so then you have to do something different with the track that the pre-application earnings. So that's the second thing. The third thing is that this idea that these folks, we look at the folks who received,, who had a plan and therefore received services, we compare those people who didn't have a plan and didn't receive services. So he received service, he didn't. Or, in economics or the social sciences, you call it a treatment group and a comparison or a control group. Well, we thought you could do a little bit better than that. What we look at is we look at anywhere from 7 to 9 to 10 to 11 different types of services things like diagnosis, medical treatments, college education, training, all those sorts of things. We say, first of all, how is the decision made that you're going to receive this type of service? And then secondly, what impact does it have? So what factors influence the decision to We see what type of services and what impact does that service have in the labor market on gaining and keeping competitive employment. So we look at that. So we look at different types of service. So you can see already it's a much richer type of analysis therefore much more complicated types of analysis. And then the last part is that we built sort of a state of the science model. And that's what makes it complicated for many people to try to implement. And by that we mean that this correlation versus causation. So instead of doing a randomized clinical trial you have to take the data as you receive it. So therefore you kind of build control by saying how do you control for different things that might affect this that you don't observe. Now one of these might be motivation, right? So if you have someone who's particularly highly motivated that will might lead them to both apply to a VR program and a plan, follow through and move on, successfully complete the program, and might also quite separately, whether or not they receive services. It helps them in the labor market, right? Because they're motivated to succeed. So how do you distinguish those things? That's tough. You do randomized clinical trial. You can't because both types people end up in both parts motivated and unmotivated. So we have to impose this controls. And that gets a little complicated. So that's basically the model is then once you're done. So then we get impacts by type of service. We also collect cost of providing those services. Cost of the program. We have those impacts. We let them spit out and say what would happen if they kept getting this benefit level for the next five to 10 to 15 years? And then you have to do some what's called discounting in technical and finance and econ. So you do that and then you say, okay, this is the total gain from that service or actually from all the services combined. And this was the cost. And the difference to that is kind of cost versus benefits, right? Hopefully the benefits exceed the costs, right? And that's how much they've gained because of the service per versus both the. That's essentially what you do. And the other thing about that is we can calculate that for each individual in the sample. So we have individual level returns on investment individual level benefits or effectiveness. And you can then aggregate that up and say okay agency wide. This is what it looks like. The agency's return on investment for a particular disability. That's what their return on investment look for males their females. Any group you want to do you can just do it because we have the individual impacts of it. So that's the model. And we want to see whether a simplified model can get us similar sort of information.   Joe: One of the things, Carol, that I find compelling about the model in particular is something Bob just pointed out, and that is it's built on the individual customers and how well they do in this process and what their outcomes are, and it builds up. So it starts at that individual client level. The other thing, when the economists were developing the model and they were looking at the data of people who went through the system, they observed that there's a lot of variability in the types of services that are provided. So they built the model around that variability of services. So that individual service model, that is VR is what makes the variability work for this model. So it's very much tied to the core tenets of the VR program, that individual services model. And that's where the variability comes from. And that's why it can give us some causation. So I think it's really important to note that it is consistent with how we do services and how we provide what we do. The other thing I will say about The Economist is they have been dedicated to understanding how VR works. They often in the early days when we were going out, they would sit down with the agencies and say, does this make sense to you? And then they would look at the model to see what would make it make more sense in terms of telling how VR works or the outcomes of VR. So they've spent a lot of time trying to understand the system and get knowledgeable about how VR works and what the opportunities are, what the process is, so that what they're modeling is consistent with how we do business. So I think that's a key component.   Carol: I think that's really cool that you said that, Joe, about taking it back to the individualized nature of the program because VR, you know, you think about it in an aggregate, we get this big $4 billion in a lump. And, boy, each person's experience within that is so individualized. It is, you know, whether you're getting this or that, you know, are you getting educational sorts of services and access to training and post-secondary and all kinds of different things? Or are you a person on a different trajectory, and maybe you needed some medical rehabilitation type of stuff going on? You needed something completely different. Like, people have so many ways to mix and match and use the things they specifically need to get where they need to go. You probably can't do it unless you get down to that level. So that is very interesting. Now, Joe, I know we've talked about this in our team a little bit even. And I know you said you wrestled with your group, but this whole notion of return on investment or taxpayer return on investment has been a really interesting topic and is fraught with some issues itself. And I remember coming into Minnesota and the general agency director like taxpayer return on investment, and I was brand new in the program. I'm like, I don't even know what you're talking about right now, but a lot of times you tend to hear it discussed that way. But I know, Joe, you've said there's a lot of issues around this. So what are some of those issues?   Joe: It's an interesting little issue. The very first meeting we had, it was at Carver, and we had a number of people from different agencies and state rehab councils come into a meeting, and we were laying out the first model. And one of the directors at that point said, well, are you doing a taxpayer return on investment? And by that he meant returning Taxes, increase in taxes, receipts going back to the Treasury. And that was his definition of it. That was the first one. And then when we were in North Carolina at the consumer forum that we did the stakeholder and consumer forum, we got the question from some advocates and said it doesn't seem to go away. We always get that question, but the issue is what is the appropriate way to determine the return on investment for a particular type of program. And it was interesting. We got this question so often, even from some of our workforce friends that are the economists said about writing a paper to describe why taxpayer return on investment is not appropriate for a VR type of program. And they submitted it to, I think it was three, maybe four different econ journals, and some of them didn't even send it out for review. They said, this is already settled. It's not appropriate for this kind of program. So the issue is another workforce programs or human capital development. And the purpose of a human capital development type of program is to in our case, find people employment and look at that probability of employment. And then conditional on that earnings, if you've got people in your system and they're entry level, a lot of them are not going to be at the level where they pay any kind of taxes at all for several years. So you really don't have a lot to show when you do taxpayer return on investment in terms of that. Also, one of the things that we noticed when one of the studies that was done is that in some cases, and this is with a particular type of one of the particular disabilities, is the only one they looked at this with when we had some Social Security earnings available data available to us for a short while. Not only do we get people off of Social Security benefits, but we also find people that go on to Social Security benefits from being involved with VR, and that often makes them more stable. So then they can then participate in a VR type of program and be successful. But it's a long, long term process to do that. So in the short term, you're not going to show anything but about as many come on as go off. So you're really not showing that. But if you're doing what the authorizing legislation says you're supposed to do, which is get people employed, let's just take it down to a simple level and then the question becomes, are you efficient and effective in that process? And that's what this particular return on investment model is about. And that is what the economists would say is the appropriate way to look at this. Now they would call this a social welfare type of program is the category they put it in. And then human capital development. But there's other kinds of benefits that accrue to the individual. Because this model, this type of approach looks at it benefits to the individual and to the society in general, which is the individual being employed. And in this case, there are other benefits that we can't observe. Self-confidence would be a good example. Quality of life would be a good example. So in our case, what we're able to observe is how they're interacting in the workplace. And that's really the piece that we can measure. And that's where we're going with this. And the others might be important, but very few places have really figured out how to measure that.   Carol: Well, Joe, I actually I was telling Bob before we hopped on, I said, you know, I threw something in ChatGPT because I was like, all right, VR return on investment. Explain it to me. And ChatGPT it spit out. It talked about financial return on investment, you know, with employment earnings, cost savings. But it was talking about social return on investment, improve quality of life, community contributions. You know people experiencing that enhanced self-esteem, independence, all those things. And then personal return on investment with skill development, career advancement, those kind of things. It was just kind of fun to run it through and go, hey, yeah, because I know you guys have wrestled with like, what are you going to call the thing? Did you come up with like the name, The Thing??   Joe: Yes, it's interesting. I think what we came down with is that we think the vocational rehabilitation return on investment is the name we're going to stick with. And then say, you know, what we have is a human capital development project, and that's how we're measuring it or return on investment. But what we're going to have to do this is so ingrained in the culture of VR that you've got to return taxpayer dollars. Well, that's really not what VR says it's supposed to do. And so how do you get people to understand that that's not the appropriate way to look at the VR program. So we're going to have to do some education. I think about what return on investment is. And I may use your ChatGPT story...   Carol: Yeah.   Joe: To ...tell it.   Carol: Bob, I see you have something you want to jump in with.   Bob: Yes, and I think well, I have several things. One is I think the reason it's so ingrained, I think I might be wrong. Joe can correct me is because agency directors have to testify before the state legislature to get the money they want from the state legislature, right? And say the legislature, at least for a while. I don't know if they're still doing it. They're saying, yeah, but what's the return to the taxpayer on this? Why are we funding this if it's a money losing proposition Well, that's the thought process. But the problem with that is the state legislatures are kind of going against the odds. The federal authorizing legislation, you know, VR dates back to again, Joe can correct me. After World War One, when veterans came back from war and they had some severe physical injuries, and the federal government said, well, let's try to get them services to help them vocationally help them get back to work, get a job, and keep it so that they're effective in the workplace. Well, that thing was incredibly successful. So over time they said, well, this works so well. Can we expand it to other disabilities? Maybe states want to get involved in this as well. So what's happened over time is every one of the 50 states has this kind of co-funded arrangement with the federal government. And the Rehabilitation Services Administration oversees it, where they jointly sponsor these things, and it now covers many disabilities. Some states have more than one agency, one for the blind and visually impaired and one for the general. Other disabilities. So it goes back that far. And the authorizing legislation says is specifically provide services to help the individual gain and maintain competitive employment. And we're back down to the individual with that. It doesn't say to pay for itself to the fed, to repay the state or federal government for those services. So that's one thing. It's not what the metric to do it by. A second thing is, I mean, I never did like the social welfare. I'm an economist who would never call this a social welfare program. First of all, welfare has a negative connotation, even if its denotation is not negative. It's social improvement or anything. But it's really less a social more. As I said, the human capital development, that's what it's all about. And he also mentioned the issue that a lot of some things just aren't measurable. So when you mentioned financial return on investment, that's what we're talking about. Is the agency doing its job of getting people back to competitive employment and leading a better life, and maybe freeing up some of their family work to do other things. There might also be a multiplier effect in the sense that they earn more money, they spend the money. Other people, as a result, earn more money. And economists call that a multiplier effect. So that dollar has more on it. But it wouldn't get measured in this taxpayer return on investment at all.   Carol: Okay, cool. So I know you guys have made some interesting observations in reviewing the data and looking at some of the longitudinal data. What kind of things are you guys seeing?   Joe: My observation is that it concerns me that some people we've  learned recently that some of the states aren't capturing data after the fourth quarter after exit in terms of UI data. I know one state that is capturing going for that after the fourth quarter for their Social Security cases, because it helps them obtain more resources through cost reimbursement. But I think that we're underselling the value of VR when you only do the fourth quarter up to four quarters after exit. And I realize that's a lot more than we used to do. But on the other hand, it's probably not the best way to tell the VR story, because you just don't capture everything. And younger population exacerbates this. You just don't capture it with all the impact of VR can be for an individual over time. So I think that's one of the things I have seen. We had a study we did from a long time ago, from the first since I did with David, Dean and Bob, where we had a program, that transition program, and the students that participated in it were focused on post-secondary opportunities, and they were measured against the counterpart group that went in the VR system of youth. And the other kids typically went to work faster than the participants in this program. But at year six, after application, the perk students took off in terms of their employment, and the other kids just they were still employed and they were doing well. But the perk kids took off with this post-secondary approach, which is what we're being asked to do now. And you really wouldn't have told the story if you only went for five years after application. So those are the kinds of things that I'm concerned about with the longitudinal data.   Carol: Joe, so what about this to with it. You know, like especially blind agencies tend to provide a lot of the services themselves. What kind of problems are there with that and not sort of capturing the data?   Joe: We have seen that as an issue with the 2007 data set. We have in the 2012 data set, we had and our colleagues in the blind agencies were very clear that there were services that they were providing that were critical to successful employment and adjustment, but we didn't have any way to capture it. And so you're, again, you're undervaluing the impact of those agency provided services by not capturing them. And I think that's going to be critical. I think there's some requirements now that they have to be reporting some of this information, but it's a question of whether it's getting into that case management system and it becomes readily available administrative data that can be used to help tell the story of the impact of the great work that these counselors and other kinds of specialists are providing to help people become employed and adjust into their settings. Bob, you want to talk a little bit about what you're seeing in the data?   Bob: Well, yes. And now with the new data set, RSA 911, that quarterly report that all agencies have to provide and again for four quarters after closure that thing now they've made some changes and it's now required whereby types by 32 different service types they report. Did you provide purchase services during the quarter. If so how much did you provide it in-house or was it provided through a comparable benefit, some other external agency and that might have a dollar value attached to it? So we're going to use that data and see what we have. Now of course with any data set. Now I'll tell you purchase service data that's pretty reliable because they need to get their money back, right? They need to get reimbursed. They need to pay the bills. And so they track that through their accounting system very well. But the other things are and had entered often by counselors who are harried and busy and have a lot of other things to do, rather than this bureaucratic kind of form filling out, so it's only as good as the data that are put into it, and we won't know how good that is, but we'll see how much we learn. this way, hopefully we'll learn some things we didn't know.   Joe: What we have been told is that the data is not there for us to capture, and that it undervalues the kind of work that's being done. So we're hoping we can find a way to tell that story, because it sounds pretty important. And then from my personal experience in managing some of these services, I know how hard these folks work and how valuable these services are. But if you can't capture it, you're not able to tell the story.   Carol: Yep. If it isn't documented, it didn't happen.   Joe: Yeah.   Bob: That's right.   Carol: So what are the next steps on the grant and how can we get folks involved? Are you needing people to help with anything, any states or anything we've got?   Joe: North Carolina is, we're working very closely with them and they've been really good to work with. We will be once we get the prototype, I don't know what to call it. The economists are putting together the data system information so that they can begin to apply the new model and that'll be happening hopefully within a couple of months. And then once we've run the model a couple of times, we'll be asking some other people to come in sort of a national audience to take a look and hear what the model is, what it offers to get their feedback on. Yes, that would be useful or that doesn't seem to work for me much. Could you do this other thing? And then we'll also be asking them about. We'll be showing them what we've come up with for the simplified model to see if that version is going to work or if we need to be developing maybe a template RFP for them to use with a local institution that they work with, then they would be able to get the data set. So we're going to be looking at that. We may be asking folks to work with us a little bit on the capacity survey, where it talks about the training that states might be wanting to say, who can provide this kind of service, and would this be valuable to do to increase people's ability capacity? Because there's a lot of data needs out there. And I think if it would help our project, it would probably help a lot of other projects as well.   Carol: So, Joe, are you thinking about that for fall, possibly at CSAVR or something?   Joe: That's November. That should be a time when we would have an opportunity to gather some information. Yeah, because we might be ready for it by then. Of course, that might put a little pressure on the economists, but I don't mind doing that.   Carol: Yeah. Bob's looking like, oh well okay.   Bob: You love doing that, Joe. I mean, one of the things my major professor in graduate school always said, I love working on a research project where I learn something and what Joe said is exactly right. So we would take and vet our results to various agents. We may make a trip to the agency before Covid. We go and we sit down. We go through everything, explain what we're trying to do when we sell. And then they would say, that looks a little wonky or something, or did you do this? And you say, no, we didn't do that. Yeah, we could do that. Let's do it. And then we would revise the model or no, unfortunately we don't have enough information to do it. Could you collect it? You know, that kind of thing. So yeah, we keep learning things and that's what these groups are intended. That's what they're for. For our selfish purposes. That's what we like about them.   Carol: That's excellent, you guys.   Joe: So November would be good, Bob.   Bob: So you say.   Carol: Well, I'm definitely looking forward to seeing what comes out of all of this. And you were saying that the end of the grant then is in 2025.   Joe: August 31st of 25.   Bob: Right.   Carol: All right. That's coming up quick you guys, really quick.   Joe: Oh it is.   Carol: Well, awesome I appreciate you both being on today. I cannot wait to hear more as this unfolds. So thanks for joining me.   Joe: We really appreciate the opportunity.   Bob: Yes we do.   {Music}   Outro Voice: Conversations powered by VR, one manager at a time, one minute at a time, brought to you by the VR TAC for Quality Management. Catch all of our podcast episodes by subscribing on Apple Podcasts, Google Podcasts or wherever you listen to podcasts. Thanks for listening!

Bob Right came to our studio and we talked about the wars, Navalny's death and elections in Russia and the US Full episode on Patreon: https://www.patreon.com/posts/rwa-news-ft-non-99475557 Or Gumroad: https://russianswithattitude.gumroad.com/

Description: Unlock the art of strategic business communication in our latest episode, 'Inbox Intelligence.' Dive into the world of email correspondence and discover when and why it's your most powerful tool. Explore effective practices, enhance your professional connections, and master the finesse of choosing email for impactful business interactions. If you're looking to harness the potential of email for impactful interactions, this episode of 'Inbox Intelligence' is a must-listen. Resources: Effectively Using Email in the Workplace Video  Business Email - Write it Right Course  Business Writing for Impact: How to Write So People Will Read Course Overcoming Inbox Overwhelm: Streamline Your Processes Course  MRA Membership  About MRA  Let's Connect: Guest Bio - Andy Marris  Guest LinkedIn Profile - Andy Marris  Host Bio - Sophie Boler  Host LinkedIn Profile - Sophie Boler  Transcript: Transcripts are computer generated -- not 100% accurate word-for-word. 00:00:00:00 - 00:00:21:03 Unknown Hello everybody and welcome to 30 minute Thrive, your go to podcast for anything and everything HR, powered by MRA, the Management Association. Looking to stay on top of the ever changing world of HR. MRA has got you covered. We'll be the first to tell you what's hot and what's not. I'm your host, Sophie Boler and we are so glad you're here. 00:00:21:05 - 00:00:48:22 Unknown Now it's time to thrive. Well, hello everybody, and welcome to episode number 59 of 30 minute Thrive. Today we're going to dive into the world of email, specifically inbox intelligence and discover when and why it's your most powerful tool. So today I'm joined with expert Andy Marris, MRA learning and development instructor, as he runs through his tips and tricks on using email in our professional lives. 00:00:48:24 - 00:01:14:14 Unknown So thanks for being here today to be here with you. Okay, so let's start out with the positives. Andy, what are the key advantages of using email as a form of business communication and in today's digital landscape? Well, email is really fast. You can reach a mass audience very quickly and it's documented forever. It's a great follow up tool at a conversation or a meeting so that we talked about this before, right? 00:01:14:15 - 00:01:38:15 Unknown People know what to do when. But it's also a great way to inform people of things that are easy to understand. Right? If it's confusing, though, I wouldn't put it in email. And then, of course, it's a great documentation tool. So now let's flip that question. What are the biggest challenges of email? It's really fast. You can reach a mass audience really quickly and it's documented forever. 00:01:38:16 - 00:01:57:03 Unknown Literally, the pros are also the cons because once you hit send, yeah, that's gone. But anything that's real complex or difficult to understand, that's just going to make it a difficult concept and then they're going to not get it. You can't watch somebody react. You can't read their body language and if they get it or not, you can read that in someone's face when we're looking at them. 00:01:57:03 - 00:02:20:24 Unknown You can't get that out of an email. And it is a big one when you're emotional. Right. Be very careful to take a break, get yourself collected and cool, because if you type in your emotional, it's going to come way worse on the other end than even you intend. Sometimes you got to, you know, go take a walk, yell at the trees, whatever you got to do, take a deep breath. 00:02:21:01 - 00:02:40:08 Unknown But you want to make sure you're careful with those emotional emails because it comes off the way worse than you than you originally intended. And then anything that's not for public consumption or confidential, as we said, email is never gone. Yes. Great point. In addition to that, tone is really difficult to read. You know what? What a cliché. 00:02:40:08 - 00:02:55:18 Unknown I'm using my mother in law as an example, but when she says I'm fine, she's fine. When she says I'm fine, I don't know what I'm going to find out later, but it's going to be a while. Yes. Before she reveals that, Right. Well, you can hear that in someone's tone. You can't read it very well in an email. 00:02:55:20 - 00:03:26:12 Unknown And so that's also a problem. And then even the mechanics. I had a woman I worked with years ago who had a she was really into grammar to be in the grammar police, and she had a really funny sign on her desk that said, I'm silently judging your grammar in my head, and these make me chuckle. But even something as silly as, you know, using a colon instead of a semicolon or a comma after your greeting, that's supposed to be the business way to do it. 00:03:26:12 - 00:03:45:22 Unknown I couldn't care less. I'm not the grammar police. But you know, something that like that simple could set your email sideways. And then also the design really matters. We've probably all seen somebody as a very stylized background, and because of it, it's really hard to read. Sometimes you please a whole block of text and it just, yeah, your eye doesn't know where to stop. 00:03:45:24 - 00:04:05:14 Unknown And so there's lots of things that can go wrong with it, even though it's a wonderful tool and use. Well, yes, I'm like picturing now the worst emails I've ever gotten or written, but I feel like I all I'm like an emoji person. So in my emails I will always add an emoji to help with tone so that they know like, Hey, I'm not meaning this in a bad way. 00:04:05:14 - 00:04:29:24 Unknown And that's good. Emoticons are invented for then. Is it a smart alec smiley face or a happy smiley face? And how professional is that? Right? So you've got to know your audience when you're sending that out. Yeah, but that is the purpose, right? To add tone to text. And that's, that's not soft serve. Sophie So what examples do you have on when tone was maybe misinterpreted with email? 00:04:30:01 - 00:04:49:03 Unknown I've got a funny one from several years ago. I had a participant in one of my classes and we were talking about how difficult tone is to read. And I was in in Chicago, and I remember as we're discussing that she kind of starts laughing and she says, Well, I've got kind of an embarrassing one that just happened to me. 00:04:49:03 - 00:05:08:19 Unknown And I said, Well, you comfortable sharing? And she said, Sure. And she said, And folks, this is not necessarily the people at your company. But she said, my my I.T. guy is kind of the stereotype on Saturday Night Live or makes me feel bad for doing his job because over in like, click, click, click. It really? Yeah. Did you even plug it in that guy? 00:05:08:19 - 00:05:27:20 Unknown Right. So she's like you. It's alter the computer kind of thing. That was her relationship with him. And so there was a vulnerability. There was a virus going around, and he wanted to save some time. And this was many years ago. And I remember when I was in the IT industry years ago, these are called the sneaker netting because the I.T. 00:05:27:20 - 00:05:41:10 Unknown Staff would put their sneakers on and run from computer to computer. This is before I had all these things behind the wall. They could just fix it. Yeah, well, he sends out an email because he's going to try and get to each computer, but it's going to take them a while to get to everybody. So he sends out an email. 00:05:41:10 - 00:05:57:04 Unknown So if they can install this patch to keep them from getting the virus, all the better if they can beat him to it. Right. So he sends out this this email and I'll quote unquote read it to you. It says, hello. There's been a huge virus going around the country. You want to we want to make sure we don't get it. 00:05:57:06 - 00:06:12:01 Unknown Here are the steps to install the attachment. He did Remember to attach it, by the way. Yeah, that's always a new right here are the steps. And then in bullet points, which I love, right? I want it to be one pane of glass. Bullet point. Bullet point. Bullet point. Bullet point. All of the directions on how to do it. 00:06:12:03 - 00:06:33:08 Unknown Thank you, Jim. It said please. It said thank you. Should they sprinkle in a little tone? She was so angry after reading that she went running to H.R.. Look what I have to put up with from this jerk. She had it in her hand as she printed it out. Any. Any idea why? It's pretty funny when she realized what had happened. 00:06:33:14 - 00:06:55:15 Unknown I don't know why, Because, you know, the human resources, the person's looking at the thing and go, What's wrong with it? It's very technical. There's nothing emotional about it. And she read it and she read it. I'll give you a hint. It was just one word. It was at the very beginning. Do you remember how that email started? 00:06:55:17 - 00:07:16:03 Unknown Hello? Yeah, hello. It's a greeting. Right? So a feeling. Hello. How are you? What's wrong with that? Well, can you think of any other interpretations of Hello? Maybe you've seen the movie Back to the Future. I guess. Hello, McFly. Buddy Holly. She read the entire email as if he was knocking on her head like she was an idiot. 00:07:16:03 - 00:07:35:16 Unknown Oh, wow. And it wasn't based on one word. Based on one word. We read tone into our messaging, and that's what we're up against. I think it's scary. I also think it's a very funny story that is fun. But wow, right? This is what we're up against. And that's why your idea about the emoticons or any of the emojis. 00:07:35:16 - 00:07:54:24 Unknown Yeah, that's why we use them. Maybe he needed to add a smiley face. Yeah, I don't know. And then she might have thought as a smart aleck smiley face. So who knows where that would have gone, but. Well, that's what we're up against. So good story. So are there certain situations then we're using email might hinder rather than enhance business communication? 00:07:55:01 - 00:08:11:15 Unknown Yeah. If anything has to be confidential, don't put it in an email. There is no such thing as a confidential email. Which is funny because there's even a little button you can push that says confidential. It's not defensible in court at all, and anyone in the world who has an email address can have that sent to them. Exactly. 00:08:11:21 - 00:08:33:22 Unknown We've seen so many examples over the years of people getting in trouble because of email be in ink. It's found even if you you know, there's been stories of people using software like bleach bit to get rid of emails and sure that got it off your server and in your computer, but it's still on the server or the network or the computer, the people you sent it to or the people you sent it to, who sent it to somebody else. 00:08:33:24 - 00:08:54:09 Unknown And so it really has no no end in mind digging the one forever as long as somebody has an email address. So that is kind of frightening. Don't put it in email if you wouldn't want anybody to read it outside of, you know, normal conversation. It's kind of like the tree falling in the woods, you know, nobody hears it. 00:08:54:09 - 00:09:26:03 Unknown Did it really make a noise? Well, everybody here's an email because it can be forward to any anyone that has an email address. I also run into different relationship things, right? So once you hit send, as I said, they can change the relationship forever. And so we see people using false urgencies, urgent and exclamation point and red and all caps and all those things can really set people off if it's too long on one hand, too wordy, and then if it's too abrupt, not wordy enough. 00:09:26:05 - 00:09:46:22 Unknown It's funny how this really can have a lot of problems in typing an email when we're emotional. Really, that can really cause problems because tone is so hard to read. Yeah, it comes off way worse than even we were anticipating. And if we're heated when we write it, it comes off isn't serious. Yeah. Going back to your that emails are not confidential. 00:09:46:24 - 00:10:11:08 Unknown It's kind of like social media to whatever you put on social media. Don't expect it there forever. Yeah, exactly. It's going to be there forever. It lives forever. But we talked about some of these challenges. How can you overcome them? It's a good question. One of the things we had that podcast, a few podcasts ago, we talked about meetings and I talked about can this meeting be an email if it's something really simple and easy to understand? 00:10:11:10 - 00:10:37:12 Unknown Well, you can ask the opposite question Should this email be a meeting? Yes. If it's more complex, we better do that right. Emails for simple concepts or to follow up is when it's best, right? So we use. I learned this from my colleague Janet. I love this. She calls it the grandma or judge rule. If you're going to make grandma blush by what's in there or you got to stand in front of a judge, don't put it in an email. 00:10:37:14 - 00:11:00:04 Unknown And so I think that's that's something to really remember when you're considering what you're what you're hitting send. Yeah, absolutely. Any other scenarios where you should not definitely send an email or I know we talk about here if if you're writing and writing and writing and you can't just quickly send it, you should just pick up the phone and call that person. 00:11:00:06 - 00:11:16:18 Unknown Yeah. If you have to explain something, it's so much easier just going in person or picking up the phone. I like to call that the three thread rule that if I've sent it, they've replied, I've sent another one. It goes back three times, pick up the clock, pick up the phone and call them if you can see them. 00:11:16:18 - 00:11:41:03 Unknown Even better yet, go see them face to face. You're just going to pile on the confusion. Yeah, the lack of clarity. The more you try to explain something email, if it's not, if it's not understood. I think everyone here in who's listening can agree that we simply get way too many emails, though. Sure. And that means that a lot of emails can also be missed too, because our inbox is so big. 00:11:41:05 - 00:12:04:06 Unknown So how can you make your message stand out among the mass amount of emails that we already get? Lots of lots of ways that really, really help. You really want to think of your readers perspective. You know, I tell this joke in class, it's lame. Sara I heard it before, but w I have them in the morning. It's what everyone is listening to. 00:12:04:07 - 00:12:25:22 Unknown I do my radio voice there, but it really does. It is not a radio station. It's it's what's in it for me is what that stands for. And that joke doesn't work. West of the Mississippi, by the way, everything starts with K. But anyway, we want to put our our tone in our in our message, in their reading perspective right now. 00:12:25:24 - 00:12:43:21 Unknown How do I want to best send it? It you know it. You've got your message to your head. How will they best receive it so they can act? And so I haven't kind of put myself in their shoes. How does this make sense to them? Yeah. Is there a meaningful and searchable subject line? I encourage people actually to fill that out second to last. 00:12:43:23 - 00:13:00:24 Unknown People usually type it right away. We'll talk about that in a little bit, but it's actually something that I prefer to do once I've written the whole thing. Because sometimes if I start out with any with a subject line in the email, I could change significantly by the time I've typed it in, by the time it hit send, maybe I need a new subject line any way. 00:13:00:24 - 00:13:20:24 Unknown I think I want to make sure that it's searchable in case somebody is looking for that in the future. That's easy to find and it's not, you know, just to get their attention. You know what you'd see and you cry wolf because it really wasn't that important. Right. And there's that urgency thing again. Yeah. So that makes me think of like you customize your emails based on different people, too. 00:13:20:24 - 00:13:43:23 Unknown So I know some people who would just like, want one word in the subject line, No, open it. Or I know another person who would want like a detailed subject line. So it's like it's also funny thinking about the person who you're sending the email to, how it changes. Basically, there used to be people would use it like instant messenger before the thing and would say poem for end of message and everything was in the subject line. 00:13:44:00 - 00:14:04:13 Unknown Yeah, don't do that anymore. We moved on right now, but that was a thing years ago. One of the things I always suggest is to make sure your message as much as possible is on one pane of glass. And of course, you've got your your surface in the view pane of glass is about this big. What about cell phone? 00:14:04:13 - 00:14:22:13 Unknown Right. Can can you get it so small that they don't have to endlessly scroll now that's not always possible. Yeah, you need to give them enough information that they can take action but the shorter the better. Yeah. And I even prefer if I can get away with it. Bullet points as opposed endless paragraphs. Right. They're going to scroll and scroll is probably not to get read. 00:14:22:13 - 00:14:48:16 Unknown Absolutely. Well, we talked about one. You should not send an email or use Email is the best form of communication. So do you have any specific scenarios where email is proven to be the superior choice for professional interactions? It's an awesome follow up tool. I love after a phone call or after a meeting or even a face to face conversation. 00:14:48:18 - 00:15:05:14 Unknown Here's what we spoke about. Bullet point, bullet point, bullet point so that, you know, the person can take action and we can remember and it's documented, right, So that people can say, Well, you didn't say that or we didn't agree to do that. Well, here's what we agreed upon and that they disagree with it, then we can have that discussion over the follow up email. 00:15:05:14 - 00:15:29:17 Unknown Yeah, but I think it's a tremendous tool for that. I love that. It is great when you reach a mass audience. Yeah. And so we can do that really quickly, really efficiently. Just be just be really sure that it's ready to go before you hit. Send in with like follow ups. Like you said, the meetings, you can include resources than in the mail to Great idea. 00:15:29:19 - 00:15:55:17 Unknown Great. Are you one of my favorite things with helping people tailor an email message is to help them understand that if you know the communication style of the person you're emailing that can really help you. Folks that are very analytical want lots and lots of information, folks that are what are often called Thrivers or dominant communication styles. They want it as short as possible, right? 00:15:55:19 - 00:16:15:01 Unknown Well, how can you how can you make both happy, Right. If you're sending to a mass audience? Right. Well, what I suggest is you have it short, but then have a link is best if you can have a link or second passes an attachment. But you've got to make sure you remember to send it. Yeah, attach it right before you send. 00:16:15:03 - 00:16:33:18 Unknown We had that oops moment before, right. But then anyone that wants to swim in all that data and information can go to the attachment or go to the link. Yeah. And a person that couldn't care less doesn't have to read all that. Still gets what they need to be able to act on that email. And I think it's really important to remember business email should be actionable, right? 00:16:33:20 - 00:16:56:06 Unknown It's it's for accomplishing things and so there should be some action tied to it. It can be just to make something clear, to follow up, which I think is also a good tool, but usually following up on something that needs to be acted upon. Yeah, that's a great point. So how does email contribute to effective collaboration, especially when working with remote or international teams? 00:16:56:06 - 00:17:15:05 Unknown It's a great question, right? Follow up is so critical when you're in different time zones. I mean, it's critical even in the same building. Yeah, but it really helps us to make sure everybody is literally on the same page, is doing the right things at the right time by the due dates. Email makes that really easy and it can be asynchronous. 00:17:15:08 - 00:17:35:22 Unknown Somebody could open it on the other side of the world and it's instantaneous, right? So that is a really great factor with it. You can add the little at symbol in somebody's name and then you can actually send it to several people, but actually have individual call outs where they have different action items they have to do. And so that can really use it. 00:17:35:22 - 00:17:53:00 Unknown You can use it that way as a collaboration tool and people can read it when it's most convenient to them, their timeframe, their time zone, Right? Yeah, I just kind of a funny little ad I try to tell people don't put. Good morning. Good evening. Good afternoon. Because you don't know when they're going to read it. It might be that time when you send it. 00:17:53:00 - 00:18:11:11 Unknown It's just a little awkward. It's not a big deal. But I want I want to make sure that that is your maybe has a greeting because I think that sprinkles in some tone. I like using people's name if I can, or my colleague Cheryl says it's the most beautiful sound to a person's ears. And I say, I say that the way they like to be, call it too. 00:18:11:11 - 00:18:29:13 Unknown I. Mandy Somebody calls me Andrew. I think somebody is mad at me. So especially Bob Right. But, but yeah, I think that's how we sprinkle in a little tone because it is really hard to read. Yeah. And, and I think it's really considerate when they can read it when they're able to. Yeah. And the email allows for that in a clever way. 00:18:29:15 - 00:19:01:24 Unknown So how about then some of the other email etiquette rules that people may not know or just generally think of? Great question and there's no Emily Post Guide to email etiquette. There's nothing like that. Yeah, but I think most people will agree on a lot of these because they've just seen it abused so many times and they get irritated when they see this one thing, especially that you just mentioned about international, for example, I want to reflect the formality of my reader. 00:19:02:01 - 00:19:23:20 Unknown If it's a first time conversation or, you know, email read with somebody in another culture, I probably would start out with Hello, Miss Bowler or Hi Mrs. Bowler. And I'd Hey, Sophie. Right? It just it it's not as professional. But if they are, if they then reflect back a more casual tone, then I think that that's a good place to start. 00:19:23:22 - 00:19:44:05 Unknown Limit those emoticons in those emojis that we talked about, you know, is it professional here? It's okay if you've got that type of relationship and they know you. But here's the biggest one for me as far as etiquette. We've got to watch out for that reply to all button. I am so tired of somebody saying we're ordering from cousin's subs. 00:19:44:05 - 00:20:06:12 Unknown What do you want? And somebody replies to, Oh, I'll have the turkey with extra mail. I don't care. I didn't ask. Raised me up this way. So we reply to all and everybody needs to know. Well in there's like emails where people are like just reply to me and then it's like implied all Hi, I got to give some people some grace on this. 00:20:06:12 - 00:20:25:23 Unknown I understand that there's certain phones that if people reply from their phone it automatically replies to all, Well then we should talk to that company and get them to fix that. But that's beside the point. So then assume good intent that they didn't mean to send that to everybody. But good gracious, I don't care about your turkey sandwich if I didn't have. 00:20:25:23 - 00:20:52:00 Unknown I'm not taking the order. So now, looking ahead with the rise of AI in automation, how do you really first see the evolution of emails of role in in business overall? Yeah, that's a that's an that's an interesting one. Now, I think we're going to not know whether it's a human being there or of a AI writing us on one hand, but I think it'll be even easier to find what we're looking for. 00:20:52:02 - 00:21:13:18 Unknown Even if somebody does a poor job in the subject line or the message, if you needed six months later, what did that person say? What do I need to know? I think that'll help us find those types of things. The it's still the Wild West. We're going to we're going to find out. But I think those things maybe could be some advantages in AI can help craft an email or help you create an email template. 00:21:13:18 - 00:21:42:10 Unknown So before we close out the episode, what is one more thing that you want listeners to remember about email? I mentioned a moment ago that we should fill out this subject line second to last writing. We don't really know what the message is going to say until we typed it, right. Sure. Well, I'm pretty passionate about this and I wish I could petition Microsoft to change this because you should fill out the to the CC in the back fields last. 00:21:42:12 - 00:22:01:21 Unknown And why do you think that is? Because you might forget. I don't know. You might forget that a certain group has to be included or a certain person. So that's definitely true. Maybe I'm missing somebody in those fields if I if I do it too quickly in it. Because again, I don't know what I've type, but I can't send it anywhere. 00:22:01:23 - 00:22:18:02 Unknown Oh, if there's nothing there, I can't accidentally go oops. And should keep going on out and so I would love to petition Microsoft because it's in the upper left hand corner of your screen, Right. I want to have them put it in the lower right, because when you were in kindergarten, what did your teacher drill into your head? 00:22:18:02 - 00:22:37:09 Unknown Always put your name at the top, right? And where did you put it? In the upper left hand corner because we read left to right. Well, what do people do First? They put your dress in there. Well, it's the worst thing you can do, because if something's not ready, you can't even accidentally hit send. Now, your question about I don't know, because now they might be monitoring your keystrokes so you still could get in trouble. 00:22:37:09 - 00:22:55:24 Unknown So watch out for those nasty grams. Right. Because some people will do that to get the emotion out when they're mad and they get delete. Maybe we don't even do that anymore. Maybe find a new way to vent your vent your frustrations. But that's a good right and not send it if there's nowhere for Yes. And sure, a lot of people would appreciate that change. 00:22:56:01 - 00:23:13:00 Unknown Yeah. And I'm so careful with that, especially if it's something more sensitive. Yeah, I will. If it's a reply, it puts it in there immediately. Right? If it's a forward, it puts it in there immediately. I will cut and paste it somewhere else and bring it back when I'm done. If I'm worried that could accidentally hit, save, send too quickly. 00:23:13:00 - 00:23:35:22 Unknown Yeah, that's a great idea. So if our audience would like to learn anything else about email etiquette, do you have any recommendations for anything else Emery can offer? So we have a great class and of course I think it's great I teach it, but it's called date. It's called business Email How to write it, Right? And it's a terrific class. 00:23:35:22 - 00:24:08:17 Unknown It's a half day and we basically focus on the things we we talked about today with a much deeper dive. In addition to that, we have an even more robust class. It's business writing and all the stuff that's in the email class is also within that class. But then we get best practices for letters and text messages and emails and even how to make the tone come through better and all those types of things because we have a full day to really address lots of business writing issues because it is just so hard to read tone in any type of textual message. 00:24:08:23 - 00:24:26:22 Unknown Well, we will make sure to link those two classes in the show notes below. So if you're interested, you can just take a look the show notes below and and register and have Andy as a teacher. Yeah, I'd love to see you in class or Andy. That's all the time we have today. But I want to thank you for all the great content and tips that you gave us. 00:24:26:24 - 00:24:45:01 Unknown I think I will now think about this episode every time I debate sending an email, and I hope you do too. But to our listeners, if you liked our chat and topic today, I would urge you to come in any any tips you have here on email, best practices, or just anything that you want to add on to our conversation. 00:24:45:03 - 00:25:07:00 Unknown Don't forget to share this episode out and consider joining MRA if you aren't a member already. Like I said, we have all the resources you need in the show. Notes below include including resources on this topic too. So thanks for tuning in today and we'll see you next week. And that wraps up our content for this episode. Be sure to reference the show notes where you can sign up to connect. 00:25:07:00 - 00:25:22:04 Unknown For more podcast updates, check out other MRA episodes on your favorite podcast platform. And as always, make sure to follow MRA's 30 minutes Thrive so you don't miss out. Thanks for tuning in and we'll see you next Wednesday to carry on the conversation.  

This is a free preview of a paid episode. To hear more, visit nonzero.substack.comSeems like only last week I was saying there wouldn't be a Nonzero Newsletter sent out today, owing to the end-of-summer quasi-vacation granted to hard-working NZN staffers. And it's true that the Earthling, the weekend edition of NZN, is skipping this week and next. However, yesterday I had a conversation that was so timely and interesting that I figured I'd share some transcript excerpts—below—with NZN subscribers.The conversation is with Nikita Petrov, who left Russia shortly after the invasion of Ukraine but is monitoring the Russian zeitgeist (and publishing his newsletter Psychopolitica) from Armenia. The subject of the conversation is Yevgeny Prigozhin, long-time leader of the mercenary Wagner Group.This June, you might remember, Prigozhin staged a short-lived mutiny against Russia's military leadership. So when his plane blew up a couple of days ago, pretty much everyone suspected Putin's handiwork. (Although, as Nikita explains, according to a conspiracy theory circulating in Russia, there's less to Prigozhin's apparent death than meets the eye.)Paid subscribers can listen to the full conversation via the audio player above or via their NZN member podcast feed. (To set up that feed, if you're a paid subscriber and haven't done that already, click “Listen on” in the audio player and follow the directions.) Hope you enjoy the excerpts below. More of the conversation will be available in the public podcast we post next week, though the Overtime segment—the final 40 minutes or so—will remain exclusive to paid subscribers.—BobBob: We're taping this on the day after a plane went down that apparently included Yevgeny Prigozhin, the head of the Wagner Group, along with his top commander, the guy from whom the Wagner Group got its name—“Wagner” was his call sign. Nikita: Yep.Bob: And I actually haven't even looked at the news this morning, but it didn't seem to me there was that much doubt, even though they hadn't identified bodies or anything. I assume no one's doubting that he's— Nikita: Well, there are two main theories that I've been hearing. One is the straightforward one: Prigozhin and the top command are dead, and Putin is behind it. The other version is: This is Prigozhin's disappearance. He's somewhere on an island right now drinking a martini, and this is his way out of the business. Normally I would say there's no reason whatsoever to contemplate that approach. But since this is Prigozhin, and we've seen like six fake passports of his with toupees and beards and whatnot. And generally, he's, you know, a peculiar character, he's fighting in Africa, and then he's in Ukraine, and he also has a catering business, and a troll farm. I think that's not a zero-chance probability, but I don't think it's a high-chance probability either.Bob: On the other hand, Russia has always been a hotbed for this kind of theorizing, right? Nikita: Yes. Yes. It's a normal thing for Russians. Whatever happens, there's always a conspiracy theory right away.Bob: So there's a pretty high false positive rate on conspiracy theories in Russia—and increasingly in America. Maybe this can bring the two nations together, that we have this in common.Nikita: I think there is some overlap. I mean, before the war, there were tribes within Russia and the US who were growing closer together, like the QAnon people. And even with the war—Bob: That kind of makes sense actually. Go ahead.Nikita: I was surprised. About a month and a half ago, RFK [Robert F. Kennedy, Jr.] got into that scandal because he said something about Covid, and the way his words were interpreted was that there is a chance that it was designed by the Chinese in a lab and it targets certain groups more than others.Bob: Right. Nikita: And he started talking about bioweapons and whatnot. I think he talked about biolabs in Ukraine. Bob: Yeah. That's a thing. That's a talking point.Nikita: Until then, I was not aware that anybody in the West thinks that. But it was a big part of the Russian propaganda, some versions of which are very strange. On the one hand, according to Russian state propaganda, the Russians and Ukrainians are really the same people, but also, there are biolabs in Ukraine that were designing viruses that would target specifically Russians.Bob: It's a very discerning virus! It picks up on the most subtle differences in DNA. . . .Bob: But, on Prigozhin, tell me… presumably the [staged disappearance] theory is that he actually feared something like this happening for real, right? I mean, he didn't feel safe in this world. Nikita: Either that, or another version of the same theory would be that he made a deal with Putin, that this is how I'm gonna go out. Bob: Oh, and then you [Putin] will look like you were the tough guy and did crack down. Nikita: That's right. And I'll [Prigozhin] get my pension and I'm fine. Bob: I've got a feeling he doesn't need a pension. I forget how much cash was found in his apartment, but I suspect that he's got stashes in various places. Nikita: [laughter] That's right.  Bob: So anyway, your sense is, not that you're in Russia, but your sense is that this will be a minority interpretation anyway, that he's not actually dead?Nikita: From what I've heard so far, most people say there's also this possibility, but it's probably a low possibility. So, I haven't met a true believer in this theory so far. I mean, it's been a day—it's been less than a day. But it's brought up and discussed as a low probability option. And we will never know, I suppose, because the bodies are burned. We're not going to see a picture of Prigozhin that we can recognize. And the people who will tell us (and they might have already; I saw some reports that sounded more official than what I saw last evening, saying yes, this is Prigozhin and Utkin and the other passengers who were supposed to be on the plane) the people who are going to tell us this are the authorities, which if they are the ones who decided to do this staged disappearance, you know, you're not supposed to trust them.Bob: Right. Nikita: But I don't think it matters, frankly. I think that's the low probability version, and I don't think it matters, because both options lead to Prigozhin not being here anymore. If he lives a private life on an island somewhere—Bob: He seems out of the picture. And everyone else will act on the assumption that Putin did it.Nikita: That's right. Bob: Is your sense that among those Russians who do believe Prigozhin's dead, overwhelmingly the assumption is Putin decided to take him out? Nikita: Yes. Yes. Bob: I can't even come up with another theory. Has it been confirmed that there was an anti-aircraft missile fired at the plane, or is that still—Nikita: No, I think they are saying now that there was an explosive in the chassis, the wheel of the plane. And they say they have a suspect, Prigozhin's private pilot, who was supposed to be on the flight maybe, or at least was able to access the plane. And he's MIA somewhere. Some friend of his said that he's trekking in Siberia, or something along those lines. So, they have a suspect and a theory. It doesn't go further than that guy so far, like, why would his pilot do this? But I think that might become the official narrative. This is what I'm seeing this morning.Bob: So is it confirmed that the pilot was not on the plane, the regular pilot? Nikita: I think. He was called Prigozhin's private pilot.  I'm not sure he was supposed to be on this plane. He just flew with Prigozhin before, so they are singling him out as a suspect. Bob: I see. Do you think Putin would go to the trouble to frame somebody, and do the whole court proceeding, and put them in prison? I mean, it's weird, because presumably Putin wants a certain crowd to know he did it, including possibly much of the world, right? He wants some people to think, yeah, Putin cracked down, let's don't plot any mutinies anytime soon. I mean, that's the thing about this. It's so blatant, right? With most of the past assassinations attributed to Putin, there wasn't rock solid evidence. And in fact, I would run into smart people who paid attention, and I'd say, what do you think the chances are that this guy was taken out by Putin? They'd say, well, probably, or 90 per cent or 95 per cent. I don't think you're going to hear many people as low as 95 per cent on this one. It seems like this time, it's a more unabashed assassination.Nikita: I think that's true. But also, nobody tried to, you know, take his private army and march on Moscow before. Bob: Right, right. Absolutely. You know, right after this happened, right after the mutiny, and after the deal was negotiated, American Russia hawks like Michael McFaul said, see, all this stuff about how Putin if you corner him is dangerous, is wrong. We don't need to worry about pushing them out of Crimea and back into Russia and even, what is happening now, attacks on Russian territory. McFaul said, this just shows he'll fold; it's a bluff.  What McFaul said is that he capitulated. And first of all, I pointed out, he did not capitulate. He didn't meet Prigozhin's demands. That's capitulation, if you do fire Shoigu and Gerasimov, the two military chiefs he wanted fired. And I'd be interested in your take on this. Leave aside the fact that apparently, ultimately, Prigozhin paid the ultimate price. I thought, given the situation Putin was in, he didn't handle it that badly. I mean, you've got 5,000 troops marching to Moscow. Things could get seriously out of hand, even if you're confident you can put it down. These people are considered war heroes by a lot of Russians, right? They're the guys who did Bakhmut. They have a base. And after Wagner had shot down the planes, to get out of it with no further bloodshed… Leaving aside the fact that ultimately Putin had it both ways, he finessed it without a big confrontation and got Prigozhin killed, what did you think after the event?Nikita: Well, first of all, during the event itself, and the few days after, the prevalent feeling among all the Russians I know, whether inside or outside Russia, was just how bizarre this whole thing is. Especially as the events were unfolding, like, he started to march, you start to get these audio messages, you get updates in Telegram from Prigozhin himself.For a while, it wasn't clear whether this is actually happening or not. He's saying that they're marching on Rostov and it's like, is he? I haven't seen any pictures. It's just Prigozhin saying that, and he's known for playing games. And then suddenly there are tanks in Rostov.And then he's saying he's marching on Moscow. My brother was in Moscow at the time, and he went into the streets, and he said it was a weird, weird feeling, having been there for a long time, that the cops and the people are on the same side, because the cops in Moscow and people in Moscow were expecting this army to show up. And the cops seemed nervous and unsure what to do.. . .Nikita: So the prevalent feeling from this whole experience was just: This is bizarre and weird. When the analysis started to come in three days, four days after the thing, I had the feeling that maybe this is us trying to pretend that we understand what is going on. Because these past couple of days, nobody knew what was happening. Every theory was thrown out there, whether it's staged, whether it's real. You've heard these, you know, Prigozhin agreed with Putin that he's going to do this thing to find the people who are actually not loyal enough. There was all of this, and nobody had a good theory because the straightforward one seemed also too weird.Bob: Yeah.Nikita: But now in the aftermath, I agree with you that Putin did not lose control. And now, the Russian word they use is signal. This is a strong signal that he's sending that if you try to do this, you're going to blow up.But I think a lot of people did feel as this was happening, surely, that this is not the behavior of a strong leader, because he was nowhere to be found. The day of, Peskov, his spokesperson, said that Putin knows about the situation. But that was all. And then in the morning, he [Putin] made this speech. And during the day, as this was happening, there weren't a lot of people who really jumped in front of the situation and said, I support the president of my country and this is mutiny. They started saying that as the situation progressed and it became more clear that this is what you're supposed to be doing.. . .(Overtime segment available to paid subscribers below the paywall.)0:42 Nikita's life as an expatriate 5:18 Theories among Russians about Prigozhin's death 17:29 Putin's handling of the Wagner mutiny, reassessed 25:46 Did Prigozhin lose his mind? 35:36 How worried should Putin be about Prigozhin's supporters? 43:15 Russians' evolving views of the invasion 50:50 Is Putin feeling heat from the nationalist right? Robert Wright (Bloggingheads.tv, The Evolution of God, Nonzero, Why Buddhism Is True) and Nikita Petrov (https://psychopolitica.substack.com/). Recorded August 24, 2023.Comments on BhTV: http://bloggingheads.tv/videos/66636 Twitter: https://twitter.com/NonzeroPods

The Biden age issue ... Are Republicans setting the stage for Biden's re-election? ... Bob: Right-wing “non-interventionists” are rabid China hawks ... The Pentagon's no good, very leaky week ... Is Clarence Thomas corrupt? ... The New York Times hunts down a leaker ... Elon vs. Matt Taibbi and Substack ... Parrot Room preview: The new legal theory for prosecuting Trump; Biden's border policy; Mickey vs. Ross Douthat on AI alarmism; government programs Mickey likes; the movie Megan comes to life; the potential of Substack Notes. ...

00:00 The Biden age issue 5:59 Are Republicans setting the stage for Biden's re-election? 15:10 Bob: Right-wing “non-interventionists” are rabid China hawks 24:48 The Pentagon's no good, very leaky week 31:39 Is Clarence Thomas corrupt? 37:50 The New York Times hunts down a leaker 43:39 Elon vs. Matt Taibbi and Substack 48:07 Parrot Room preview: The new legal theory for prosecuting Trump; Biden's border policy; Mickey vs. Ross Douthat on AI alarmism; government programs Mickey likes; the movie Megan comes to life; the potential of Substack Notes.Comments on BhTV: http://bloggingheads.tv/videos/65962Twitter: https://twitter.com/NonzeroPods This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit nonzero.substack.com/subscribe

The Biden age issue ... Are Republicans setting the stage for Biden's re-election? ... Bob: Right-wing “non-interventionists” are rabid China hawks ... The Pentagon's no good, very leaky week ... Is Clarence Thomas corrupt? ... The New York Times hunts down a leaker ... Elon vs. Matt Taibbi and Substack ... Parrot Room preview: The new legal theory for prosecuting Trump; Biden's border policy; Mickey vs. Ross Douthat on AI alarmism; government programs Mickey likes; the movie Megan comes to life; the potential of Substack Notes. ...

FamilyLife Today® Radio Transcript  References to conferences, resources, or other special promotions may be obsolete. Manhood and Spiritual Leadership Guest:                        Dennis RaineyFrom the series:       Stepping Up (day 4 of 5) Bob:  Being a man involves taking some risks: stepping up, being courageous, leading, initiating.  Here is Dennis Rainey: Dennis:  What if I failed every time I've initiated?  Well, the easiest thing to do is nothing and to stop initiating.  The reason we fail to initiate is we may have trained our wives to just jump in and do it for us because we haven't stepped up and taken responsibility for our finances, for the spiritual well-being of our family, for the direction we're headed as a couple.  All of these demand initiative from a man who knows where he's going. Bob:  This is FamilyLife Today for Thursday, March 10th.  Our host is the President of FamilyLife Dennis Rainey, and I'm Bob Lepine.  We're going to begin today to unpack some of the essentials that make up biblical manhood.   Welcome to FamilyLife Today; thanks for joining us on the Thursday edition.  Do you think men know what it is they're looking for, they're aiming for?  I mean, do you think they understand what manhood looks like? Dennis:  No.  I don't.  In fact, I think there is so much taking place in our culture today it is like real manhood, as God designed a man to be, is an elusive goal at best.  For most, they have no—they haven't even got the foggiest idea what that looks like. Bob:  Well, I remember—this will date me a little bit, but I remember trying to figure it out myself and thinking, “So, as a real man the tough John Wayne, Rambo, you don't share your feelings; you just go out and get it done.”  Is that a real man? Dennis:  Don't eat quiche.   Bob:  Yes.  Or is a real man a sensitive, caring, kind of person who is tender and who is kind and who pays attention and listens to the heart of his wife?  Is that a real man?  We get such mixed messages in the culture that I think that a lot of guys are looking around going, “I want to be a man.  I'm just not exactly sure what that means.” Dennis:  Well, I don't often quote from advertisers, especially advertisers that advertise jeans, as an authority; but I ran across an advertisement for Dockers jeans where I just felt like they nailed it.  In fact— Bob:  Now hang on.  I'm wearing Dockers right now.Dennis:  Are you? Bob:  Okay.  Yes. Dennis:  Well, this is a good ad for Dockers jeans, but I want you to listen to this because this appeared in an advertisement for their jeans.  You tell me if you don't feel like they nailed it.  Once upon a time, men wore the pants and wore them well.  Women rarely had to open doors, and little old ladies never had to cross the street alone.  Men took charge because that is what they did, but somewhere along the way the world decided it no longer needed men.   Disco by disco, latte by foamy non-fat latte, men were stripped of their khakis and left stranded on the road between boyhood and androgyny; but today, there are questions are genderless society has no answers for. Now, I'm going to finish this, Bob, but can you believe this is for jeans?  Now I know Dockers makes other things too— Bob:  Right. Dennis:  But this is advertising their jeans.  They continue:             The world sets idly by as cities crumble, children misbehave, and those little old ladies remain on one side of the street.  For the first time since bad guys, we need heroes.  We need grown-ups.  We need men to put down the plastic forks, step away from the salad bar, and untie the world from the tracks of complacency.  It is time for you to get your hands dirty. It is time to answer the call of manhood.  It is time to wear the pants. Talk about politically incorrect.   Bob:  They've been reading your book haven't they?    Dennis:  Here's what they are saying, and again, an advertisement is not my authority.  I'm about to go to Scripture, but they are picking up on the theme of Scripture that there is a lot about manhood that is all about a man taking initiative.  Manhood is about initiative. 1 Corinthians 16:13-14 talks about standing firm in the faith, acting like men.  Be a man, it says.  1 Kings 2 David is about to die.  He charges his son, Solomon.  He says, “Show yourself a man and keep the charge of the Lord your God walking in His ways, keeping His statutes, His commandments, His rules, His testimonies.”  I mean, he's calling his son up: be a man; step up, son; don't fritter away your manhood on lesser callings.   Yet, this culture is sending messages to boys that make the waters incredibly murky.  If there is someone that needs to be clarifying what it means to be a real man today, it ought to be followers of Jesus Christ who are tethered to the Scripture. Bob:  So, you would say that the Scriptures give us a clear picture of what mature manhood is? Dennis:  Right. Bob:  Okay.  So, unpack it for us. Dennis:  Well, first of all, let me tell you what it isn't: it's not passivity.  It has been suggested in the Garden in Genesis chapter 3, that when the serpent came to Eve that Adam was standing there.  Adam was present, but he did nothing.  It has been suggested that perhaps the first sin of man was passivity.   If you think about it, if initiative is the essence of manhood, could it be that the sin of arrogance and pride of doing nothing and just standing back watching may be the opposite?   I think there are three reasons—actually I'm going to give you a bonus reason.  Four reasons why men are passive today, they don't take the initiative.   First of all, taking the initiative is hard work, and I'm tired.  It is the end of the day.  I don't feel like leading my family in a devotion at the dinner table.  I don't feel like putting the kids to bed and serving my wife by helping the kids be tucked in and praying with them.  The easiest thing for me to do is to sit in my easy chair and become a giant amoeba and just do nothing. It is hard work to lead.  Being a man calls us out of our passivity, out of doing nothing into engagement, into serving, into helping others and shouldering the burden with them. Bob:  It is not just the end of the day when it is hard work.  I mean the beginning of the day, just heading off to work.  There are a lot of guys who are checked out of manhood at the very beginning of the day because, frankly, as you've said it is taking initiative.  That means you've got to step up, you've got to take some responsibility, you've got to go to work— Dennis:  Right. Bob:  A lot of guys are going, “Who wants to do that?”   Dennis:  If you want to be a man, it is going to include pain because I promise you, to deny yourself and to abandon yourself to serve others will involve self denial and that does involve pain.  No, I don't like pain.  My flesh doesn't like not getting its own way, but that is a part of being a man. Remember Mark 10:35-45, the disciples came to Jesus and asked how to be great.  He basically said, “The Son of man came not to be served, but to serve, and to give His life a ransom for many.”  I think that's the essence of manhood: serving others, giving up your life for another.   Another way men fail to take the initiative is they say, “I don't know how.  I don't know what it means to initiate.  I didn't have a father who did.”  The slate is blank, and so, they use that as an excuse.  I would say to a man who didn't have a father, either present or who didn't have a father who demonstrated this, “Find a man who does.”   Go and find a man who'll practically illustrate and coach you in what that looks like, like interviewing your daughter's dates.  You've never perhaps thought about interviewing your daughter's dates.  Well, you know what?  There are men who can train you in how to do that.  There are books that are written in how to do that to show you how to be a man and how to initiate and how to step into a fearful place and be the man. A third reason why men don't take the initiative is it means I might fail.  What if I failed ever time I've initiated or my wife has made me feel like a failure every time I've initiated?  The easiest thing to do is nothing and stop initiating.   That really leads me to the fourth one: our wives can do it for us.  The reason we fail to initiate is we may have trained our wives to just jump in and do it for us because we haven't stepped up and taken responsibility for our finances, for the spiritual well-being of our family, for the direction we're heading as a couple.  All of these demand initiative from a man who knows where he's going. Bob:  We back off.  We don't assume responsibility.  A wife who looks around and says, “The job's not getting done,” and starts to feel fear, she'll step in and do it.  That's what you're saying? Dennis:  That's right.  So, the opposite is also true, Bob.  Instead of being passive, we initiate.  What is one of the things we can initiate as a real man?  Well, we've taken surveys of more than a hundred thousand people in local churches around the country, and one of the top issues women are looking to their husbands to provide is spiritual leadership of their marriages and their families.   One of the ways a man can assume responsibility and take initiative for leading his wife spiritually is to begin to pray with her every day.   We've talked about this on FamilyLife Today numerous times.  I feel like it's one of my life messages.   Barbara and I prayed together last night.  It was a short pray.  We were both exhausted because of travel.  In our case, we have seventeen grandchildren now.  We just had the birth of a new little one, Alice Pearl.  So, Barbara and I prayed for her last night as we went to bed.   This morning I read in John 4 about Jesus' interaction with the woman at the well.  He made a phenomenal claim.  He said I want to give you water, that's living water.  If you take a drink from me, out of your innermost being will flow rivers of living water— Bob:  You'll never thirst again. Dennis:  Never thirst again.  The woman was astounded by this man who told her about her past and seemed to love her and speak genuinely kind to her.  At one point, she talked about the Messiah; and he said, “I, who speak to you, am He.”  Well, you know what?  Praying together is all about coming to the Messiah, Jesus Christ, coming to Him over and over and over again to get a drink of the living water.   If you drink from Jesus Christ, out of your life will flow rivers, it says, of living water.  If you picture a husband leading his wife spiritually, that means that stream can be rich and deep and crystal clear and pure.  It means a man can truly love his wife in a whole new level.  Bob, I think a lot of men don't love and lead their wives spiritually because they don't know how.  They've never had anyone challenge them to do it, and it is as if right now I'm on these steps of manhood and I'm reaching down to a guy who may be straddling manhood and adolescents. Bob:  At least in the area of this kind of spiritual leadership you're talking about. Dennis:  Right.  May not be taking the initiative.  I'm reaching down and saying, “Come on.  Turn your back on adolescents.  Turn your life away from excuses.  Step up and become the man God made you to be: loving and leading your wife spiritually.” Bob:  Don't you think, though, that there are men who are intimidated in this area because they know their own spiritual nature.  I mean they think if you're going to lead somebody spiritually you have to be—well, you've got to be ahead of them.   A lot of guys look at their wives, and they go, “You know what?  Spiritually, she's ahead of me.  I mean she's got time to go to Bible study fellowship or precept classes.  She's doing more quiet time.  I mean, how do I lead her when she's the one who is farther down the path than I am?” Dennis:  Well, if you are not involved—I'm speaking now to this man not to you, Bob.  If you're this guy that Bob is talking about, you've got to find a Bible study with a group of men that are absolutely being ruthlessly honest about their own lives and digging into the Scriptures to find out how to really become all that God created you to be.  There's a lot of guys today who are not engaged in any kind of a Bible study. I was with a man here recently, and I looked him in the eye.  I said, “Tell me what's going on in your life spiritually.”  And it was a blank look.  Every area of his life is full with business, family, other issues with his life, recreation.  Spiritually speaking, there is no food. Bob:  There's just no margin for that.  He says if I'm going to keep the business going and the family demands, I just—I mean I hear you saying get in a Bible study with other guys.  I've been in a couple of those, and it kind of you know—it didn't feel great.  I just don't have the margin for it. Dennis:  Well, you've got to create the margin for it because if you don't—this is the margin you create to live.  It is back to the illustration of Jesus being the one who claimed to be the living waters.  If you don't have time to study about Him and His claims about life and how you as a man ought to live, then how are you going to know how to live as a man?  How are you going to know what God expects of you?   It is instructive to me that as David as dying when he turns to his son, Solomon, it is primarily focused upon the Scripture.  He is charging Solomon: follow the law, obey the Scriptures, do all that God has commanded you to do today.  Why?  Because he said you are going to find life.  He didn't say you'll find you'll find the living water, but it might as well be written there.  That's what he's talking about.   So, the question for men today is “Where you going to find out about life?”  If you're just punching the clock and doing your forty, fifty, sixty hours a week of work and not taking time to grow spiritually, there are some warnings in the Bible about the man who is not into the meat of the Word.   He's not digging into the Scriptures and finding out how it applies to where he is today, to the choices he's making, and to his responsibilities as a man, husband, father.  Maybe a single guy needs to find out what does God expect from me today. By the way, Bob, there is nothing magical, mystical, or spiritual that is going to automatically make you a man of God when you get married to all of the sudden start leading your wife spiritually.  In other words, now is the day to begin tracking with other men and growing spiritually with them as a single young man.   If you want to know how to love, lead, care for, provide, and nurture your wife and cherish her and provide protection for your family, you need to get busy today as a single man practicing those spiritual disciplines of getting in a Bible study of daily prayer, of growing spiritually as a young man.  Marriage will not make you— Bob:  Right. Dennis:  A man. Bob:  Okay.  So, the guy who says, “Alright, I'm in a Bible study.  I am growing.  I'm reading my Bible.  I'm having a quiet time, but I still feel intimidated with the thought of coming to my wife and saying, ‘Let's read this together' or ‘Let's pray.'  I think part of the intimidation is she knows the real me.  She has seen my feet of clay.  For me to come and say, ‘Well, let's pray together.'  She's going to think, ‘Oh, how come you're all of the sudden so spiritual.  You, who I just saw being carnal thirty minutes ago?'” Dennis:  Yelling at our kids. Bob:  Yes. Dennis:  Okay.  So, we fail.  Who doesn't fail?  We're not all living out this perfect, cookie-cutter lifestyle of being these perfect, little Christians.  If we're speaking to a wife here who tends to be focused on what her husband does wrong, why don't you try catching him doing what's right?  Why don't you, the next time he does something to attempt to lead your family spiritually, say, “Sweetheart, that was fantastic.”   It may have only been prayer at the dinner table, but you know what?  He stepped up and stepped out and provided some spiritual leadership of his family.  So, rather than doing it for him as a wife, instead catch him doing it right and cheer him on and don't always be focusing on where he has failed. Bob:  You think this issue of a man providing spiritual leadership is central to being fully on that manhood step to really embracing what God's called us to be as men? Dennis:  I do, Bob.  The reason is as men who are standing on this manhood step looking down to our sons who are at various stages of growth, stepping up themselves.  They're locked onto our lives like little radar units: picking up what we're about, what our values are, what our priorities are.  Who we are as men, what we're attempting to be, and how we're attempting to lead is caught by our sons. One of my favorite poems that was shared here on FamilyLife Today a number of years ago by Coach John Wooden, was actually a poem that was given to Coach Wooden.  It just reminds us of how powerful a man's model can be to his family.            Coach Wooden [recorded message]:  Well, the poem you're thinking of was given to me when my son was born in 1936.  I finished a project for Harcourt, Brace, and Company.  They sent me a picture with a man walking along the seashore and his little son is trying to step in his foot stamps just behind him before the wind brushes them away.  There were some lines along the side that said: A careful man I must always be, A little fellow follows me.  I know I dare not go astray, For fear he'll go the self same way.   I cannot once escape his eyes. What err he sees me do, he tries.Like me, he says he's going to be, This little chap who follows me. He thinks that I am good and fine.Believes in every word of mine.The base in me he must not see, This little chap who follows me. I must be careful as I goThrough summer's sun and winter's snowBecause I am building for the years to be This little chap who follows me. Dennis:  Bob, as men, it is better for us to fail in an attempt of leading our wives spiritually than doing nothing.  Perhaps the greatest and most courageous thing a man who is listening to this broadcast will ever do, will be to take his wife's hand and say, “I want to lead you in prayer” or “I want us to pray together as a couple.”  These are not minor deals. When a couple bows before Almighty God, their souls can be knit together by the One who made them.  It is worth it, just like David's charge to Solomon: be the man, show yourself strong, obey God. Bob:  Yes.  I think a lot of guys miss the fact that our walk with God and our spiritual leadership is central to stepping up.  You know they look at kind of the machismo of the culture, and they say, “Well, okay, being a man is all about physical strength.  It's all about daring, courage, or heroism.”  We would agree with a lot of those things; but at the core, you've got to be God's man. Dennis:  Right. Bob:  You've got to be a man who is in pursuit of a right relationship with God in Christ and who is leading others in that direction.  Otherwise, it is all about self.   I am hopeful that many of our listeners are going to call us this week or go online at FamilyLifeToday.com to get a copy of your new book.  It is called Stepping Up—A Call to Courageous Manhood.  You can request a copy this week if you help with a donation to support FamilyLife Today.  We are listener supported.  Those donations are what keep us on this station and on our network of stations all across the country.   So, this week if you make a donation, we want you to feel free to request a copy of the new book, Stepping Up, by Dennis Rainey.  The book is not currently available in stores or on Amazon.  So, if you are interested in a copy, you'll need to contact us.  If you're interested in multiple copies for a men's study or a group's study, you can contact us; and we can let you know how you can purchase additional copies. If you make a donation this week online at FamilyLifeToday.com, just type the word “STEPUP” into the online key code box.  When we see that, we'll know to send you a copy of Dennis' new book.  Or call 1-800-FL-Today, 1-800-358-6329.  It's 1-800- F as in “family”, L as in “life”, then the word “TODAY”.  When you make a donation, just ask for a copy of Dennis' new book, Stepping Up; and we'll send it out to you. Now, tomorrow, when we come back, we're going to talk more about the characteristics of authentic, biblical masculinity.  That is coming up tomorrow.  I hope you can be here. I want to thank our engineer today, Keith Lynch, and our entire broadcast production team.  On behalf of our host, Dennis Rainey, I'm Bob Lepine.  We will see you back next time for another edition of FamilyLife Today.   FamilyLife Today is a production of FamilyLife of Little Rock, Arkansas.  Help for today.  Hope for tomorrow. We are so happy to provide these transcripts. However, there is a cost to produce them for our website. If you've benefited from the broadcast transcripts, would you consider donating today to help defray the costs?2011 Copyright © FamilyLife. All rights reserved. www.FamilyLife.com 

FamilyLife Today® Radio Transcript  References to conferences, resources, or other special promotions may be obsolete. Approaching Adolescence  Guest:                        Dennis RaineyFrom the series:       Stepping Up (day 3 of 5)  Bob:  One of the key steps a young man will take as he progresses toward courageous, authentic, biblical masculinity is the step where he begins to assume more responsibility.  Here's Dennis Rainey. Dennis:  You know what?  As a young man, get used to stepping up.  Get used to taking on more responsibility because it is the stuff of manhood.  It's why God created you.  Back in Genesis, chapter one, you were designed to reign over the creation and make a living by the sweat of your brow and be a part of God's redemptive work on the planet. Bob:  This is FamilyLife Today for Wednesday, March 9th.  Our host is the President of FamilyLife, Dennis Rainey, and I'm Bob Lepine.  We're going to explore today what has to happen for a young man to move through adolescence and to embrace authentic masculinity.   Welcome to FamilyLife Today.  Thanks for joining us on the Wednesday edition.   We're going to have to start with some definition, maybe, or some discussion here at the beginning.  You've just finished a book that you call Stepping Up, a Call to Courageous Manhood.  You're challenging men to step up.   One of the things you address in this book is the idea that men go through a middle phase, from boyhood to manhood, the phase of adolescence.  You know there are people in the culture today who push back on that whole idea of adolescence and say that's an artificial construct.  Back a hundred years ago there was no such thing as an adolescent.  You just went from boyhood to manhood.  So what do you say to that, huh? Dennis:  Well, they're right.  It wasn't even in the dictionary at the turn of the twentieth century.  In the early nineteen hundreds there were two steps, boyhood and manhood.  There wasn't anything in between.  You stepped up from boyhood to manhood and probably did so at a much earlier age back then than we do today. Bob:  So you'd have teenagers, young men, fifteen, sixteen, seventeen years old getting married, taking jobs…Dennis:  Oh, yeah!  Right. Bob:  …taking responsibilities for families.  The idea that there would be an extended period where you would learn and study and grow and just kind of enjoy life before you got down to the duties and responsibilities of adulthood?  That just didn't exist. Dennis:  It didn't.  In fact there's a guy who wrote a book, Dr. Michael Kimmel, called Guyland.  In it he describes a world where young men live.  He said it's a stage of life, an undefined timespan between adolescence and adulthood that can stretch out for a decade or more.  It's a bunch of places where guys gather to be guys with each other, unhassled by the demands of parents, girlfriends, jobs, kids and other nuisances of adult life.   What he's saying is he actually wants to add another step between adolescence and manhood, one that can go on into the late twenties.  In fact, it's happening! Bob:  Guyhood? Dennis:  Guyland, I guess.  I don't know. Bob:  You get your video game controller and you work a job where you can go home and sit down with the dudes and crack some beers and get out the videogames and have a blast. Dennis:  Yeah.  In fact, listen to this statement that Dr. Kimmel concludes with.  He says, “In this topsy turvy Peter Pan mindset, young men shirk the responsibilities of adulthood and remain fixated on the trappings of boyhood while the boys they still are struggle heroically to prove that they are real men, despite all the evidence to the contrary.” Bob:  Well, he's really just saying that adolescence has been extended in our culture and there's kind of this state of perpetual adolescence.  In fact, again as you've addressed in this book and you've spoken to men, you're calling all of us to step out of what is that inertia that pulls us back into the irresponsibility of adolescence and say “Step up to the responsibility of manhood.” Dennis:  I don't think it's wrong that adolescence ultimately emerged.  I think what has become a trap, however, is when young men are allowed to stay in some in-between world, in between boyhood and manhood for an extended period of time where no one in the culture, no one in their family, no one in their lives, is stepping into their lives and saying, “It's time to grow up.  It's time to assume responsibilities.”   I have to say it's interesting in this culture to watch a bunch of single people, for that matter single men, moving into their thirties delaying marriage with one foot in boyhood, one foot in adolescence.  I think they need some older men in their lives who are on the steps above, looking down at them, and not in an arrogant fashion, but reaching down to them, saying, “Come on up.”   It may be frightening.  It may feel like it is more responsibility, because it is but you need to get out of childhood.  As Paul said in 1 Corinthians, chapter 13, verse 11, “When I was a boy I acted like a boy.  I behaved like a boy.  I spoke like a boy.  But when I grew up I put away childish things.”  We need a generation of young men putting away childish things. Bob:  But you know the messages they're getting in the culture, the messages on TV, from their peer group, the messages in the movies, and even the message of their own flesh, it's not calling them to put away childish things.  It's saying, “This is a time for fun.  Enjoy it!” Dennis: Well, you were a teenage young man one time. Bob:  I was!  I remember! Dennis:  Do you remember it?  I mean, it was totally confusing and life was a lot simpler back then.  But what's happening today I fear, is the older men in the lives of these young men, instead of reaching out with their hand and calling them to step up, they're not challenging them to much of anything.  They've forgotten what it was like. Let me just read to you what I wrote in the book in terms of what teenage boys are facing today.  “A teenage boy's body is changing in strange and foreign ways.”  Think about it!  I mean, hair growing in some unusual places!  What's he supposed to do?  He's starting to think about things he's never thought about before.  All of a sudden, sexual allurement and the mystery of sex becomes powerful.  If you've never been spoken to about this, what's a boy, a young man, going to do with all that? Secondly, he's bombarded with bewildering thoughts and choices about sex and morality.  In other words, when can he have sex?  Now he's thinking about it.  What is appropriate?  If you watch what's on TV, there are no boundaries.   Barbara and I sat at the movies back around Christmas watching previews and there was, and I forget the name of the movie and I'm glad I'm forgetting it here, because I don't want to give it any advertising, but it was all about having sex.  That was the theme of the entire movie.   It was like all these single people were just born for this purpose, to just figure out how to ultimately make out and get in bed with one another.  There was no restraint on passion.  So here are teenage boys coming to a movie like that.  What are they supposed to do with those images? Third, he faces relentless, unbelievable peer pressure, friends encouraging, enticing him to go along with, frankly, barbaric ways.  I mean teenage boys left to go their own route are going to be little barbarians. Next, he battles an emotional upheaval of anger, sometimes rage that he has no idea where it's coming from.  I watched out sons going through this.  Without a strong daddy in their lives, they can be punitive upon a mom. Bob:  They're getting some hormones squirted into their systems that haven't been squirted there before and aggression is a part of what comes with that.  It's got to be directed and it's got to be channeled. Dennis:  Yes.  And in this culture, in addition to all that, he's also has to deal with other people's expectations.  I mean, with all the expectations around the tests they're taking, the college they go to, how well their grades are, it's pressure on pressure on pressure.   The last one is he feels this strong gravitational pull toward independence.  He wants to spin out and away from the family orbit and establish his own authority away from his parent's authority all on his own. Bob:  And that's a good thing, isn't it?   Dennis:  It is. Bob:  …that he wants to do that? Dennis:  It is.  But it is if he's trustworthy, if he's been trained, if he understands how to begin to exercise his own authority. Bob:  If he wants to kind of be in charge of his own universe simply so he can indulge his own fleshy desires then that's a recipe for trouble. Dennis:  It is. Bob:  But if he wants to be out on his own so that he can subdue the earth and fulfill it as the biblical mandate calls him to do, then that's a good thing. Dennis:  Yes.  But just pull back for a second and think as a parent. Here's a young man that you're observing that has this wash of chemicals and hormones surging through his system, all these outside forces impacting him.  He's spinning off to his own orbit and two things can happen with parents.  One, I call the push back and the other is what I call the pull out.   The push back is when a young man begins to push back against his parents, specifically his father, and the father lets him.  He lets him push him back and push him out of his life so that the father is not in there helping him navigate uncharted waters.   The second area is the pull out.  Some parents just get busy and it's a hassle to engage your teenagers.  The easiest thing to do, again, is nothing.  So a dad can pull out of his son's life, in my opinion, at one of the most dangerous, most important times, when a young man needs an older man, in his entire life. Bob:  So ideally, as I hear you describing all of this, I'm thinking to myself ideally you want to get a son from boyhood to manhood kind of as quickly as possible, get him  through the adolescent rapids as quickly as you can? Dennis: Well, you know, you really understand why back at the turn of the twentieth century, why they got married and started their own families.  These young men had to step up and had to assume the responsibilities of a man.  They were given no other choices.  The problem is we've built an entertainment culture appealing to these teenagers, enticing them to stay in this phase well into their twenties. Bob:  A lot of the young men at the turn of the century weren't in school after the seventh or the eighth grade.  Now they're in school to college and beyond and their only responsibility is to study. There's no job.  There's no work.  All of a sudden you've got all this free time.  I mean, I remember when I was a student thinking, “Boy, I've got no free time.”  Well, I'd go back and trade, you know? Dennis:  No doubt. Bob:  …because you've got all kinds of time.  If there's no direct responsibility attached to that, that's a recipe for mischief. Dennis:  You know, Bob, my boys at this point would cringe because they know exactly what I'm about to say.  When they entered that phase I would look at them and I said, “You have the least amount of responsibility you will have for the rest of your life.”  But the idea there is that, you know what, as a young man, get used to stepping up.  Get used to taking on more responsibility because it is the stuff of manhood.   It is why God created you.  Back in Genesis, chapter 1, you were designed by God to rule.  You were designed to reign over the creation and make a living by the sweat of your brow and be a part of God's redemptive work on the planet.   Probably the best illustration I have of what the teenage years look like and the assignment of a father during those years, used to occur as I completed my sixth grade Sunday school class.  Now this was a class I used to teach.  I had seventy, seventy-five young people in that class so it wasn't just to the boys.  But I would always use a boy to illustrate the last principle. Bob:   Now this was seventy twelve year olds? Dennis:  Yes, eleven and twelve year olds. Bob:  Oh my goodness.  Alright… Dennis:  What I did in that class was I used to call it the traps of adolescence.  So I had a bear trap that represented sexual immorality.  I had smaller traps that represented drugs and alcohol and pornography, other traps that represented peer pressure.  I had a dozen traps that were illustrated.   For the last session I had all the traps set on the floor.  It's a miracle, Bob, that in all the years I taught this I never once caught a kid.  They never once stepped in any of those traps!  I was relieved! Bob:  It was a miracle that the Fish and Game people didn't come in and shut down your Sunday school class! Dennis:  No doubt about it. But I had all these traps and kids knew what those traps stood for.  So I took a young man on the other side of the traps, on the other side of the rooms, and he could see the traps in front of him, and I blindfolded him.  Then I said, “I want you to take off your shoes.”   And on the other side of the room, with the traps in between us and the young lad, was his father.  I instructed the father in what they were supposed to do.  I would say to the young man, “On the count of three I want you to come to your father and to me.  It's representing going through adolescence all the way to adulthood.” Bob:  So come barefoot through the traps with blindfolds on? Dennis:  Right!  Exactly!  And I would say, “One.  Two.”  And the father would interrupt me every time and say, “Hold it son.  Don't' take a step!”   He would walk over, around the traps, would go over and whisper to his son, “I want you to stick your hands on the back of my shoulders and I want you to scoot along and follow me very closely because we are going in between these traps.   So the father would begin scooting through those traps, all of this taking place in front of seventy-five young people about to encounter these traps and the parents who were about to raise them.  They were in the room too because this was graduation.   The father and the young man, closely behind him, would make it through to the other side and the class always began to applaud and clap and cheer as they finished it and the young man took his blindfold off and gave his father a hug.   That's a picture of what adolescence was meant to look like--a father in the midst of doing life with his son, in the midst of the traps.  First and foremost, staying out of the traps himself. Bob:  Right. Dennis:  And then calling his son to step up and away from the traps and to step with him toward manhood.   What is missing today are the fathers walking around the traps and then sticking with it all the way through the next five, six, seven years.  It's not a matter of having one birds and bees conversation with a thirteen year old boy.  It's a matter of talking with him as you're watching a football game and a commercial comes on and you tell him to look away.   It's a matter of talking about the movies he goes to and having boundaries in his life.  It's a matter of training him to know how to deal with the opposite sex and honor a young ladies' femininity by keeping his hands off of her body.   Young men today, more than ever, need a daddy, a daddy who is on the manhood step facing upwards, who knows who he is as a man, who's not dabbling in pornography himself, so he can reach down to his son and say, “Let's go.  Come on.  Follow me as I follow Jesus Christ.” Bob:  The dads who are there and who can't reach back because they're got one foot still stuck in adolescence themselves?  How do they get unstuck? Dennis:  As we've talked here Bob, we've created a picture of five steps, a step going upwards from boyhood to adolescence, from adolescence to manhood, manhood to mentor, and, the ultimate step and most noble call for a man, that of being a patriarch.   We also created an image that a man can find himself with one foot on the manhood step and one foot on the lower step of adolescence, standing sideways.  When a man finds himself standing sideways, he has to realize a couple of things.   Number one, his own life is in peril.  Number two, the kind of model he is leaving for his son, and for that matter the rest of his family, is not a good one.  And third, he needs to realize that from time to time all of us make foolish decisions.   All of us step down and we have to turn our back, that's call repentance in the Bible, we have to turn our back on selfishness and on sin and turn away from it and turn upward toward Jesus Christ and the scriptures and being obedient to what God has called him to do.  So I wish it was a simple matter of just turning away from evil one time and stepping up.  But it's never just that.   I mean, it occurs as we walk in the middle of an airport and you look over in the magazine stand.  I don't ask to see those pictures.  I don't ask to have those magazines faced outward to me, thirty feet away, not even going into the book store that's in the airport.  But they're there and they can be a temptation and they can call a man away from what he knows is right to becoming a doorway through which sin can gain entrance, not only to his own life, but also to his son's. There's a warning in scripture that the sin of one generation will be passed down to four generations.  To me that's a frightening thought, that my life would be used to pass on sin rather than righteousness to my descendants. Bob:  If a dad is going to lead his son through the phase of adolescence to manhood, the dad's got to have a pretty secure standing on the manhood step himself. Dennis:  He'd better keep short accounts with God.  All of us make mistakes.  I've shared many of them here on FamilyLife Today.  I run into listeners all around the country who says, “You know what?  We appreciate the no baloney approach to the Christian faith and to real life as we all live it.”   I've shared about cutting down trees in front of my own son.  And I've shared to repenting of cutting down a tree that wasn't on my property and calling the owner of that tree and confessing my sin and offering to pay restitution in front of my son.  Now that's no fun.  But you know what?  It's a part of showing our sons where to find life. Proverbs 4:23 says, “Guard your heart for from it flow the wellsprings of life.”  My heart is a precious thing for life in terms of it beating right now.  It's also a precious thing, if I understand the scriptures, spiritually,  for me to continue to guard my heart so that I might be a source of life, that my life might be a spring that would come from my life to my wife, to my sons, to my daughters, and to those that I impact and influence.  That's a great picture for any man standing on the manhood step.  There needs to be a stream of water influencing all those around him. Bob:  I think it's helpful, and this is one of the things you do so well in the book, men need to see that the essence of authentic manhood involves sacrifice, involves laying down your life, giving your life away for others.  It's not about being a man for yourself.  It's about being a man for others and dying to self. That's what's at the heart of authentic manhood.   I want to encourage listeners to get a copy of this new book.  Again, it's called Stepping Up—A Call to Courageous Manhood.  This week we want to send it to you.  All we're asking you is that you make a donation to help support the ministry.  When you do, we're happy to send you a copy of Dennis's brand new book.   If you're donating on line at FamilyLifeToday.com, when you open up the donation form there's a key code box there.  Just type “STEPUP” in the key code box and we'll know to send you a copy of Dennis's book.   Or call 1-800-FLToday and make a donation over the phone.  Again, just ask for a copy of Dennis' book when you do. Right now the only place the book is available is here at FamilyLife so, if you want to get a copy, go online or call us and make a donation.  If you're interested in multiple copies of the book, those are available for purchase as well.  I know there are a lot of men's groups that are going to look at doing a book like this for a men's study.  So if you want to get multiple copies, contact us, again, online at FamilyLifeToday.com or when you call 1-800-“F” as in family, “L” as in life, and then the word “Today.” Now tomorrow we're going to talk about what authentic, mature masculinity looks like.  What are some of the characteristics of someone who has stepped up to manhood?  We'll talk about that tomorrow. I hope you can be with us for that. I want to thank our engineer today, Keith Lynch, and our entire broadcast production team.  On behalf of our host, Dennis Rainey, I'm Bob Lepine.  We will see you back tomorrow for another edition of FamilyLife Today.   FamilyLife Today is a production of FamilyLife of Little Rock, Arkansas.  Help for today.  Hope for tomorrow. We are so happy to provide these transcripts. However, there is a cost to produce them for our website. If you've benefited from the broadcast transcripts, would you consider f to help defray the costs?2011 Copyright © FamilyLife. All rights reserved. www.FamilyLife.com 

FamilyLife Today® Radio Transcript  References to conferences, resources, or other special promotions may be obsolete. A Call to Manhood Guest:                        Dennis Rainey          From the series:       Stepping Up (day 5 of 5) Bob:  As a husband and as a dad, Dennis Rainey has not always done it right.  He remembers times when he embraced his role to lead courageously. Dennis:  I remember one time when our daughters came downstairs ready for church, and one of our daughters was wearing a dress that was immodest.  Instead of telling her to go change I was wimpy.  I didn't engage her because I didn't want to experience the pain of the conflict, and so I was a good man who did nothing.   All of us make mistakes that we can look back on and have some regrets about, but the key is, as we look forward, how are you going to protect your family today?  How are you as a man going to take responsibility and not give evil a chance to triumph in your family? Bob:  This is FamilyLifeToday for Friday, March 11th.  Our host is the President of FamilyLife, Dennis Rainey, and I'm Bob Lepine.  We'll talk today about what it means for a man to be on the alert, to stand firm in the faith, to act like a man and to be strong, to let all that he does be done in love.   And welcome to FamilyLife Today.  Thanks for joining us.  You think those who have been with us all this week have been kind of feeling the – smelling the testosterone as we've been talking about what authentic manhood ought to look like? Dennis:  Calling men to step up.  In fact, a call to courageous manhood is what we have been talking about.  You know, here's the thing, Bob:  We watch TV.  We watch a sporting event.  We watch the golfers, the football players, the baseball players, basketball, doesn't matter what season it is, and you hear somebody say, “He stepped up his game.” Bob:  Yes. Dennis:  We're used to using this phrase, stepping up.  It is used all the time.  Now I know I am sensitive to those two words because that's the name of a book that I just finished, that I've been working on for more than 10 years.  But I do feel like men today need someone in their lives calling them to step up and out of boyhood and adolescence and step fully into manhood and to be the man God made them to be. Bob:  Well, and we've already acknowledged this week that this is a theme that God seems to be stirring in our culture today.  We talked about the movie that's coming out in the fall that the folks at Sherwood Baptist have put together called Courageous.  It's around the same theme. Dennis:  It is.  In fact it's interesting that so many different Christian organizations, groups, and churches are all raising the same issue.  The guys at Sherwood seem to have their fingers on a pulse that I believe is something God wants to do in the church.  I think this movie is going to stir individual Christians, and I hope men to step up and be courageous in their most fundamental callings in life. Bob:  Give me a definition of courage.  Can you do that?  I mean, how do I understand what courage looks like biblically? Dennis:  Well, courage is doing your duty in the face of fear.  Doesn't mean you don't have fear.  In fact, one of my favorite questions to ask at a dinner table – I think you've probably been at a few meals – Bob:  I've been the victim of this question before, yes. Dennis:  You get at a table that's a round table and has four or five couples at it, or ten people at your table.  You hate to bore one another with yourselves, you know.  Life is too short.  Let's cut to the chase; let's talk about some stuff of meaning, you know?  So I like to ask the question, “What is the most courageous thing you've ever done in all your life?”  It's been interesting to look at how people have answered it.   People have talked about a decision at work to push back against deceptive business practices where it could have cost them their jobs, maybe stepping away from their existing job and pursuing a dream.  Others have protected an unborn life.  I've heard young men answer this question talking about stepping up and away from pornography.   But the most frequent answer to the question, “What's the most courageous thing you've ever done?” usually involves the person's father, where they stepped up and either took another job and didn't go to work for the family company – recently I was at a dinner table and a man said “It was my decision to not go to work for my father but go to college.  I was the first person in our family to go to college.”   There's something about our parents, standing up to our parents and taking a stand for what we believe God wants us to do that calls upon a bedrock of courage from a man's life. Bob:  And not to do that disrespectfully; to do it in the context of honor, but there is something about declaring, “I can navigate life apart from your guiding me.” Dennis:  I actually think it is a form of a rite of passage, as you've said, to adulthood, where we take a stand and we go, “You know what?  I'm my own person.  God has a plan for me.  I'm fulfilling that plan, and I will honor you, but I am going to be obedient to the God who has called me to do this thing.” Bob:  What you've done in the book is kind of chart the trajectory a man follows from boyhood, which dads can help make more intentional for their sons by pointing them in the right direction and calling them onto the right path, and then adolescence, which is full of all kinds of traps that a young man needs to be navigated through so that he can get to mature manhood. Dennis:  And one that every man needs to understand that his son desperately needs him to engage him during this period of time and not just kind of wipe his hands and say, “It's done.  He's a teenager now; he's 16, 17, 18 years old.  My influence is over.”  No it's not.   There will come a time when your influence will be lessened substantially, but until that time we're charging men to reach down to those young men in adolescence and call them fully up to the manhood step.  Step on up to what it means to be a man, and step away from, well, the lure of childishness and acting like a boy and prolonging youthfulness too long. Bob:  Well, if a guy is going to call younger man to step fully up onto the platform of manhood, he's got to be there himself, and to be there he's got to know what it looks like.  And as we've already said, a lot of guys just don't know what it looks like.   You've said it looks like taking initiative rather than just drifting into passivity, and one of the places where that initiative starts is in the area of spiritual initiative:  being a spiritual leader in a marriage relationship and in a home, in a community.  A single man can still be a spiritual leader in his community, whether he's exercising that in a home setting or not.  But it goes beyond spiritual initiative, doesn't it? Dennis:  It does.  It goes to the area of protecting, protecting your own life, your own heart; protecting your wife; and protecting your children and your family.  I believe, for a number of men today, Bob, I believe they are being called to protect their community.  They are being called to make a difference where they live, in their church, in their neighborhood, perhaps in a larger span of control in their community or state.  But I believe men are called to protect others who could be preyed upon by evil.   One quick quote here:  it's a familiar quote by Edmund Burke.  He said, “All that is necessary for evil to triumph is for good men to do nothing.”  I actually spent a good bit of time in one of the chapters of the book talking about how good men, really good men, can easily do nothing.  In fact, from my own life I wrote about some of the things that I wish I had pushed back against.   As a single man, I didn't push back against peer pressure, and I went with the flow.  I'm ashamed of the evil that I encouraged and participated in.  As a married man, early in our marriage I didn't protect my wife when we had six kids in ten years, for example -- all the demands and expectations of others who had no idea of the load she was carrying.  I should have protected her.   I remember one time when our daughters came downstairs ready for church, and one of our daughters was wearing a dress that was immodest.  Instead of telling her to go change I was wimpy.  I didn't engage her because I didn't want to experience the pain of the conflict, and so I was a good man who did nothing.  And then there was a time when a teacher at school really wasn't being very fair or kind to one of our children, and I allowed it to go on too long.  I finally did step up, but I should have stepped up sooner.   All of us make mistakes that we can look back on and have some regrets about, but the key is, as we look forward, how are you going to protect your family today?  How are you as a man going to take responsibility and not give evil a chance to triumph in your family? Bob:  You know, I'll never forget hearing an essay on the radio.  This was more than a decade ago.  The essayist is a woman named Frederica Mathewes-Green.  She was talking about her daughter working at a pizza restaurant, and her daughter was a delivery driver for the pizza restaurant.  And she said, “My daughter told me that one night at work an order came in and they read it out.  She was the next one to take out pizzas, and they read out, ‘Okay, here's your order.  It does to –‘and they read out the address.”  She said, “The guy standing next to me grabbed it out of my arms and he said, ‘I'll take that.  You're not going to that part of town.' “  And Frederica Mathewes-Green said, “You know, we live in a culture that talks about gender equality and gender neutrality, but,” she said, “everybody can resonate with the idea that there are parts of town that you don't let young women go to by themselves.  They go accompanied by someone who will protect them.”  This idea of men being the protectors, I think goes bone-deep.  I think it resonates in the hearts of men and in the hearts of women.  Dennis:  It does, and I'll give you an illustration from our own marriage and family recently.  We just had our 17th grandbaby born, a little girl, Alice Pearl, six pounds, four ounces.  We're excited to welcome Alice Pearl to the family.  The question was, was Barbara going to go visit our daughter and son-in-law and celebrate the birth of the baby, and was she going to do it alone, or was she going to do it with me?   My schedule was such that I had a good excuse not to go, and yet, as I stepped back, I was actually thinking along the lines of the story you just told, about the wrong part of town.  I just don't like the idea of my wife traveling by herself, and if I can travel with her and get the car and get the bags and get the hotel room and get there safely, that just seems more prudent, rather than allowing my wife to go by herself.   She's gone by herself on occasion.  This particular occasion I could have stayed home.  But I chose to go with her because I wanted to see my granddaughter for one thing, and my daughter, but I also wanted to protect my wife.   There are a number of principles that I write about in the book Stepping Up: A Call to Courageous Manhood that I just want to list here, Bob, just in terms of coaching men on how to protect their wives and their families.   The first one is protecting your marriage.  I don't meet with women alone for lunch.  I don't have lunch with any other woman other than my wife.  I don't travel alone in a car with a woman other than my wife.  I don't meet with women in my office unless the door is open, or there's a window there, clearly evident, where everybody can see what's taking place in there.   As a man, you have ways that you communicate to your wife that you're protecting and preserving your marriage and your relationship.  Some of these things might seem like small matters, but to our wives it builds thirty-foot thick walls that are a hundred feet high around your marriage relationship, and it lets her know that you're the man, you're taking responsibility for her, and you're going to protect your relationship. Bob:  So as men we need to take initiative to establish concrete ways that we protect our marriage.  What else does protecting look like for a man? Dennis:  Well, there's one more way, too, that I forgot about, Bob.  We have date nights, a standing date night on Sunday night during the child-bearing and child-rearing years of our marriage.  Now we're empty nesters, so we can have a date any night.  But we took the time to preserve and protect our marriage in the midst of raising kids.  A lot of our listeners are in the midst of some of the most challenging days they'll ever experience as couples.   I just encourage the dads listening; find a way to discover a babysitter.  If you want to give your wife a great gift some of your wives would – they'll go crazy.  They'll say, “You found a babysitter so we could get away, so we could talk, so we could have some time together?”  That's really important in terms of protecting your marriage.   When it comes to protecting your family and your children, one of the most exciting ways that we've come up with here at FamilyLife is Passport to Purity.  There are a number of families that are taking their 11-, 12-, 13-year-olds through a weekend getaway called Passport to Purity.   There's nothing better than a dad getting away with his son and listening to those CDs and talking about issues of peer pressure, of self-esteem, of who God is in the young man's life, of moral boundaries, and also talking about sex and how far you're going to go with a girl prior to marriage, and helping that young man establish spiritual and moral boundaries in his life.  A boy at the age of 10, 11, 12, 13 really needs a daddy to talk with him honestly and frankly about this, and doesn't need him to back out of his life and allow the world to educate him. Bob:  Well, and you're up against some pretty stiff competition as a dad, because – Dennis:  Tell me about it. Bob:  -- the peer group, the culture, the impulses of your child's heart and life. Dennis:  The media that has access to your child's life.  If there has ever, ever been a time for men, and I'm going to use an old, agricultural term here – I know that, but the imagery is good – Jesus used it.  If there's ever been a time for a man to have both hands on the plow, looking straight ahead, knowing where he's going and how he's doing, it's today, especially with his marriage and with his children.  Helping your sons grow up to be young men who understand the sex drive and what's about to happen to their bodies before it happens, so they're not caught off guard. Bob:  Right.  You've got to be alert, you've got to be in the game, you have to know what's coming, and you have to be involved.  And that's not just during the pre-adolescent years.  That's all through adolescence. Dennis:  Yes.  And Passport to Purity will give you a great weekend with your son.  It also is a great weekend for a mother-daughter.  But what it does, is it will establish a foundation of knowledge and experience with your son so that, from that point, as you go through 13, 14, 15 years of age, all the way through adolescence, you'll be able to revisit those themes with your son.  And you'll be able talk with them about a simple illustration of how close to the edge of the cliff are you going to go with the opposite sex, son? Bob:  Right.  Right. Dennis:  So when you say that, instantly he knows exactly what you're talking about, and you can re-engage with him.  Our sons need us to engage with them, and especially around issues like pornography, not asking if they've seen anything, but what have they seen?   If you have a child who is 13, I'm sorry to report to you, but more than likely they have been exposed to some kind of pornography.  I would much rather my son, at the age of 13, 14, or 15 share that he had seen it and what he had seen and talk with me about it, than bury it and screw the lid down tight and hide it and be confused by it, and never talk to me as a father or his mom about it.   I would much rather that he talk with me and have the conversation and get it out in the open so we can talk about it.  And we can talk about the enticement, and we can have a discussion like you find in Proverbs chapters 4, 5, 6, and 7, where the older father is advising and admonishing the young man about the harlot, the prostitute, the one who entices with her dress, her look, and her invitations. Bob:  What does it look like for a dad to be protecting his daughter through the adolescent years and beyond?   Dennis:  Well, I think I mentioned this earlier, but I think a Dad needs to interview his daughter's dates.  I said plural, didn't I?  They will have multiple dates, more than likely. Many of our listeners have heard me talk about this, how I interviewed, I don't know, somewhere around 30, 35 young men.  I actually wished I'd had a t-shirt made that said, “I survived Mr. Rainey's interview.”   (laughter) But, you know, Bob, young men today really need dads to engage them and expect them to treat their daughters with dignity and nobility.   I got an email from a dad who had ready my book, Interviewing Your Daughter's Date, and he had interviewed a young man, and he talked about what he wanted to be when he finished growing up and was in adulthood.  The young man said, “I might like to be a fireman.”  And the father said, “That's good.  That's good.”   They finished their conversation, and evidently the young man passed muster because he allowed his daughter to go on a date with this young man.  And when the young man arrived at the door to pick up the father's daughter, the father stepped forward with the daughter, and also with something unusual in his hands; he had a fire extinguisher.   (laughter) He sent the fire extinguisher with his daughter and the young man -- Bob:  You want to be a firefighter, here's a tool, son. Dennis:  -- on the date!  That's a true story.  Happened to one of our listeners and they wrote us to tell us about it.  Here's the point:  As dads, we need to engage life where it's happening with our kids.  One of the big areas is a relationship with the opposite sex.   I haven't written this book, because I haven't finished interviewing all the guys yet that I have to interview, but I also think that dads need to have some heart-to-heart conversations with the young men who come to ask for their daughter's hand in marriage.   I've told the young men who have come to me asking for my daughters' hands in marriage that they could ask for the hand, but they couldn't have it until they meet with me and have four conversations around issues I know they're going to face after they get married.   Now here's the point, Bob:  After they get married, these conversations are off limits unless the young man invites you in to have these conversations.  But until he gets the prize, as a father – Bob:  The door is wide open. Dennis:  -- I'm telling you, it's not only open, it is our responsibility as daddies to protect our daughters before these young men get the prize, because after they get the prize, they may not be quite as teachable from you as a father as they currently are. Bob:  Well, and of course we've got copies of your book, Interviewing Your Daughter's Date in our FamilyLife Today Resource Center.  And then Voddie Baucham wrote a book that's like the one you're talking about writing; he wrote a book called What He Must Be. . . If He Wants to Marry My Daughter, and we've got that in our FamilyLife Today Resource Center as well, so if our listeners are interested they can go online and get copies of those books.   But I think the big point you're making here is that there's a role that men play as protectors, and it's a part of what authentic, courageous, mature masculinity looks like.  And you cover that in the book that you've written called Stepping Up—A Call to Courageous Manhood, and I want to encourage our listeners to get a copy of that book this week.   In fact, if they can help us with a donation this week to support the ministry of FamilyLife Today, we'll send the book to them as a thank you gift.  All you have to do is go online at FamilyLifeToday.com and made a donation.   When you do, type the words “STEP UP” into the key code box on the online donation form, and we'll send a copy of Dennis' brand new book, Stepping Up—A Call to Courageous Manhood.  We'll send that out to you as a thank you gift for your donation.  Or, call 1-800-FLTODAY, make a donation over the phone, and again, ask for a copy of the book, Stepping Up, and we'll send it to you.   If you'd like to order multiple copies, those are available for sale.  You can find out more online or when you call us, but we want to make the book available this week to any of you who will help support the ministry.  We appreciate your financial support.  We are listener supported; without your donations we could not continue on this station and on our network of stations all across the country.  So thanks in advance for whatever you are able to do in supporting FamilyLife Today. And with that, we're going to wrap things up.  Hope you have a great weekend.  Hope you and your family are able to worship together this weekend.  And I hope you can join us on Monday.  Kay Arthur is going to be here, and we're going to talk about the problem of pain and about what the Bible has to say about it.  She has just written a new book called When the Hurt Runs Deep, and we'll visit with her on Monday.  Hope you can be here as well. I want to thank our engineer today, Keith Lynch, and our entire broadcast production team.  On behalf of our host, Dennis Rainey, I'm Bob Lepine.  We will see you back next time for another edition of FamilyLife Today.   FamilyLife Today is a production of FamilyLife of Little Rock, Arkansas.  Help for today.  Hope for tomorrow. We are so happy to provide these transcripts to you.  However, there is a cost to produce them for our website.  If you've benefited from the broadcast transcripts, would you consider donating today to help defray the costs?  2011 Copyright © FamilyLife.  All rights reserved.www.FamilyLife.com    

Dr. Lonny Shavelson is the founder of Bay Area End of Life Options, a medical practice in Northern California devoted to educating about medical aid in dying and supporting patients and families through this process. Contact Bay Area End of Life Options Transcript Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Please note there is some content that is explicit in this episode. Dr. Bob: Dr. Lonny Shavelson is the founder of Bay Area End of Life Options, a medical practice in Northern California, devoted to educating medical providers about medical aid and dying, and supporting patients and families through this process. As you'll soon discover, Dr. Shavelson is an intelligent, articulation and passionate physician, who has a huge heart and is committed to providing excellent care to people dealing with terminal illnesses. He and I are bonded by a similar commitment. We also share a bond in that we were both emergency physicians in the past. We've seen the standard way people are cared for at the end of life, which is often not very pretty, and often not aligned with how they've lived their life. As you'll hear in this interview, Dr. Shavelson has experienced his own brush with death, which has created far more understanding and empathy than he could've imagined. I hope you find this discussion as informative and interesting as I did. Well, Lonny, I've been looking forward to this conversation with you for quite some time. I saw it coming up on my calendar. I was excited and woke up today really energized to have this conversation and be able to explore deeply, what it's like for you to be a physician that's in the same realm as I am, in support of medical aid and dying. Thank you for taking the time to speak to me and my listeners today. Dr. Shavelson: You're really welcome, I'm glad to be here. Dr. Bob: Yeah. So, just maybe give me a little bit of ... Give all of us a little bit of background, as to how you came to be the physician with Bay Area End of Life Options. What was your journey leading up to that, and what made you decide to venture into this? Dr. Shavelson: Let's see if I can condense this a little bit. When my interest in going into medicine in general, as happens with many people who go into medicine, comes from a family history of dealing with illness. I think many people in medicine if you ask them this question, why you went in, they'll start off with the, "I want to help people," answer. And if you dig a little bit deeper, you'll find there was some illness in the family in their prior history. So mine, very specifically, was my mother had Crohn's Disease. It's an inflammatory disease of the bowel. And because of that disease, imagine having cramps and diarrhea all of your life every day and having multiple surgeries on your bowel to try to accommodate it and bowel obstructions and all that. She was a pretty miserable person, and also in retrospect, severely depressed. So when I was starting at the age of about 14, I became not only aware of the fact that my mother was suicidal, but she enrolled me in pacts for her death. Part of the reason that I was guided toward medical school was because of the, my mother sort of wanting to know that I would be available, not only to help her in her illness but also to help her die. Dr. Bob: Wow. Dr. Shavelson: So we used to have conversations around the dinner table about my mother's dying. And I thought that was the normal way people grew up. I didn't, you know ... You know, if you grow up in a certain way, you assume that that's the way it is. You don't have any other experience of any other childhood to compare it with. So I thought discussions about death and dying were what people talked about during dinner. Dr. Bob: Not me, it wasn't happening at my dinner table, I'll tell you that much. Dr. Shavelson: Yeah, now I realize that [inaudible 00:03:48] doing that. We didn't have football and baseball on the TV. We had sort of philosophical conversations about death and dying, including suicide. Dr. Bob: Wow. Dr. Shavelson: So my mother- Dr. Bob: We had the Dick Van Dyke show, and the Andy Griffith Show. Dr. Shavelson: Well, we did some of that too. It falls short to what it was. So anyway, I grew up with death and dying discussions, including the potential for suicide as a rational way out of an illness. That was one thing that guided me, certainly into medicine, and when I got into medicine, I kind of left that behind for a long time, realizing it was pathological. It wasn't reasonable, especially in my mother's case. She was severely depressed I was her son. She had asked me to help her kill herself a number of times, and I had turned that down. But in the end, I knew that if she was very sick, and if that was what she did, and if it was more reasonable that I would then help her. And this was way before anything like medical aid in dying or what was then called physician-assisted suicide, was even thought to be legal at any time in the future. We were back in the 1970s by the time I went to medical school. Anyways, so that led up to ... You know, I got into my medical career as an emergency medicine doctor. Over time, I developed a dual career as a journalist and a photographer, as well as a medical doctor. So I worked about half time at each and actually moved fairly advanced in journalism with writing some books, with working with NPR as a reporter. So my journalism career took off in the same way that my medical career did, pretty much advancing over time. And to cut this to the chase, in 1996, I wanted to explore this question about what was then called physician-assisted suicide more deeply on an official level. The reason was that Jack Kevorkian was starting his nonsense, killing patients. And I always change that to killing patients who weren't his patients. And I thought that that was not a very good model of what we could look at for helping people die in the United States. But it really struck me that there was a significant underground, where ... You know, and I know, Bob, that before anything was legalized, if somebody were close to death and were really suffering, we would turn up morphine drips, we would increase medications in such a way that we knew we were participating in aid in dying. But with a wink and a nod to the families saying, "Give him morphine once an hour," type of thing. Knowing that would bring on the death. Because the patient was having severe suffering and was nearly unconscious and just needed to be helped along. That, and the presence of the ... I was going to say [inaudible 00:06:38] presence of the AIDS community. People were dying of Autoimmune deficiency disease. And they were really actively participating, but in the underground, of hoarding medication. So if you had AIDS, you could easily tap into the AIDS community and get thousands of tablets of morphine or methadone. It wasn't hard to do, because people were hoarding their medications with the intent of using it themselves. And if they end up not needing it, then they would pass it on to this sort of medical bank where medications were stored. That was the beginning of an interest I had in the pharmacology because they had the pharmacology to really try to do this right. Whereas individuals in their homes and in darkened bedrooms were talking with their family about wanting to die and then taking all of their, let's say their hospice medications. That often did not work. Anyways, this led to a book I wrote, called A Chosen Death, in 1996. And it was called the Dying Confront Assisted Suicide. It was about this underground ... I found families and doctors and nurses, and various people who were participating in a very significant underground. Where they were helping people, who requested aid in dying. They were doing it without charting a note; they were doing it without keeping any record of what happened. But I was able to write the story of five different families as they progressed through this. And in 1996, A Chosen Death came out. And the conclusion was very, very simple. When you look at what I call dark bedroom suicides when you look at those dark bedroom suicides, hidden, and nobody could talk about them, there were so many things wrong. One was that often because of inexperience; the wrong people were taking the wrong medications at the wrong times for the wrong reasons. And then taking medications that didn't work and having disasters follow. It just was a terrible scene, actually. And my conclusion was, this is going to go on like ... Comparison with abortion is very strong, is that there were back-alley abortions, and we were having dark bedroom suicides. What's wrong with the back alley abortions is that they were terrible, they were not supervised, they were not done well. And they would continue no matter what. What's wrong with the dark bedroom suicides was the same. So I made a very strong, I think argument in the book for legalization. Based on the fact that making this illegal was not working, was creating a disaster for families at the most important parts of their loved one's lives. That started, my political involvement for about three, four years I stayed very politically involved as the supreme court was writing its decision. In 1998, the Supreme Court made a decision where all nine justices decided this was not a constitutional right. But that the states had the right to do this. So in other words, there's nothing in the constitution that says that legal medical aid in dying should exist. But there's also nothing that prohibits the states from doing it. So one by one, I watched the states Oregon, Washington, Montana. It took 22 years more after I wrote the book A Chosen Death before we got this all legalized in California. And then, to bring it up to the present, when the law was legalized, I thought the way of starting it up was terrible. There was not enough primary education happening. Doctors were confused about what it was. The people who were looking at it were like, medical risk advisors and hospitals, and lawyers in hospitals trying to figure out their policy. And nobody was looking at the clinical practice of how this would work. So I decided to start up a practice with the intent of a couple of things. One was that I would be available to patients who could not find another doctor to do medical aid in dying with them. So if a patient had a desire for medical aid in dying or at least a question about it, and they approached all of their physicians, and the physicians said, "No," for a variety of reasons ... And Bob, I'd like to talk to you more about that in a bit. But if they couldn't find another doctor, then I would become their doctor and help them with the physician aid in dying. And that started up in day one of the new law, on June 16, 2016, and has been going ever since. And has grown so much, the request for services from my practice Bay Area End of Life Options has grown so significantly that I had to take on another doctor. So I now have Linda Spengler working with me, another physician. And then we took on a wonderful nurse, Thelia De Wolf, who is a hospice nurse. And we sort of borrowed her permanently and brought her into our practice. So we have a practice of three people now. To date, we have taken over 800 requests for medical aid in dying from different patients across the state of California. And for various reasons, we sort of brought that down by referring patients to other doctors or talking to their doctors about participating. There are lots of ways we'd windle that number down. So right now, about 240 patients have been in our practice, where we follow them for a request for medical aid in dying. And to be clear, when somebody calls us for medical aid in dying, it doesn't mean that we just give them medical aid in dying. There's a long, evaluative process. We work with them about their palliative care, we work with them with their hospices. We talk to them about ways they may die, and that this is just one of the ways that they may die or choose to die. And what that's resulted in now, we stay at the bedside when a patient takes the medication. It's the hallmark of their practice. Is that we don't feel that this should be the responsibility of the patient or the family to be taking medications at such a difficult and anxious day, the day that somebody is about to die. And everybody's worried about it. And when we walk in the door, the worry just goes out the window and they're able to do what they should be doing, which is pay attention to their loved one who's dying. And pay attention to themselves and how they're reacting, instead of being the ones who are mixing up medications and worrying if it's right, and worrying how it's going to go. And they're all alone doing this medical procedure, with the patient. We have been at every one of the bedside deaths. We'd been, I'm sorry, at the bedside of every one of our deaths, which are now 114 deaths at the bedside. The advantage of that is that we've been able to get really good at this. We get a sense of the social aspect; we get a sense of the family aspects. We get as a sense for the need of how much palliative care, and how to talk with the patient about alternatives. They don't have to do medical aid and dying. But if they really do decide that they want medical aid in dying, we are there for them. And that's the fundamental part of our practice. The other thing that having such experience does is it lets us travel the state a lot. We get requests from all over, and we travel quite a bit in order to help patients. And every time we go to a place where there's no access, where the patients ask all of their doctors, and they couldn't find anyone. We would then talk to the doctors in that community and usually find two or three. So a great example is we found that we were having to go very far up north for us to Paradise, California, near Chico. It's a three-hour drive. We get tired doing three-hour drives and coming back. So we started looking around and beating the bushes, and finding docs in Chico who might be open to it. And we now have a group of three doctors in Chico who are very open to starting their ... To adding to their own practices, their family practitioners. And they are now going to add to their practices medical aid in dying. And we are going to train them. And soon, we will not have to go to that part of the state again. And that's the wonderful part of this. Is that we don't want to have this practice of medical aid in dying become centralized to a small practice like ours. We want many, many doctors around the state to be doing this. And slowly we're seeing that happen, where there are areas of Northern California where we no longer go because we know the doctors up there who will. Dr. Bob: And that's phenomenal. Just being able to expand the access for people. And of course ... First of all, thank you for sharing that background, and kind of expressing in such great detail what your practice entails, how you support patients. Thank you for doing the work. I know that it's not easy. It can be extremely challenging, emotionally, and taxing in many ways. Because I'm also doing a very similar style of practice. As much as it's challenging and taxing, it's also very gratifying, right. I know that you feel the same way. That there are people who are suffering and struggling, and they've been shut down by many physicians, and they're just so grateful to find someone who's willing to not just support them in going through the process, but truly support them. And truly support their families, and make sure that they have all their questions answered, that they know all the options. And that the fear of this is, if not completely removed, certainly lessened. Dr. Shavelson: Yeah. You know the most common, repeated expression I hear is about what you just talked about. Is about fear. Commonly when somebody's dying, they've never done that before. And so they're quite afraid, what does it feel like when I get that close? I mean, you may know you have your cancer and all that. You know what it feels like. But when you're that close to dying, you don't quite know. It's really frightening as to where do you go, and how does it work, and how much suffering is entailed in the process of dying. So I'll sit down with a patient for an hour or two. And we will talk about what I call the how you die conversation. And the thing that, the response that's most common, is that they will tell me, this is the first time that I'm not afraid of how I may die. That nobody has explained that to them, and given them all of the options, including medical aid in dying. And really explain, this is how the process works. You may slip into a coma, and be quite comfortable. Or you may have an anginal agitation. Or you may be short of breath, and that can be treated symptomatically, but not completely. And we go through the how you may die conversation, and then every individual. And then they take a deep breath, and say, "My god, this is the first time since my diagnosis that I am not sitting here afraid of how I die. I know that I control it now." And that is the most moving, and tearful moment that I've ever experienced. Dr. Bob: Yeah, what a beautiful thing that is. And it's kind of crazy to think about, but I have that same experience over and over again. No one has told me, no one has talked to me about this. No one has actually talked to me about my death. All they talk about is how they can palliate me, and how they can comfort me and everything leading up to it. Dr. Shavelson: That's right. Dr. Bob: But even hospice folks. For some reason, there's just this reluctance. It's a fear on the part of the providers to actually engage in that conversation. Maybe it's their own fear; maybe they're afraid they're going to upset people. But it's just the opposite. Dr. Shavelson: Yeah. You know, I think Bob, that in a lot of ways, the entity of the legalization of medical aid in dying, has made it so, that before you offer somebody such a serious option, you have a real conversation with them. It's kind of almost built into the law, though I don't think that's necessarily the reason. The law really says that we have to explain all alternatives before we can accept a patient for medical aid in dying. And that's not what drives my conversations with the patients. What drives my conversations with he patients, is that they really should know what's up in their future, and how they're going to die. But that conversation about, how will dying happen, is oddly enough in legislature for the first time. And I think that's a healthy thing. There are many bad things about this law, but there are some good things about this law. And as it sounds like, your practice sounds very similar to mine, in that we spend time because we are not going to have this decision taken lightly, to take medications to end your life. We don't want that to be a casual decision. And therefore, we're going to have a really in-depth and truthful conversation with our patients. Dr. Bob: Right. And really, by setting up our practices the way that we have, it really facilitates that. I understand the limitations that a lot of providers have, a lot of physicians. They don't have the time, or it's very difficult to make the time to have the depth of conversation that is required to work through all of these different aspects of life and death. There have been a number of occasions where I have been asked to come and speak with someone who's requesting support through aid and dying. And after exploring all of the things that are leading up to it, and their reasoning, and what they're going through, they've actually made the decision to not request medical aid in dying. But to choose a different route, which in several cases, has meant bringing things into their life which will enhance the quality of their life. To try, some of the integrative therapies that we offer. They'll bring in a music therapist to do some legacy work. They'll bring in exercise, or physical therapist to provide them a little bit more human touch and connection. The conversations that sometimes occur unexpectedly have been so meaningful and profound. And then they may come back, in another month or two, or may not. But I think the opportunity to explore this option, for many people, has allowed them to look at things in a different light. And I think as you've experienced as well, sometimes people just want the option available to them just in case. They have a clearly terminal illness. They know what's coming in their future. But they're not in the point where they're ready to check out. But once they have this available to them, they have such a dramatic shift. And part of it is- Dr. Shavelson: It's a shift in thinking and feeling. They become comfortable to explore. I'm right with you, is that what happens sometimes when you tell them that medical aid in dying is available when I sit at the bedside and I hold somebody's hand, and say, "It's okay. We're here if you want that we will do that." And agree with them, which is the first time they've had agreement rather than battles about it. And I say, "It's okay if you want to do medical aid in dying, I'm here. I will do that if you get to the point where you're suffering enough." And that allows them to go back into treatment. I'll give you a very specific example we had just recently. We had a 58-year-old guy with lymphoma mass in his chest, who was quite uncomfortable from it, that turned out to be cancer in a lymphoma, which is quite treatable. But the treatment takes chemotherapy and radiation, and he had seen the path that some people with chemotherapy or therapy and radiation go. And it's really suffering and uncomfortable for some people. So he turned it down. He said, "Okay, I'm deciding not to have that treatment." They told him it was still treatable; they told him he could live with it. But he decided, no I'm not going to do all those nasty chemicals and the radiation. And he was sent home to hospice because that time he was getting sicker. And then it took him a month to get somebody to agree that they would help him in medical aid in dying, which was what he was asking for. So he was in a hospice that didn't participate, and the family found my practice on the web. I came down to see him. And he ... You know, we had the long conversation about how you die, and why he wanted to reject treatment. And he was just fundamentally scared of dying, and he wanted not to have these sort of dangerous, and difficult treatments on the way that would make him even more uncomfortable and give him more agony. He just didn't get it. So, I agreed. I said, "Okay. You can, if you want, have medical aid in dying. We will be there if you're suffering. And it's not there yet, but we will be there if you're suffering in any way, shape or form gets too bad that you want medical aid in dying. We will be there for you. And oddly enough, he turned back around, decided to go back and have chemotherapy and radiation. He knew that if the chemotherapy and radiation got so bad for him, he could turn to us and have medical aid in dying. He knew if he's dying eventually got so bad. So he went back, and he had chemotherapy and radiation, and lived for another year and a half as a result of that decision, always knowing that he had the ability, if things got so bad, to have medical aid in dying. That we would help him die. And then it took a year and a half, and then three months after that when he went back into hospice after the treatment stopped working it was another three months before he finally got to the point of saying, "I'm now uncomfortable enough." And we helped him to die probably about 18 months after his initial diagnosis when he was dying within weeks when we first met him. So these turnarounds can be very dramatic by just saying, "If things happen that are bad, we'll be there for you." We actually have two patients now on the transplant list. One for a bone marrow transplant, and one for a liver transplant, who are keeping us just sort of in the sideline. Dr. Bob: Yeah, in the wings. Dr. Shavelson: Where they're, in case ... The bone marrow transplant especially, because if a bone marrow transplant fails, it can fail spectacularly. So he's starting the bone marrow transplant only because he knows that if things really go down fast, if he gets very, very sick very quickly during the transplant process, that we will be there to help him die. And that's allowing him to move forward with the transplant. I think those are phenomenal stories. They're not the typical death that we do, but they happen often enough, that I can tell you taking away the fear of death allows you to really push forward with your life. Dr. Bob: And that happens from the very first conversation, right. And it's so profound; it's palpable. It's palpable when you walk ... And sometimes it happens from the first phone call when they know that you're going to be coming out to meet with them. There's already this sense of, oh my goodness; someone is on my side. They're willing to hear me. It's been ... There's been so many conversations that have been so touching. And it affects not just the individual, but their entire family. Dr. Shavelson: Of course. Dr. Bob: You know, one of the things that we talked about, and I think you wanted to come back to this as well, was why physicians say, "No." Why they're ... So there are two parts to this. One is, what's going on, why are physicians reluctant or unable to provide support? And then the other part of that, is what's the danger of having more physicians participating, who haven't gone through a training process, or who don't have the experience that people like us have. Dr. Shavelson: Yeah, you hit this on the nail. This is exactly the dilemma of how to deal with the access problem. So let me take that on if I can. The major problem we're having in California now is lack of access for patients who want medical aid in dying. There just aren't enough doctors participating, in order to do this. And I think when you look at the data, and everybody says well if you look at California in 2017, there are only 376 deaths from medical aid in dying. It's a tiny number relative to the total number of deaths. My answer to that is that's not because so few people want medical aid in dying. It's because so few people can access medical aid in dying. If you really wanted to do a survey, you have to find how many people have requested medical aid in dying, and then were turned down and just couldn't find anybody else. And I think that's a huge number. So it's a problem of supply, not demand. The demand for medical access in dying ... Medical aid in dying, I think is quite significant. The supply is not that high. So let's get into that. There is the most common reason that I hear that a doctor says to a patient. And these patients relay these conversations to us. They'll say, "I called my doctor up, and he said you know what, I understand your position, but I don't know how to do this. I have no experience in it. It's not that I'm morally opposed. In fact, if I knew I could do it, I'd be glad to help you. But there's been no training; there's been nothing that I know about it. In fact, you're my first patient asking for it." Is really common. And so, I don't know, and I'm not comfortable doing a procedure I've never been trained in. I get that comment from doctors, more commonly than I get that the doctor is morally opposed. So many, many, many patients tell me about their doctors who say, "Yeah, I understand what you want, but I can't do it because I've never been trained." Doctors, as a rule, like to do things they've been trained in and don't like to do things they haven't been trained in. And this law never incorporated anything about training. Bob and I can tell this audience, that you don't want to do this without knowing what you're doing. We've heard some strange stories about doctors using the wrong medicines because nobody told them what to do. And they sort of thought, well this is logical. I've got a hundred tablets of Ativan here; I'll just give them that. And that leads to a potential disaster because Ativan will not bring on death. It will bring on a deep sleep for a long time, but you will not die. So anyways, mistakes happen. The answer of that, from my point of view of practice, is that we have a policy where any doctor that says that I don't know how to do this, but I don't mind doing it, we'll call them up. And we'll say, "Can we help you through the process?" And we have done that with a number of doctors who said, "Wow, you do that?" And we don't charge a fee for it. We will just talk them through the process of what we've learned, and how this works. That could be the minimal amount of training that somebody needs. And at times, we'll do this thing where I become the attending physician for that patient. The doctor who was hesitant becomes the consulting physician, which is just the confirm diagnosis and prognosis and mental capacity. So that doctor basically sits there and watches while I help the patient to die, and watches how we do the paperwork. And watches how we write the prescriptions and what the pharmacology is. And then the next time, we'll do it again together, but we'll switch roles. And that doctor will be the attending and controlling physician who supervises the process, and I'll be the consulting physician. And so we switch roles, and we've done two cases together. And then after that, they're on their own. They've learned. And so, I have found that if one by one, we can train doctors who are interested in doing this, and then have the experience. I think you and I both know this is the average doctor in the United States probably has maybe five to 10 of their patients die in a year. So if you think about that, if maybe one out of every will ... Make a very high number, let's say one out of every 500 people who dies wants medical aid in dying, that means the average doctor in the United States who sees five to ten patients a year, will only have maybe one request for medical aid in dying every three to four years. And in my opinion, that's not enough to get good at what you're doing. If a doctor does one medical procedure every three or five years, they never ever have enough patients to really get good at it. And then that brings on the debate of who should be doing this. I can't say I have the answer for that. I think that patients who have a lot of ... I'm sorry, doctors who have a lot of patients who die, like oncologists, like maybe ALS doctors. They certainly would have enough patients die in a year, that they could get pretty good at doing this and they would know what they're doing. Mostly for me, I believe it should be hospice doctors. Because they're the doctors who see the most patients die of anybody in the country, and they're the best at seeing people die. They have access to nursing care; they have access to home visits, which are crucial. Because these patients are sick, and they can't get to their doctor's office for help. So I actually think this should be incorporated into the hospice model as one of the things that happens if you go into hospice you can get wonderful palliative care. You can get wonderful social workers, and chaplains. And if you want medical aid in dying, that's just one of the things that hospices offer. That hospice offers. And that's the ideal. We now have, Bob you've got a hospice in San Diego, I know, where there's a doctor who's the attending physician. There's your medical practice which models that. And I know that we have three hospices up here, where the hospice just if they get a request for medical aid in dying, they take care of it. It's part of hospice care. So that's kind of where I go. I actually think, in some ways, it should be a specialty care. Because it's much more complicated than most doctors think it is. It's not as simple as writing a prescription, and you're done. Dr. Bob: Right. And that's been my concern. And I've heard about some stories ... And at the beginning of our experience, we discovered some things that we weren't aware of. It was a learning process, and we discovered that different counties, medical examiners approach medical aid in dying differently. Certainly, at the beginning, they were unfamiliar with it. And there were some situations that occurred in patients' homes that were very traumatic for families when the police showed up at 2:00 am in the morning and asked a whole bunch of questions because they just weren't prepared and familiar. Different counties have different rules regarding the involvement of the medical examiner. Different hospices have different approaches. There are so many nuances that, if you're just doing this once in a while, you may actually be doing the patient and family a great disservice, if you're not aware of these nuances. So I think as you've been doing, we've also been trying to guide and train some of the physicians who've expressed a willingness. One of the things that I love is when I have a patient who tells me ... Who comes to me, because they want this to be done properly. And they know that they can trust us, and will get very intimately involved and provide a high level of support throughout the process. And they tell me that they don't know if their doctor's willing to be the consulting physician. Or to be involved in any way. They're not even comfortable necessarily approaching it. And we've had, as I'm sure you've done, we've had the opportunity to call and speak with these physicians. And help them understand more about the process. Help them understand what involved to be the attending physician, what it would involve to be the consulting physician, and to offer that support and to try to, I guess in a sense, convert. Because these are people, who may be open to it. They're not morally opposed; they don't have a religious opposition. They just aren't familiar. Dr. Shavelson: That's right, that's right. And I think convert is the right word. Dr. Bob: I think that's exciting for me when I get to speak to another physician and help them understand what the process is, and then become a resource for them, whether they're willing to take it on and receive guidance and training and make this a part of their practice. Or just know that there's a resource, there's someone else to reach out to when somebody does bring up this possibility to them. Dr. Shavelson: Right. You know, I think guys like me and you, we become ambassadors. Dr. Bob: Exactly. Dr. Shavelson: And that's a significant part of my practice, and I love it. The things that, to move this to a very positive note if I may. When I started, it was disastrous. There was just an overwhelming need, and a lack of response because nobody knew what they were doing. When you look at the beginning of when this started up, it was hospices we're against, and everybody I talked to said we don't know how to do this. So we don't agree with it. And over time, what's wonderful to watch, is how patients have been the leading force in making this expand and work and get better every single year. And you see what I've seen with our hospices in Northern California. Is as they've started getting patient requests, they couldn't just keep saying, "No." Hospices are fundamentally a loving and caring and responsive organization. And with so many patients asking for help with medical aid in dying or the way I phrase it better, to consider medical aid in dying, the hospices had to do something. And what we see now, is that something like 60 to 80 percent of the hospices in my area have now come over and say, "Yes, of course, we respond to requests from medical aid and dying. We'll do referrals." Or we'll be the consulting doctors. Or we'll refer to your practice if we can't find that their regular doctors do that. And so I have watched, number one, in terms of hospice care over two years, watched most of the hospices completely change their attitude, because of patients' desires and the need of the hospice to respond to the patient's autonomy requests in making their own decisions. And that's been very gratifying to watch. As well geographically, I've now seen that there are areas of the state that we no longer have to go to in Northern California, because they have enough doctors in that area, and doctors that we know that if we get a call from Chico, we now say, "Oh, don't use us. Call Doctor so-and-so. He's in your area; he can be close to you. You'll probably even know him." And most of the time, they actually know the doc. Dr. Bob: Because smaller communities than ... Yeah. Dr. Shavelson: Exactly. Exactly. So I'm gratified by the amount of progress we've made, and I'm shocked by how much more there is still to go. Dr. Bob: Yeah. And you are a phenomenal ambassador. Every time I hear you speak, and it's been several times now in various capacities, I'm inspired, I'm grateful that I get to be part of this world, alongside people like you. Dr. Shavelson: Thank you. Dr. Bob: No, absolutely. And Lonny, you actually not long ago went through your own medical challenge. And I'd be interested to know ... I'd like you to share a little bit about that. I know you indicated that you'd be willing to do that. And I'm also interested in how the awareness that this was potentially, if it ever came to that, available to you. How that impacted you. Did you see it from a different perspective? Having been going through your own cancer journey? Dr. Shavelson: Yeah, well. So just a year ago, I'm actually one year out of the end of my treatment now. So I had a cancer development. An [inaudible 00:40:33] cancer that this thing was located at the back of my tongue, not where I felt it. I found it because I had a swollen gland in my neck, and realized that it was unusual to have that gland in that space, even though it was tiny. So I got it quite early because I went immediately to the hospital. And being a doc, I can order up my own tests. Silly of me, but that's the way I work. Walked in, and had the interventional radiologist that I knew to do a biopsy, get a piece of this thing. And it turned out to be a squeamish cell cancer that was metastasis from my tongue. So I had a bunch of lymph nodes involved, and a primary cancer in my tongue. And took a rather, I went down to Stanford and had a rather hellish treatment, to put it mildly. I don't want to scare people away from good treatment, but we did a significant amount of radiation and chemotherapy to knock this thing down. And it did, it worked. But during the six months of treatment, I became quite delusional, paranoid. I just got very, very, very sick. It was an awful experience. Nonetheless, at the end of that experience and a very slow recovery. It's surprising how long it takes to recover from that. I'm now well, and back to full speed and have a couple of long-term side effects from the chemotherapy, like a dry mouth and some toe numbness. But otherwise, I'm healthy and full strength and all that. And it's now a year and a half after full diagnosis. And a year after the end of the last radiation treatment. So how did that affect me? One, it scared the shit out of me. It made me feel vulnerable. I had been ... This was diagnosed when I was 65 years old, thank god for Medicare. It was two months after I crossed the Medicare threshold. I was covered for all of this; it would've been a disaster even with my good health insurance. But it took away my feeling of having had a life of lack of fear. Just felt like things were going well in my life always. And suddenly it became, I'm the cancer patient. So the vulnerability persists. And the feeling that bad news can happen at any time. You know, it's not like I didn't know that. I've been a ... I was an emergency doctor for 30 years before I started that as I think you were, Bob. We don't have to be taught that bad things can happen quickly. But they hadn't happened to me, and I was feeling pretty good. And the feeling of vulnerability persists. The feeling of medical aid in dying being available, well I've been a pill hoarder for the potentiality for this since I was probably 22. Again, I grew up in a family that confronted death very early, and we all had our hoard of pills in case anything would happen. So there's no news in that for me. I like the idea that it's freely available, and that I won't have to do it myself. But in terms of empathy, I think I gained a whole lot about being with patients and kind of knowing the information they want. And how truthful and calm the information has to be delivered, and it's not like I didn't know a lot of this beforehand. I kind of like to think I was a fairly empathetic doctor before this. But the tone is different. And I let all my patients know that I just came through this cancer experience. It creates this different bond with us. And I think that's important. It's a new tool. For me to talk to them from a patient perspective, as well as from their perspective, from the doctor perspective. Dr. Bob: Yeah. I can just see that being so incredibly valuable, and such a point of connection with the patients. Because that's what they want. I think in many cases, that's what patients, that's what people had been lacking, and are looking for in the relationship with a healthcare provider. Is just this sense of connection and understanding. And so knowing that you went through an experience, where you stared at your mortality and feared for what the outcome was going to be, suffered through the treatments. I think that was very comforting and probably endearing. Having lost both my parents in a short time a few years ago to cancer, gave me a different degree in insight and empathy to what family members are going through. Which has really been a gift. But having not faced the illness from a personal perspective, I think that adds something to your toolbox. There's no replacement for that. There's no way to substitute for that. I know that given the choice, you probably wouldn't' have chosen it, to go through that. But as it turns out, it's probably quite a gift for you. Dr. Shavelson: Yeah. You know, the other part of that interestingly, and I haven't thought this through as I probably should, is that the level of suffering that I went through was pretty intense. It wasn't a fun treatment, to put it mildly. But I had the very, very high rate ... there was an 85 percent chance of cure with this particular cancer that I had. So I had in my mind at least through the delusions that I was having in the really bad side effects of the chemotherapy hit my mind very badly. But even at all times, I knew that I was going to have a continued life. An 85 percent chance was pretty high. So there was a real motivation to go through that suffering. That, I want to make very, very clear. When people use the term assisted suicide, let me differentiate assisted suicide from physician aid in dying. Had I chosen during my treatment when the suffering was worse, was most severe, to do a medical aid in dying, it would've been a suicide. And the reason is because I consider a suicide to be when you end your life and you can still have the potential to live. So when somebody has the potential to keep living, and then chooses and decides to end their life, that's a suicide. However, when patients are having the kind of suffering that I was having, and they know that that's the route to dying. That they're close to death. And so they're having the same symptoms that I was having, severe pain. My pain was so severe that I was on a really high dose of opiates. I couldn't swallow, it was a terrible thing. My throat was closing up; it was hard to breathe. And yet I knew that I could live if I could just get through it. The patients who are at the end of their lives, having symptoms like that, severe pain, hard to breathe. Existential angst. Those patients don't know what I knew, which is that I could go on and live. They know that they're about to die. And so the value of going through the suffering is diminished for them. There is no value because their death is imminent. Those are not suicides. Those are decisions about how they're going to die, because they will die soon, no matter how they do it. That's a very different circumstance. I've come to understand that there's a level of suffering you endure if you know the outcome is good. That's very different than the level of suffering you endure if you know the outcome is not good. And those are really different things. Dr. Bob: And that's a fascinating conversation. And actually, I think I'd like to have a follow-up call podcast with you. Because this is something, I don't think we can cover in the next few minutes that we have. But those nuances, those situations where a person could actually go on living if they make certain choices. That they may not be willing to make, because they understand the impact on the quality of life. And I speak predominately of neurological conditions. Circumstances where people are experiencing dramatic suffering. The actual timing and course of their illness may not be quite as clear as with an aggressive cancer. But the suffering is different. Those are the cases that really require so much exploration, and a lot of time and ... They're difficult. Nothing simple about them. Dr. Shavelson: Yeah, you're talking probably mostly about the neurodegenerative diseases. ALS, multiple sclerosis, multiple strokes. Those are ... Those neurologic diseases, when I walk into any other room for those patients, I take a really deep breath, because they are not easy. And you know you're going to have to spend a lot of time with that patient, trying to figure out what's going on. What's the prognosis. Cancer's easy. Neurologic diseases are hard. Dr. Bob: And those people are looking for support, they're looking for resolution. And a lot of times, it's really ... It's not because they are trying to immediately get out of their suffering and their struggle. They know that things will change dramatically. And they're also always terrified that they will lose the opportunity if they take too long. And I think that's not just within our logic conditions. But there are so many nuances to this. I think I've taken enough of your day. This has been fascinating. It's really wonderful to listen. You're so articulation and obviously passionate about this because you know it's the right thing. But you're also responsible. You're taking a very responsible approach to it, recognizing that it's a delicate issue. It's a controversial issue. We know what our stance is, we would never want to try to force our position on anybody else. But I really, I feel a real kinship, and there's a clearer I don't know, a brotherhood of willingness to help people reduce their suffering even if it's not the easy thing to do. Dr. Shavelson: Yeah, and it's wonderful to have you as a colleague, much appreciated. Dr. Bob: Well Lonny, thank you. This has been wonderful. I'm looking forward to listening to it again, and I'm sure that there's a lot of people who will get some great value out of listening to it as well. Keep up the great work, and we'll be back in touch soon. Dr. Shavelson: Thanks, Bob. Keep doing this.  

Dr. Michael Fratkin founded ResolutionCare to insure capable and soulful care of everyone, everywhere as they approach the completion of life. Learn how telehealth applications are bringing a greater quality of living and dying to those in need. Contact ResolutionCare website Transcript Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Please note there is some content that is explicit in this episode. Dr. Bob: Dr. Michael Fratkin is the President and Founder of Resolution Care. Dr. Fratkin is a father, a husband, a brother, a son, a physician, and a very dear friend of mine. Dr. Fratkin is dedicated to the well-being of his community and the community of all human beings. Since completing his training, he's made his home and built his family in rural Northern California. He's served his community as a primary care physician in the community health system, as a medical director of the local hospice, as a leader in the community hospital medical staff, and has been a transformative voice for improving the experience for people facing the end of life. At a time of great demographic and cultural change in our society, Dr. Fratkin has created Resolution Care to ensure capable and soulful care of everyone, everywhere, as they approach the completion of their life. Resolution Care is leveraging partnerships with existing healthcare providers and payers to provide telehealth services that bring a greater quality of life and greater quality of dying. The palliative care team at Resolution Care openly shares their expertise and mentorship so that people can receive the care they need, where they live, and on their own terms. In this podcast interview, Dr. Fratkin shares his passion and his intimate experience as a provider of care. He's innovative; he's creative, he's dedicated beyond what I've experienced with just about anybody else who I've communicated with about palliative care and end-of-life care. I think you're gonna find this podcast to be incredibly informative and really interesting. Okay, Michael, thank you so much for taking time out of your day. I know you've got lots of irons in the fire and lots of people vying for your attention. So I really appreciate having time to connect with you. Yeah. You know, it's interesting. I always enjoy talking with you. We connect sporadically, not as much as either of us would probably want, but we have been pretty consistent in finding times to connect and catch each other up on what's happening with our lives and our different enterprises. And what's interesting is, after our conversations, I always think to myself, "I wish other people could have heard that. I wish other people had a chance to listen in and hear what we're developing, and sort of the passion that comes out in these conversations." They're so informative, for me, and I find it so inspiring to hear what you're doing and the service that you're providing and creating. So today we have that opportunity so that people are going to be able to listen in on our conversation. In the introduction, I shared a bit about what you're doing, who you are, but I'd like to have you just do a little synopsis of what Resolution Care is doing currently, where it started from its humble beginnings, and what your vision is for where this is heading. Dr. Fratkin: I'm a dad, I'm a husband, I'm a brother, I'm a son, I'm a whole lot of stuff. But I'm also what's called a palliative care doctor. And your group of listeners probably know a little bit about what that is, but the way that I describe it for people is that there are really three central elements. That number one, we don't take care of any patients. We support people as they find their way through serious illness. We support people with a team; we support their families. Our team includes nurses, doctors, social workers, chaplains, nurse practitioners, community health workers, and all the people that they don't necessarily see, but that are just as important to creating a container for our care, the back office, and operational people. So the first principle is, is that we are a person-centered, not a patient-centered, but a person-centered initiative. And that those persons, the reason I distinguish it ... It's not just the patients or their families, but the people providing the care that are centrally important to everything that we do. And then we build out from there. So the first thing is, we're a person-centered organization, using a team to accompany people with serious illness as they navigate it, right? Dr. Bob: I love it. Dr. Fratkin: So the second thing that we do is that we're really damn good at managing symptoms. Our team has quite a bag of tricks around the treatment of pain and nausea, breathlessness, and various other physical manifestations of illness. And we know how to use that bag of tricks. So symptom control is the second thing. And the third thing is, we help people and their families to navigate what is a completely dysfunctional, fucked up if you don't mind me saying so- Dr. Bob: Let's call that like it is. Dr. Fratkin: Of fragments and silos and conflicting interests, and stakes held. We help people navigate, somewhat, through the complications of their illness, but more so, we recognize that people are trying to make their way through a human experience, not a medical one. And so, we help them navigate through that, bringing the personhood that we are to accompany them with the wisdom, skills, and shortcuts and strategies that we know about navigating. So it's person-centered around the people we care for and us as well. We matter, too. It's impeccable symptom control, and it's navigational assistance. And really tough times of life in a really complicated health care system. So Resolution Care does that. And we use some technology tricks, video conferencing, all of our care is based in the home. And that's that. But I think I also wanna tell you about how I got here and why. Dr. Bob: Please do. Dr. Fratkin: So I came to far Northern California, Humboldt County, in 1996 and joined a community clinic environment as the only internist in a five-clinic system. And my job was to take on all the patient V patients and all the complicated conditions that provided kind of complex case management approach for the heavy hitters, the outliers, the hot spotters. They're called lots of things now, but they were just languishing without the attention they needed when I showed up in town. And for six years, I took the hardest cases in the system, and helped with diagnosis and treatment planning, and burned out rather quickly, because I didn't have a team. I then sort of shifted my attention to my deep connection with hospice work and became a hospice medical director, where I did have a team. But I also had a very constraining box around me, a structure of hospice defined by the Medicare benefit that was limiting our ability to do what made sense, rather than meeting all of the regulation and compliance that continues to accumulate in the hospice model of care. And I burned out again. And then, I did some hospital work. When I started, I was seeing 9-12 people in a day, and I really enjoyed being at the point of the sphere where people were sick enough to be hospitalized and to attend to them both with good medicine, as well as a respect, and frankly, love in the face of what they're going through. And that was great until they started to push me to see 15 or 18. And now, it's 22 patients in a 12-hour shift. And I burned out again. And all the while, paying attention to the rising credibility and relevance of the palliative care movement. So I became first certificated in 2000, and board-certified a few years after that, in palliative care. In 2007, I worked with the hospital to launch a guided care consultation service in the hospital. And as soon as I got started doing that, there was almost immediately, four or five times as many people as I could care for. And I wasn't able to scare up the resources in the hospital to build out a team. So for a period of years, I wrote business plans, I went to committee meetings, I tried to advocate for greater resources to do this good work correctly, and failed to do that. So in 2014, I had had it. Exasperated, fatigued, burned out, I guess for the fourth or fifth time. God knows I can't keep track. I was looking for a job. I figured I couldn't stay here in this beautiful community, because I couldn't figure out how to get a sustainable job with a team that builds capacity over time. And so, I looked for work. And as you know, Bob, a palliative care doctor these days doesn't have to go too far to get too many interviews. I had three interviews in three weeks in the Bay area, and on the way to the Bay area. And they offered me three jobs, quickly, were better resourced, better compensated, more controlled work hours, but none of them were where I lived, where I made my home, where my kids were born in my house. I live on this five-acre piece of redwood forest. My kids were born there. My dogs and cats are buried in the yard. And I didn't wanna leave. So come around spring of 2014, I started to think about maybe there's a way to build capacity, build a team, and share what I know to others so that they could make that work for the people they're caring for. And so, the three ideas were video conferencing, Project Echo, which we could talk about later, it's a telementoring structure that allows a specialist to share information to primary care providers, et cetera. We can talk about that later if you want. And then the third thing was crowdfunding. So in November 1st or 2nd in 2014, we launched an Indiegogo campaign and based on all of my relationships in the community and people's trust in my work, we were able to raise $140,000 in a little over a month. And in January 2015, myself and one other person walked into a donated office space and turned on the lights. Dr. Bob: What a great story, and a great confluence of ... And you being true to your vision, being true to yourself, to what you knew was the absolute right way to practice the ... And you took a risk, right? And you continue every day, taking a risk. I know it. We've had these conversations. I'm trying to remember when we first connected because I've watched this thing go from birth to flourishing. And flourishing may not mean the same thing to you that it does to me, because I know your vision is grander. Dr. Fratkin: Well I know where we met. We met around ... There's a group in San Diego of one old-timer, one mid-timer, but some folks that have been inspired for more comprehensive cancer care in the community for a long time. A fellow by the name of Dan Vicario and the dear, dear friend of mine. I call him my grand brother, Paul Brenner, a psychologist with a deep connection. A psychologist and physician with deep connections to really thoughtful and complete approach to people with serious illness. And it was through them that they connected me to you. Dr. Bob: Right. And I remember that part very clearly. And I've had the honor and the privilege of collaborating on patients with both of them. And it is really; it's magical to be part of that with all of their combined years of wisdom and their just beautiful energy. But I'm trying to remember the stage that you were at. It was probably early on, and- Dr. Fratkin: It was probably in 2015. And without getting too wonkish about enterprise development so that we can get to the topic at hand, 2015 was the year of getting rolling and getting the team. And we did that. By September, we had a nurse, a social worker, chaplain, and office staff, as well as a little bit of a head of steam, with a group of patients. 2016, we really started to grow. And 2017, we continued to grow and sort of learned how to be a business that was sustainable. And coming into 2018, I'll just tell you today, Resolution Care network is tending to about 164 people in their homes, from the Oregon border to the north, the Pacific Ocean to the west, all the way to the ... I guess it's the Idaho/Nevada border to the east, south, pretty much to the Bay area with a couple of other folks a little bit further south. We've got 29 employees. We have contracts with four health plans. And we're making an impact with this model of care that we're developing. Yeah. Dr. Bob: That's beautiful. And of those 164 current patients, how many of those are receiving physical ... Are you able to get to visit physically, versus doing it entirely through video conferencing? Dr. Fratkin: It's variable. The key element is, is we really do what makes sense. So if a person lives down the street, it makes sense just to drop in and see them and sit on their couch and eat their cookies and chat with them that way. If they live 150 miles away from HQ, we're much more likely to engage with them by video conference. And it's really ... That's kind of what we built into the model. It's a hybrid model, both boots-on-the-ground, face-to-face encounters, with teleconferencing or video conferencing. And we do that in a really nimble fashion so that there are some people who really can't wrap their head around it. And if they're close enough, we provide them with a more traditional home care model. We have people who are right down the street who are very comfortable, in fact, prefer not having somebody knock on the door and walk into their house, but prefer to control the framework of the encounter. And then, different specialties. For my fellow providers and me, we're probably in the 85-90% video conferencing channel. Our nurses are probably in the 50-60% of their direct encounters are done by video. Our community health workers, the other end of the polarity, do very little video conferencing, because that's kind of what their value proposition is, is to be right there in the home with time and engagement to suss out what's needed. Our community health workers extend the reach of our doctors, our nurses, our social workers, and our chaplains. And they're given a lot of room to figure out what makes sense for each person and their family. So it's a variable ratio of boots-on-the-ground to remote engagement. Dr. Bob: Right. And what's cool about it is each situation is unique, and it probably changes over time as well. And I think it's fascinating; the different disciplines have the option of doing it whichever way makes the most sense for the provider as well as for the patient and family. Dr. Fratkin: For sure. At an organizational level for organization people who might be listening, it makes such great sense to use the technologies to eliminate the inefficiencies of travel. What's interesting ... I think we've talked about this before, but when I started to do initial consultations with people, first encounters to carry the arc of ... Oh, there are 8 or 10 elements that I've gotten accustomed to, to feel complete within an initial encounter. When I did it in a clinic setting, or at home, it was a 90 to 120-minute encounter, easily, and really exhausting. But when I started doing those same initial encounters by video conferencing, over and over and over again, they came to a place of completion in about half the time. Dr. Bob: Why is that? Dr. Fratkin: I think it's because we are primates. I think that when you walk into a person's home, there's a whole lot of social primate behavior. There's a whole lot of framing that includes so much more than just the relational engagement, one-on-one, with another person. There's the environment; there's the space, there's how the person feels about inviting a person into their home. There's their level of attention to, let's say, housekeeping, or their level of anxiety about how much energy they have to do housekeeping. There are the dogs; there's the feeling like you're hosting a doctor in your home, or a social worker, whoever. There are the elements of ... If you're really, really sick, maybe you just didn't feel like taking a shower this morning, but the doctor's coming, so you have to put yourself through a whole preparation mode. All of those things are, frankly, in the way of a relationship of trust. They're complications. So I've come to accept that actually doing care virtually is better than real life. Dr. Bob: Fascinating. I find that fascinating, because I do some care, some visits remotely that way. The vast majority, 95+% of them are in patient's homes. So those social, primal, primate behaviors, to me, I find those really endearing. And I think it's almost like a friendship is developing at the same time as a doctor-patient relationship. But I'm not seeing the same volume as you, so I have the luxury of being able to do that at this stage of the game. Dr. Fratkin: I think that's true. I think there are some other things that are hidden in plain sight that relate to it. I'm sure you'll agree that one of the great challenges for hospice work, palliative care work, complex conditions, where people with huge loads of social challenges with sensitive, inspired, caring caregivers and healthcare professionals ... One of the greatest challenges to this work is learning about the nature of boundaries. It shows up in every hospice organization, every palliative care organization, in the hospital, where people get confused about where they begin and where the people that they're attending to begin, or where they begin and end. The I and Thou, to quote Martin Buber. That is very interesting and hard to teach. The way that most of us learn is that we screw it up. We get caught up with the other person's energies. We end up feeling we must keep them pleased. We don't necessarily ... Well, here's the teaching metaphor that I use. I'll see if I can create a visual of this for you and the listeners. Bob, do you remember way back when, in the dark ages, when you took Physics? Dr. Bob: Yes, vaguely. Dr. Fratkin: Vaguely. And do you remember studying the components of an electronic circuit? Dr. Bob: Even more vaguely. Dr. Fratkin: Okay. Things like resistors and transistors. Dr. Bob: Capacitors. Dr. Fratkin: Capacitors and stuff, right? Now, I bet you don't quite remember. Maybe you do. You're a smart guy. What a capacitor actually is. Do you remember what a capacitor is? Dr. Bob: In the interest of time, I'm gonna let you- Dr. Fratkin: That's good. Good call, Doc. A capacitor is this: it's two plates. Imagine tiny little squares. One of them's a positive, anode; the other is the cathode. I think that's right, a negative. And they sit inside of a circuit with a proximity to each other and a surface area. And the closer they are together, and the more surface area they have in association with each other, the higher the capacitance. Whatever the stuff of capacitance is that contributes to doing what's needed to an electronic circuit, which is way above my pay grade, is proportional to the surface area and the proximity. And I think that that's better than thinking about staying professionally or technically detached from the people we care for. What we've built is a system that constructs ... All I'm here to do is to give you the technically, medically best treatment. And I can't really allow myself to engage with the truth of what's going on for you as a human being, because that'll make my hands shake in the operating room. That'll make me not make the right choices on your behalf, or provide you with the right recommendations. And I think what that done is it's alienated healthcare professionals from the people that have medical challenges, right? Dr. Bob: Absolutely. Dr. Fratkin: Professional detachment is a 20th century, obsolete concept. My concept is that what we're called to do, especially for people who are feeling the threat to their very existence, is to open as much of ourselves as we can, create a greater surface area, and have the courage to maintain the closest proximity to their circumstances. To understand what's going on. But what happens with the capacitor ... If the two plates touch- Dr. Bob: Kaboom. Dr. Fratkin: Circuit's completed, and there's no capacitance. If you get caught up in people's shit, then you lose the ability to really create the magic that lives between those two plates in close proximity. In human encounters, I say that it's not capacitance that arises with proximity and willingness to be open. What arises is empathy. And empathy is the secret sauce of understanding how to be of service to another person. But if you're caught up in them, if their happiness or well-being becomes relevant to your own happiness or well-being, then you've completed the circuit, and you lose the capacity to have the perspective of being of service to them. It's a long and involved metaphor. Dr. Bob: Yeah, but it's a great one. It's a great one. I'm gonna- Dr. Fratkin: Here's an example. With your wife ... Or actually, with my wife, being with my wife, not you with my wife, but me with my wife ... We are intertwangled. And we sometimes struggle to have enough individuation to understand what each other needs. But we're necessarily, intimately one. One circuit, my family, right? And so I struggle with different kinds of things there than I do in work. It's not a matter of distance; it's a matter of entanglement. When I, for example, being asked to see a 56-year-old person with a brain tumor and two children, the distance I can get in proximity to him is greater than with an old woman who doesn't look anything like my own life. So I have a little bit more room. Others on my team may be able to step right into tending to that father. But for me, I have to create a little bit less proximity in order to make sure that I don't get entangled in the reality of what's going on for him because it so resonates with my own fears and worries about myself. So I can manage the proximity consciously, and by having a team that has a whole different set of concerns and triggers. There, we're intentionally talking about the distance we can tolerate. The best possible scenario is you're almost touching, but not quite. So we have to manage that consciously, and that is one of the ways that I train people around boundaries. This is a very circular way to talk about what I think one of the great advantages of video conferencing in a frame, is that it's literally a frame around the encounter, around the relationship and development. It's necessarily a division. It's necessarily a boundary. And while I can get very close and understand empathically what that person is having, I'm not sitting on their bed. I'm not reacting to their place on the political spectrum, which may be revealed by their red baseball caps or bookshelf. I'm not struggling with my own biases. They are in their most comfortable place as a person, not having had to prepare, go to a clinic, and deal with the waiting room and all the rest of it. They're just at home, as themselves. And I am similarly in a work environment that I've constructed, that I'm very comfortable with. And so, in some ways, the frame around which we ... within which we encounter and develop a relationship, has this necessarily built-in boundary. And so I think that's part of why, rather than two hours, it takes one hour to get to the same place. And that once people have the experience, it's much, much more comfortable for them than home invasions. Dr. Bob: Fascinating. What's interesting is, I'm assuming ... Correct me if I'm wrong, but I'm assuming that this has all just been learned as you built this. The rationale and the initial inspiration for doing video conferencing, I'm assuming, was efficiency and being able to connect with people who are in more remote areas. I'm sure that you had very little awareness or understanding about all these additional benefits and advantages that you've come to, that you're just describing. Dr. Fratkin: Yeah. Well, just like I don't have any idea what benefits and nuances and subtleties I'm yet to discover over the next few years. But yeah, you're right. I mean, I started because I noticed that I have had this amazing smartphone and that I'm using it to text and to call and to talk to people on the phone and all the rest. But I realized that it was worth exploring, whether or not a synchronous audiovisual experience with two people in two different places, working on the same thing together, whether that would work. Because I have this crazy, amazing supercomputer in my pocket called an iPhone. So a lot of it was curiosity. I didn't really quite get the efficiencies and the network development until I started playing around with it. The way that I discovered it was, a friend of mine who works at Google told me about a project that came and went over about 11 months, called "Helpouts." And Google had this project where they were setting up a platform that included video conferencing, the "Hangouts" app, a webpage that you could tell your story about what expertise you wanted to share with other people, a scheduling function, a wallet function, and a messaging function, all on one little webpage. And if you had Chinese cooking that you wanted to teach, you could put your page up there, invite people to take a look, and if they wanted to schedule you, they could. And you'd charge them $15 for a half hour or whatever you wanted to charge. If you wanted to help people with their business plans or filling out their tax forms or whatever other expertise you might wanna share, you were out on the sort of open market, and direct consumer engagement would allow you to do it. So he asked me, would I wanna do it for palliative care. And I said, "Yeah, sure." So I spent two hours throwing up a little thing, and within a month, I had five people reach out to me. And the first person that did was a woman who was in a hospital in the Bronx, in terrible pain, from a metastatic cancer problem. And she was miserable and interested in talking. So we connected, and about five minutes, five seconds, the technology itself disappeared, and there I was, doing my thing. And within 30 or 40 minutes, we're both kind of in tears about the big picture of things. And it was really clear that some basic fundamentals of managing her symptoms would make a big difference. So I got her permission to reach out to the hospitalist tending to her. He was willing to talk to me. I told him, "Do x, y, and z." And the following day, she was discharged from the hospital. And I connected again, and she was so grateful for that advocacy and the difference that it made in her life. And I knew that this could so work. Dr. Bob: Yeah. What a beautiful story to spearhead and show you the impact. Dr. Fratkin: So it was more about just curiosity of what can I do with this crazy iPhone in my pocket? I hadn't really put it together that I was gonna build a social enterprise called Resolution Care at that point. I was just trying to figure out why are we not using this tool? And so I started using it, and it worked. Dr. Bob: That's great. So hey, I have a question. You and I, we're both palliative care physicians. We both specialize and are passionate about bringing people the best possible and holistic support to deal with their struggles and their challenges. And we know what works, right? And anyone who's involved in palliative care understands the value, sees the value on so many levels. On the human level, the financial level, the social level. Why are we having ... Why do you think we're having such a hard time getting traction and seeing palliative care become what it needs to become? Because you're working within the system. You're working with insurers, and you're working with the whole Medicare and insurance billing component, as well as contracting. What's your take on it? What's going on? I know it's a big question. And it's not a simple answer, but I really wanna hear your thoughts on it. Dr. Fratkin: Yeah, no. I think I would probably disagree with you. And only because- Dr. Bob: That's good. I'm happy to hear that, too. Dr. Fratkin: Only because this morning I happened to have a little bit of perspective. I don't know why that is. It might be just; I hit the number of cups of coffee just right. But I think what I would say is it's happening at an almost spectacular pace. It's amazing what's occurred for our society as it relates to our mortality in the last few years. That there's a transformative change in the public conversation around death and dying. I just happen to be pretty well-timed to get up on my surfboard and ride that wave, while also contributing to that wave through having conversations like this one. But let's go back to 2014. In 2014 in October, the Institute of Medicines Dying in America study, the second version was published. It was, I think, 10 or 11 years after they did it the first time, where they did a very deep dive into how people in America finished their lives. And what they basically said in that report was it sucks, and it hasn't changed in 12 years. It talked about how much bias there was and how little capacity there was for palliative care in cancer patients. But they also talked about the aging population, the demographic shifts that are intensifying this sort of tsunami, silver tsunami of people with a greater burden of illness, and the cost of health care, and the absence of focused and targeted support structures for people as they completed their life. And they said, "Why hasn't it changed for 12 years?" A month later, Atul Gawande published "Being Mortal," a blowout success that surprised even him, about bringing this conversation to "How do we die in America?" To a more narrative discussion. And you and I, in our field, we've been talking about these issues for 20 years, maybe longer. And I ask myself ... Well, actually, when Atul Gawande presented to the American Economy of Hospice and Palliative Medicine in 2015, he was interviewed by the Philadelphia Inquirer. And before his presentation, he says, "Gosh, Dr. Gawande, you have this blowout New York Times bestseller. Everybody's reading your book. What are you gonna tell all these hospice and palliative care doctors when you talk to them tomorrow?" And he said, "Well, I'm gonna say thank you. And I'm gonna ask the question, 'Why haven't they been listening to you?" And I was disappointed the next day when he actually didn't ask that question. He [inaudible 00:40:34] from his prepared remarks. But I found myself, for the next few days, thinking about that question [inaudible 00:40:42]. Why haven't they been listening to those of us that have been doing hospice or working with death and dying, working with families very closely, learning what brings value to them? Why haven't they been listening to us? And I think the answer is that we were talking to ourselves, talking to each other, thinking in terms of big health care delivery systems and academic papers and elevating our own careers through the accumulation of initials and prestige and all the rest. The academy of hospice and palliative medicine was academic, an ivory tower, and not really directing its attention outward. And I told Gawande, his voice was completely outward-directed, and it wasn't because he was such a great doctor. It was because he was a son. And being mortal, he's a clueless ears, nose, and throat surgeon who was getting it wrong. Then he, as a son, experienced the challenges that his father faced. And that transformed his perspective as a physician. So his story of conversion was related not to his role as world-famous, world-renowned surgeon. It was related to his role as a son. And so he ... And he's such a brilliant communicator and journalist. Now fast-forward three years later. He is selected by Berkshire Hathaway, Amazon, and whoever the heck, to lead an organization as a symbol of what's possible by thinking out of the box. And as a symbol, that his orientation is grounded, his career has exploded so that he is the leading, most exciting CEO in health care. And he's completely grounded in an understanding of what person-centered care must turn out to be. Dr. Bob: Yeah. That is exciting. That's an exciting development. Dr. Fratkin: And then there's BJ Miller and the traction that he got telling his story as a TED Talk. And then there's Jessica Zitter with her book, called "Extreme Measures." And then there's Shoshana Ungerleider, working in the Bay area, kind of behind-the-scenes, producing powerful documentary films, one of which, "Extremis," was nominated for an Academy Award. But these powerful experiences taking the public into places that we've been populating for decades. The intensive care unit, or the hospital-based palliative care program. And bringing people into that, that wouldn't otherwise look. Not to mention, the millennial spirit of younger people is that they don't blink. They don't avert their gaze at what's difficult. They tend to be drawn towards things that represented shadows for the previous generations. So I think there's a lot happening, that's happening very fast. And in three-and-a-half years, we built this organization kind of on the strength of that, and with the advantage of being an outsider like you, Bob. Dr. Bob: Well, I appreciate that perspective. And hearing you speak, it's inspiring. And it's true. Things are happening. There is a groundswell. I guess my perspective, A) I'm just, in general, a very impatient person. And B) I'm out here in the community speaking. And my of the talks are really focused on older groups, and I still have rooms that are filled with people who just don't really know about palliative care. And when there is palliative care in the community outpatient setting discussed, a lot of times, people have felt that it couldn't fulfill their needs. Because there's A) not enough providers, B) the offerings are not complete enough. And a lot of that has to do with the payment, the reimbursement models. So on the one hand, I do see that we are moving in the right direction, and that's exciting. And at the same time, I'm frustrated because I still ... And as I know, you see this as well. We still see people who are day-in and day-out, struggling, because their needs are not getting met. And we know what they need, and it's just not available to enough people today. Dr. Fratkin: No. It's super true, Bob. I mean, I feel exactly the same way. And for my own psychic well-being, there was a long time ago that I had to make the choice that I wasn't gonna focus on the unmet need or demand as the target of my attention. I was gonna focus on building capacity. And that I was gonna not worry about the fact that I could have burned myself out again trying to deal with one out of four people that I could get to in the hospital. I could have stayed inside of that, like most of us do, just trying to push that boulder up the hill. But what I had to do was to take a risk and say, "For those three or four people I don't get to, in their interest, not the same people but the next three or four or five or six or 12 or 250, it's gonna take some strategic thinking to build capacity." And there are so many sad stories. And as soon as I hear their names or hear some element of their stories, my heart starts to break and be frustrated with them that they don't get the service or don't know that there's a service that would help them. But my focus is not so much on those people; as it is, I know there are so many of them out there that my best efforts are to build capacity to manage and to set the tone of what palliative care capacity building looks like. We believe that it's not just whatever you could cobble together with crappy resources from whoever your institutional home is. Palliative care is best provided by a team of individuals who are well-supported in sustainable, soulful workplaces, but include a nursing perspective, a chaplaincy perspective, a social work perspective, and provider perspective. We are committed to that. So what we provide is actually pretty expensive. And the good news is, is that what we provide delivers to our health plan partners, a three to five x return on investment. Every dollar they spend turns into three to five that they saved. And they can measure those dollars. So they're interested in program development and building capacity for us. We think in the state of California, less than .5% of people who would benefit from palliative care support are getting it. If I focus on that 99.5 % of people who are suffering terribly- Dr. Bob: You'll be paralyzed, right? Dr. Fratkin: It breaks me down. Dr. Bob: Yeah. Dr. Fratkin: But I'm trying to get from .5 to 1. And I'm trying to do it by providing soulful, sustainable, meaningful experiences for my treasured colleagues. Nurses and all these people who, 100 years ago or 500 years ago or 5,000 years ago, would still be doing the same thing. They wouldn't be called nurses; they would be called neighbors. They would be called aunties. They would be called "the ones you call for help when you need it." It's been a part of human society forever, and we are burning out those people in a terrible way. So I'm just as loyal to creating incredible work experiences for those folks, as I am to building capacity to tend to the needs of sick folks, too. Dr. Bob: Yeah. And that's a beautiful thing. And that's how this will grow, sustain itself, by nurturing those who are serving others. Because this work, it's difficult, it's challenging, it is emotionally trying, and as I think we both experienced this, it is such ... It also fills us up in a way that nothing else does. And we don't throw the word "love" around enough. We had a meeting with my team a couple days ago. And when you try to really identify the essence of what we do, and really what we do is we love people, and then we take our skills and our experience and our wisdom, and we apply those in the way that we express our love for them. Dr. Fratkin: For sure. I was talking to a Native American fellow who lives up in the hills. And I was exploring with him his relationship to tribe and culture. And I'm not sure how we got there, and I wish I could remember the pronunciation of the word, but I won't massacre it. But he was explaining to me that there's a word that's being used by the tribe and others that kind of means "thank you," but it's being used in the "thank you" way. In a very, sort of, superficial way. But he said that the word itself is very much more specific. It's the kind of thank you or gratitude that's offered to someone who showed up to meet a need you had. If you're old and someone brings you food, it's the thank you for that. If your roof is leaking, but you can't fix it or afford it, and the guys hop in the truck and start throwing shingles on your roof, it's the thank you for that. It's the thank you for showing up and meeting a need for someone in your community. It's not "Thanks." It's deeper than that. And the presence that we bring, the willingness to love while preserving boundary, the willingness to respect the otherness of these people that we care for. And the willingness to drink a lot of coffee and build out a system to create beautiful jobs and keep the vision as clean and clear as possible. It's the thank you I feel from the community, even if I don't hear it said. I'm so proud of what this team has done for so many people we've touched. 1100, 1200 people who wouldn't otherwise have gotten this care. And that means there are 5-10,000 people who we didn't touch. I'm sad about that, but I'm proud of the work that this incredible team has done over these last three years with very little resource and a ton of coffee. Dr. Bob: Yeah. And a ton of passion and a ton of- Dr. Fratkin: Love. Dr. Bob: Love and determination. And proud you should be, my friend. And I'm excited to continue to follow your progress and the progress of Resolution Care and the impact that you're having. And your model is a model that I'm sure many will want to learn and try to apply in their communities. So before we sign off, I would love for the listeners to go and check out your website. That's resolutioncare.com. And in addition, there's a foundation and an opportunity to help support this amazing, so, so needed care. So you have a 501C3, I understand. Dr. Fratkin: It's called Resolution Care Institute, and there's a page on our website. And if people have a few dollars, they wanna donate, that's absolutely welcome. Yeah. And also, I guess I would ask them, too ... We create maybe once or twice a month what I consider to be pretty high-valued content in a newsletter. And I would love to build the community, so on the website, all you have to do is put in your name and email address, and we'll send you stuff. And if you don't think it has value, you just unsubscribe to it. But I suspect you'll enjoy being a part of our community. We tend to ... We're trying to figure out how to tell stories about the impact of the work that we're doing while getting ourselves out of the way. Just letting people tell their own stories. So we've done that with some videos, and we've done that with some blog posts and other newsletters. And the response we get is favorable. So I'd really like to build that community out if people are inclined. Dr. Bob: Yeah. Awesome. Well, we'll fully try to support that, and to everyone's benefit. And we'll also have the links for Michael's site and the ways to connect with him on our website, integratedmdcare.com. Michael, thank you. You're so passionate, articulate. I could listen to you all day, describing your views and your excitement about what you're doing. And I would love to try to connect again. And I know that there are several things that we wanted to touch on that we didn't have time to, but hopefully- Dr. Fratkin: I'm happy to do this anytime, Bob. This is how we're making an impact, is by telling the truth and sharing that.    

Alive Inside" is a wonderful film and movement that awakens the Alzheimer's mind and connects generations, comforting elders and rescuing youth. The film's Director, Michael Rossato-Bennett, shares how it all began. IntegratedMDCare.com " Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Contact Alive Inside website Alive Inside Facebook Page Transcript Dr. Bob: Today's guest is Michael Rossato-Bennett-Bennett, the director of the film, Alive Inside, and the founder and executive director of the Alive Inside Foundation. Alive Inside is a phenomenal film, and I highly recommend you find a way to watch it. The Alive Inside Foundation is dedicated to healing loneliness and disconnection in all of our lives, but especially in the lives of the very young and the very old who are living with dementia. They partner with communities to connect the generations and shift our relationship with life, aging and growing up. The Foundation seeks to end loneliness using empathy, music, life story, and film. This interview with Michael is an intimate exploration into the mind and heart of a man who seems to have stumbled upon his purpose and has been inspired to create in a much more expansive way since doing so. I hope you enjoy it. So, Michael, your life has changed pretty significantly in the last several years. From what I can gather, what started as a project that you couldn't really foresee a whole lot coming out of, to what has been created in your life now and looks amazing. What's it like? Tell me the journey a little bit. Michael Rossato-Bennett: Well, like every life, probably the most important things are your failures. Those are what you learn from, like your woundings, your emptiness, your hungers. These are the things that actually fuel you. When nothing else makes sense, I'm deeply interested in what makes sense when nothing else makes sense, and I think that's a very apt conversation to have in this time because I'm sure I'm not alone. I think if everyone were honest, they would just say right now, "What the heck is going on?" Dr. Bob: How did we get here? Michael Rossato-Bennett: How did we get here? How do we tell our children your president doesn't tell the truth all the time? How do we say your government isn't really trying to protect you? We're confused. I mean I am, and I have been many times in my life. I'm going to get a little philosophical here, but I think anyone living in a predatory culture that doesn't quite know that they're living in a predatory culture, has a feeling of disquiet and confusion, and like all of us who are trying to do something in the world, our efforts are constantly called into question. What am I doing? Am I helping create a just world? Am I helping create a world where life is recognizing and aiding life, or am I deeply investing in a system that is reducing the quality of life, literally for the planet at this time? I think every one of our occupations, from farmer to doctor, has to wrestle with these questions right now, what is my place in this world that we've created, and, unfortunately, we don't get to remove ourselves from it I don't think. Dr. Bob: It's interesting. As you're talking about this, and I don't know if you have children or not, but as you're talking about this, I'm flashing on my 11-year-old son, who is right at the verge ... If I asked him what does it feel like to live in a predatory world, I think he would know enough about what I'm asking to form an opinion and connect with it. But I, also, feel like he's still living in this other world where he can slip back into this sense of comfort and not allow that to influence his day to day existence. Michael Rossato-Bennett: I mean this is at the core of everything I'm working on, and it's simply the recognition of the idea that we actually do mature, that there is actually an arc to our lives. When I was 21, I was competing my ass off to win the steak knives at my job for Cool Vent Aluminum telephone salesmen. I wanted to be the best Cool Vent Aluminum salesman because the sales manager told me that I was nothing if I couldn't book these appointments for his salesmen to sell this poor, older people aluminum siding and new windows. Dr. Bob: And you believed that? You believed that story. Michael Rossato-Bennett: I believed it. Dr. Bob: Yeah, you did. Michael Rossato-Bennett: I believed it, and really, honestly at that point, all I wanted to do was be good, be recognized, to succeed, to have some validation, and honestly, I didn't think that the people who were in authority, that the people who were older than I was, I didn't think that they didn't know what they were doing. I thought they knew what they were doing. But your 11-year-old son, he's awakening in a world where it's obvious that we don't know what's going on, that something is happening, and it's amazing what's happening. I mean basically what's happening is we're going through a major psychic, intellectual, spiritual, existential definition of what it means to be human, and what it means to be human together, and ideas that we've had for thousands of years are no longer functional in the face of these incredible tools that we've created in the last 20 or 30 years. The computer has just turned human culture on its head, and we are not ready for it. Dr. Bob: Right. Michael Rossato-Bennett: And we're innocents, and I think in a hundred years we'll look back and this and go ... Just like slavery. At one point, slavery seemed to be a pretty good business model. We try not to do that anymore, at least in a recognizable form. But in a non-recognizable form, we haven't given up that business model, and that's what we're dealing with. I mean you're a doctor, and I work in healthcare to some degree as well, and Marshall McLuhan is a great media thinker, a thinker about media, and he said years and ... Maybe 60 years ago or 50 years ago, he said, "The medium is the message," and I never understood what that meant, but I understand what that means now, that basically, the structures that we create determine the outcomes, no matter who is in them, or no matter what the outcomes are. When you have a lot of people making money on petroleum, you get plastic in the ocean. It doesn't matter what people do. In 50 years, we won't be relying on petroleum. We won't have the pressure to create as much plastic, and maybe we can solve that problem. Dr. Bob: Well, so fascinating. Great perspective. Love it. Not exactly where I was anticipating the conversation was going to go, but I love it, and I want to hear ... So you take that. I'm sure that your awareness is continuing to mature, to evolve, and it's influenced by and influencing what you are doing day to day to improve the lives of the human beings that you're concerned about, as we both are. What's happening in your life? I want to know what you're doing. What's the Foundation doing? How are you right now serving in a way that is trying to achieve the most benefit for humankind? Michael Rossato-Bennett: Well, I mean that's a big thing to say. Dr. Bob: I know. Because it's happening. What you're doing is serving humankind in a positive way. Michael Rossato-Bennett: Right, right. I'm not young. I'm not a child anymore, and you get to a certain point in your life, and you ask yourself, "Okay. What can I do to help other people," because helping yourself is kind of boring after a while. It just becomes boring. So you want to expand your relationships with other people, and it's interesting. Dr. Bob: I lost you for a second there. You said interesting, and then I lost you. Michael Rossato-Bennett: I was relating to these thoughts. Okay. Sorry. All of my thinking comes out of working with these elders with dementia and meeting them. You're right when you say my life has transformed. I mean I walked into my first nursing home, and I wanted to run because I'd had really some very traumatic experiences in hospitals when I was a child. They put that ether on my face. I don't think they do that anymore, and I struggled and screamed, and yelled, and fought. They finally just gave me shots in my butt. But that smell of health care, of the hospital, I swore I would never, ever step inside a hospital or a healthcare facility, place forever. I promised myself I would never, ever do that. Then here I am. I had been hired to make a website for a guy who was bringing iPods into nursing homes, and he thought that it would be a good, new thing to do, and so I did it. There I was sitting in front of a man, Henry. He was the first one that I really saw the power of music to wake the hidden vitality of a mind, a mind that had lost its capacity to connect with itself and with others. I didn't want to be there. It was very sad for me to see this human being, this shell, if you will, of a human being, who didn't seem to be able to come out of that shell. Then we gave him ... Millions of people have seen this clip. Actually, over 100 million people have seen this clip. Dr. Bob: Really. That's where it's at, at this point. Incredible. Michael Rossato-Bennett: Well, it was actually one of the earlier clips to go viral on Facebook. So it was still back when Facebook was becoming before they put all these clamps and started monetizing everyone's life. It was back when they were giving it away so that people would join, and so it's a completely different animal now, and that's what we're discovering right now, and a very dangerous animal as well. But anyway, so here's Henry, and we give him some Cab Calloway, and I get to experience a human being awakening. This guy, he starts moving, and his eyes light up, and he starts singing. He starts making poetry. When I took the music away, I thought he would turn off like a ragdoll. Dr. Bob: Like a light switch going off. Michael Rossato-Bennett: Yeah. Like the electricity was going off. But, no, there was this residual aliveness and connection, and he talked to me, and he was so beautiful. The whole world saw this. I mean I went to bed that night and my son ... That I posted it. No, I didn't post it. I put it on my friend, Dan Cohen's website, and some kid found it and started spreading it in the Reddit community. I don't know if you know what Reddit is. Dr. Bob: I'm a little bit familiar with it, yeah. Michael Rossato-Bennett: It's a community of young people on the internet, and my son is in that community, and he saw ... He came into my room. He said, "Dad, they're talking about your film on Reddit," and I was like, "Really," and he goes, "Yeah. It's gone from 300 views to 400 views," and I was like, "Oh, my God. That's amazing." Oh, my God, and then we went to bed. We woke up the next morning, and it was at 180,000 views. On the next day, like a million views. It just kept going. But the amazing thing was, for me, I mean I thought we'd discovered the cure for Alzheimer's Disease. I was like, oh, all you got to do is give them music, and it makes their Alzheimer's go away. Then there's, of course, a sad realization that, no, you're just waking up some very deep pathways that are actually spared. They're pathways that are very deep in this elemental brain. Not in the forebrain, which is really the core of I think what I'm working with right now, and that is that when you don't know where to go, sometimes the deepest parts of ourselves hold profound and unexplored wisdom, and I constantly go to those deepest places, like music. Music, by now, it's part of our DNA. It's literally been adapted to our DNA. I mean a child, an infant, a human infant will respond to a beat and other primates won't in the same way. Yes. Dr. Bob: I watched the film a couple times, Alive Inside. I've watched it a couple times. I just watched it again last night. I was, again, just blown away by the little toddler who was conducting. Michael Rossato-Bennett: Oh, my God. Dr. Bob: The natural instinct in him, and he's a little performer. But I agree, you can see it in almost every child from the time that they're able to interact with the world, that they respond to music, and they've been responding to it since they were in utero. Michael Rossato-Bennett: Yeah. Dr. Bob: And that never goes away, unless you lose your hearing. Michael Rossato-Bennett: Which is another enormous problem. About half of the people who staff thinks have dementia, they probably have a little bit, but more, they have hearing problems. It's an enormous problem in elder care. So what are we doing now? At first, I was like, "Oh, my God, let's get everybody who has dementia their music, and let's make that happen." In some ways, that's happening. Michael Rossato-Bennett: It's hard to realize what we don't know, right, or what we didn't know. When I was making Alive Inside, we had so much trouble getting people to try this, to give these elders their music, and it was really a struggle because it was a new idea. But then the hundredth monkey syndrome kicked in a couple of years ago, and now this idea has literally spread like wildfire across the world, and to such a degree that I think ... I was joking with a friend way back then. I said what's going to happen is some day I'm going to say I made this movie about how you can play music for people that's their music, that gives them an emotional reaction, and if they have Alzheimer's it will awaken parts of their brain that have been forgotten, and I said in five years, I have this feeling that people will go why did you make a movie about that? Everyone knows that. Dr. Bob: Yeah. Right, what's so different. Michael Rossato-Bennett: Everybody knows that. We know that, and that's where we are. Everyone in the world knows this now. I mean I had some part to play with it, but it's that hundredth monkey thing. When something is important, and you have a disease like Alzheimer's where there is no cure, and if you have something that can help, it's going to spread like wildfire, and I think that's what's happened. Dr. Bob: Well, of course, it's very helpful for people who have Alzheimer's to try to awaken that and to bring them a sense of joy and connection, but it's, also, incredibly beneficial for people without Alzheimer's, who are just lonely, right? They're just the people throughout the nation, the world, who are isolated or limited in their own homes, or in assisted living communities, or in nursing homes. The ability to give somebody, to connect them with the music that has been meaningful for them at various points of their life, brings joy, brings comfort, brings connection. There's no way to understate the impact. So understanding that I'm curious ... I'm in San Diego. I have a concierge practice, and I take care of people who are in their homes who are dealing with end-of-life issues. They have dementia. They have cancer. They have heart disease. It's a small practice. It's like a concierge practice for people with complex illnesses and who are approaching the end of their life. As part of that, we have integrated therapies, and I have a couple of music therapists who go out. They're angels. They connect with the patients, and we see them flower. We see them blossom. Some of our patients, with these therapies, music, massage, acupuncture, reiki, they go from being bedbound, and miserable, and wanting to die, to get re-engaged with life and getting- Michael Rossato-Bennett: And it makes sense. Dr. Bob: And it makes sense, total, and I go into nursing homes, and I'll see people there, and we just created a foundation. We just got the 501c3 determination from the IRS, so we're ready to make this thing happen. How do we take advantage of what you have created to implement and leverage that in San Diego? Let's talk about how this is actually happening on the ground. Michael Rossato-Bennett: Okay. Well, first of all, you've opened up some really big cans of worms here. Dr. Bob: I have a knack for doing that. Michael Rossato-Bennett: Most of the people who have dementia and Alzheimer's, they are not in institutions. They live at home, and we have a culture that defines people as valuable to the degree that they're productive, and it's deeply ingrained in us. It's ingrained in our religion, and our morality, and our laws, even to the point where we've created lots of meaningless work, just because people want to be working, and the dark side of that, not the meaningless work, but this idea that we have no value unless we're productive, is the elders that you're finding. What is their productivity when they're just sitting? They can see their death, and they probably feel they're not contributing. As a matter of fact, they might even feel that they're a burden, which is a horrible thing for a human being to feel. One of the things that I've been so intrigued about, about people with Alzheimer's, is they forget so much, but it's strange what they don't forget. They don't forget what they used to be. They don't forget that they're having trouble communicating, and they used to be able to communicate, or at least it seems like that to me. You opened up another can of worms, which is loneliness. The UK just appointed a minister of loneliness. 40% of Americans report problems with feeling lonely. We're discovering the dark side of social media, which is this capacity that it has to make people judge themselves, their real life against the sort of phony life that's presented one snapshot at a time and edited and Photoshopped. People feel this kind of not being good enough, and when you feel not good enough, you feel separate, and when you feel separate, you feel alone, and that is one of the greatest pains a human being can ever feel, and that's really ... I had a very hard time growing up and a lot of isolation, and I shut myself down in many ways, and that's why when I saw this older man, Henry, wake up, I was like, "Oh, my goodness. Oh, my God, we can wake up. We can be awakened," and that's what you've described with your music therapists go in, and these people are like, "Oh, wow, yes. There are rhythms of life that I can share with you, and we can sing, and we can do music, and it can even go back into my memory, and oh, I have these stories I could tell you." I decided that the place that I wanted to play with was trying to reduce pain. Like you, as a doctor, you want to reduce- You want to reduce the pain and the struggle, and one of the greatest struggles that I see is loneliness and disconnection. I feel like our culture ... There are things we all need to survive, and to live, and to thrive, and sometimes commercial society says, "All right. You want those things; you got to pay for them." So it puts walls between what we want and what there is, and that's not really the way life works. If you swim in the ocean and you grab a fish, it's not like you paid for it. Well, you swam for it. That's for sure. Or you pluck a pear from a tree. It's not like you grew that tree. I'm not sure that this sort of way we are creating safety for ourselves is working, and I think it's falling apart in many ways, and so, again, I go to the very deepest place. So I developed these headphones that you could give to somebody with dementia, and it has a little hole in it, and you can put their music in it, and you can plug your headphones into their headphones, and so you can listen together, and your eyes can meet, and you can be in the music together, and I thought that was beautiful. Then I made an app so that anyone could sit with another person and try and figure out what is that deep music that's inside the soul of another person. So you can do that. But the key thing I feel is that what I've learned. If you watch Alive Inside, you see all these people awakening. But what you don't see is me on the other side of the camera going, "Oh, tell me that story. Oh, my God, you're so beautiful. Oh, yes, I want to know more and tell me. Flower. Let me see you flower." We are creatures that are called into becoming. You take a child, and you just put them in a room, and you leave them there for 14 years, you're not going to have a great kid, but if you go in there every day and you teach them how to be human, and you teach them the rules of being human, you bond with other people, you connect to them, you be kind to them, you look in their eyes, you learn to feel what comes out of another person's eyes, and you learn to give to another person through your eyes. I mean the eyes is the only organ that goes both ways. There are both receptors and apparently ... I was reading the other day ... I wish I could quote it better. But apparently, there's something that comes out of the eyes. That's why we call the eyes the windows of the soul. You're a doctor. Dr. Bob: I'm not sure what emanates from the eyes, but it kind of feels like when you're in somebody's gaze, when you're looking deep into their eyes, that there's something either reflecting back or coming out of it for sure. Michael Rossato-Bennett: At the very least, there's expression. At the very least, there are tears. Something is coming out, even if it isn't a ray. But that's the amazing thing that we're understanding now, and this goes back to the illusion of loneliness. We've created the structure where you can be lonely, where you can be a separate entity that doesn't connect with other entities, and the terrible thing is that's engineered. The truth is that we are not separate. We're talking over Skype, and my ideas are affecting your brain, and your ideas are affecting me. But if we were sitting in the same room for the amount of time that we've been sitting, your cells would be in my body, and my cells would be in yours. Every cell in your body I think changes every seven years, and the building blocks of you have been white people, and black people, and brown people, and hippos, and dogs, and ducks, and dinosaurs, and fish. I was reading this amazing book about old growth forests, like dirt. There's no such thing as dirt. There are rocks, and there's whatever, but every single piece of nutrition that has ever passed through your lips only has nutrition because vegetable matter has gone through the butt of a bug. Dirt is bug pooh, and without bug pooh, there is no nutrition in anything that grows. So we're not special. We are part of everything, and we've just created this system that ends up taking our children and putting them in these institutions, and telling them to stay there for 20 years and to compete for a few little remaining spots at some big colleges. As children, we're forgetting how to be children. And we have our elders, and, oh, my God, have we abandoned them. Oh, you're worthless. You just go sit in the little room over there. I'm sorry. Now you got a little emotion running in me, and so I said let's bring these two groups together. Let's bring the very old and the very young together, and what you do when you do that, it's like a magnet. These groups are meant to be together, and they're engineered apart. So basically a lot of people have seen Alive Inside, and they call me, and they say, "Hey, let's do something." I'm like, "Okay. Let's do something." So we're down in Mexico, and there are these abandoned elders, who are literally taken off the streets by this foundation, and of the thousands and thousands that they could help, they can help 250 a year or something, or actually more at a time, because the population changes, but it's only 250 at a time, and they were bringing in these young psychology students who sit with them for 14 weeks for an hour or two, and they detective. They use the app, and they find the music of these elders of their youth, and they listen to it together, and they learn their life stories. We've created another thing called Memories, which is this ... It's a very simple computer program that basically lets you create a digital, communally create a digital scrapbook for somebody. My vision is it's going to happen I the next year, is I want every hospital room, every nursing home, that you're going to be able to go and some volunteer will have created the life story for these elders, so that anyone in the healthcare community can just scan the QR code on their picture ... We're making these necklaces for them, and you'll know their life story in two minutes. You'll know where they came from, who they loved, what they did. Dr. Bob: I love that. Michael Rossato-Bennett: What their music was because it's just crazy. I've seen so many healthcare situations, where I've seen people care for people for 10 years, and love them, and not know who they were. Dr. Bob: Exactly. Not know a thing about them. Michael Rossato-Bennett: Not know a thing about them. Dr. Bob: Right. And that's what drove me crazy for years and years. I was an emergency physician, and I see these incredible people coming through, and they're a shell. They're in this shell, and if someone takes the time to actually connect with them and ask them something beyond when's the last time you have a bowel movement? Where does it hurt? But to actually be interested in who they are. I was just memorized, fascinated by what would come out, and that's a lot of why I transitioned in my career into doing something where I got to honor these people for the person they are and always have been, even though at this stage, it's physically they're different. The spirit inside of them, the essence of that person is unchanged from where it was when they were flying bombers in World War II, or dancing in competitions at 18 in the 1930s. And so what we do, I think we are aligned in the work that we're doing. I will want to connect with you further because I really do want to talk about how to bring the programs that you're talking about, especially the program with the youth together with the elders, and sharing this. Michael Rossato-Bennett: Oh, I would love to talk. Dr. Bob: So we may end up trying to schedule a second call. I'm going to wrap it up soon, and I just really appreciate your honest, thoroughly passionate view that you were able to share. I do want to make sure that people know how to get more information, and there will be links on my website to the Alive Inside Foundation site, and I'm happy to connect people with you. If you want, you just let me know. Michael Rossato-Bennett: Yeah. Dr. Bob: What kind of connections you're looking for, how we can help to support your passion and your movement because it's life-changing and it's revolutionary. It shouldn't seem revolutionary, because it's pretty simple basic stuff, make connections, and you create joy, right? Michael Rossato-Bennett: Well, I think it's revolutionary. We call it an empathy revolution, because certain things in our human vocabulary have been devalued, and a lot of people, myself included, it's taken long life journeys to be able to just honor the treasure that I have inside my chest. The fact that I am alive is such a treasure, and it's so devalued in our culture. The children, we don't honor the life in children. We don't honor the life on the planet. We don't honor the life in our elders, and it's all there is, and we only get it for a very brief time, and it breaks my heart to think of how many years I spent beating myself up and not enjoying life, and I look around, and I see so many people who are not able to really ... They only get this brief time with this incredible treasure called life. And that's why I bring the elders and the kids together because I think the elders actually teach the kids, "Hey, you're alive, and you're not going to alive for much longer, and look at me. This is what the end of life looks like, and guess what? I'm engaged here. I've only got a short time left, and I'm engaged." It's been shown that older people live with incredible pain and smile, whereas middle-aged people if their back goes out and they lay in their bed for a week. Dr. Bob: That's right. And they bitch and moan about how miserable they are. Michael Rossato-Bennett: Yes. Dr. Bob: Well, don't beat yourself up too badly about time that you've lost. You have lots of time left to contribute, and you're obviously doing a great job of that. So Michael Rossato-Bennett-Bennett, thank you so much for taking time and sharing your passion and more about your project and your mission, and best of luck to you, and hopefully, you'll be willing to come back, and we'll do some followup on another episode. Michael Rossato-Bennett: Well, thank you for calling me, Bob. That was very sweet.    

Dr. Bob's patient, Bill Andrews had ALS and was terminally ill. Before Bill decided to exercise his right to die in California, he agreed to do this interview to help others understand the importance of the law and his decision.     Transcript Dr. Bob:  Hi everybody. I'm here today on the phone with a gentleman who I'm really interested in having everybody hear from and meet. It's kind of a unique opportunity on all counts to hear from a gentleman who has lived life very fully, really did a lot of things that many people only dream about doing in his life and before he was able to really see that life through, was afflicted by a disease that has no cure and is universally debilitating and in many cases fatal. He's become a patient and a friend and I've had an opportunity to really be amazed by his story and by his outlook and approach, both himself and his family. We only have a brief opportunity to hear from and learn from Bill because, well, you'll find out why in just a bit. I'd love to introduce William Bill Andrews. Bill, say hello to our listeners. Bill Andrews: Hello listeners. Dr. Bob: Thanks. Bill Andrews: This is Bill Andrews reporting in. Dr. Bob: Thank you, Bill. Thank you so much for being here. Bill, who's with you? You have a couple of your sons with you as well. Can we introduce them? Bill Andrews: Yes. I'm with my oldest son, Brian, and my youngest son, Chris. Dr. Bob: All right, and thank you guys for Bill Andrews: They can say hello, I guess. Brian: Hello. Dr. Bob: All righty. Sounds good. As I mentioned, Bill is a 73-year-old gentleman with ALS. Bill, how long have you had ALS? Bill Andrews: I'm going to say probably about—I'm going to guess about two years. Dr. Bob: Okay. Bill Andrews: I was diagnosed about what, a year and a half ago, Brian? Brian: One year ago. Bill Andrews: One year ago. Then it was very obvious that there was something seriously wrong. The precursor to this is I had broken my back. I used to motocross and do a lot of surfing and stuff and I had many, many ... I brought injuries into the ALS experience. Broken back. Oh, just all kinds of stuff, so when I finally couldn't deal with the kind of the day-to-day life of my current injuries and stuff, that's when I really got [inaudible 00:02:51 ALS because I couldn't stand up. I could barely walk. I was still trying to surf, like an idiot, but it became very difficult. Just a year and a half ago I was in Peru surfing. Dr. Bob: Wow, but you knew something was going on? You had already Bill Andrews: I knew something was going on. Dr. Bob: Okay. Bill Andrews: I knew something serious was going on. Dr. Bob: Then a year ago it was officially diagnosed and then what's Bill Andrews: Correct. Dr. Bob: What are things like today? Bill Andrews: Horrible. I'm in bed. I get fed. I wear diapers. I'm kind of confined to my bed. We have a Hurley lift, I'm going to guess that thing is called. Dr. Bob: A Hoyer lift. Bill Andrews: Hoyer lift, and I just get into that and I have an electric wheelchair. Last weekend I was able to get out and see my kids play some sports and stuff, but that's about it. This is where I live now. At Silvergate, room 1-1-3 in my hospital bed. Dr. Bob: Wow, and a year and a half ago you were surfing in Peru? Bill Andrews: When was it? Brian: Yeah. It was a year and a half ago. Yeah. Yeah. Bill was surfing in Peru. Bill Andrews: But I knew there was something wrong, you know? I was struggling. Dr. Bob: Mm-hmm (affirmative). Bill Andrews: Really mightily. Dr. Bob: Yeah. As far as you are aware, and you've been dealing with this and obviously researching being treated. You've been in the system. Bill Andrews: Correct. Dr. Bob: Everybody, the best that medical care has to offer has been offered to you, I'm assuming. Bill Andrews: Correct. Dr. Bob: Here you are in this situation. What is your understanding of what will happen if things just are allowed to go on as they would normally? Bill Andrews: Well, as I understand it, I will not be able to swallow my food chew my food, swallow my food. Nor be able to breathe on my own, as I understand it. Dr. Bob: Right. Which is correct. I mean, the timeframe for those things is unclear. Bill Andrews: Right. Dr. Bob: Have the doctors given you any estimates? Bill Andrews: No. That's a moving target. No, they haven't. No. Uh-uh (negative). Dr. Bob: Okay, but that's inevitable for every person who has amyotrophic lateral sclerosis. Bill Andrews: I haven't heard of anything yet. I tell people, you know, I'd guess ... Because I have some friends that say, “Well, look, Bill, a cure may be right around the corner. You know, just stay in bed and they'll invent a cure and you're going to be fine." Well, that ain't going to happen. In my lifetime anyway. I don't want to go out with the tube in me and all that stuff. I feel at least now I'm reasonably good mentally and this is kind of where  I'm at a good point right now. Spiritually, emotionally, physically. Dr. Bob: Great. Bill Andrews: That's where I am. Dr. Bob: That's where you are. Bill Andrews: Yep. Dr. Bob: What's your game plan? You want to talk about the strategy and what's been happening? Bill Andrews: Well, my game plan is—well, for the last couple of weeks I've been trying to wrap up a lot of little-unfinished tasks and chores that I wanted to complete, little projects, but I think they're doing just fine. I think my family ... I guess the big thing for me is that my family, that we're all on the same page. That to me was crucial. That we all understood what I was doing and why I was doing it and that this was all my choice. Looking at what the options are and for me, an option is not being confined to my bed the rest of my life and being kept alive. I don't want to be a Stephen Hawking, and another thing that I wanted to really pass on to my kids is that I'm not fighting the battle, I'm just kind of lying here. I'm getting taken care of. This ain't a bad ... You know, if you like getting taken care of, this ain't bad. I get my diapers changed, get fed, get dessert. People run errands for me, but the warriors are like my kids and the caregivers and the doctors like you are. You guys are the warriors. I'm just a ... You know, you're the warriors and right now I'm just kind of a settler. I just got to lie here but you guys are out there doing the battle. Dr. Bob: What an incredibly refreshing perspective to have. You know? You're not feeling like a victim like so many people justifiably do. You know, you're seeing it from so many different angles, not just your own. Not only through your own eyes, which is remarkable, I think. Bill Andrews: Oh, thank you. Well, yeah. About 30-something years ago I was diagnosed with a real, pretty bad case of malignant melanoma and I was only given a few months to live at that time. That was about 30-something years ago. My kids were there when I was diagnosed and everything, so I've already fought that battle. I had the tumor taken out of my arm. Had my lymph nodes excised. I fought that battle because I could see there's was a way to win that one, so there I kind of feel like I was a warrior, but here, ah, you guys are. Dr. Bob: Mm-hmm (affirmative). That battle, the melanoma battle, I've seen how that turns out in most cases, which is not the way it turned out for you. It was, at least back then - Bill Andrews: No, I was bad with the - Dr. Bob: You were well aware of that. I know. Bill Andrews: I was very, very lucky. Yeah, I was very lucky. In fact, kind of going a little off track, at the time I had it they were experimenting with BCG injections. Dr. Bob: Mm-hmm (affirmative). Bill Andrews: Up at UCLA. They were going to inject BCG in the initial site of the tumor for melanoma. Dr. Bob: Mm-hmm (affirmative). Bill Andrews: I sent my path report up to them and they rejected me because the path report looked so bad, that I probably was going to die. They didn't want that on the report. Dr. Bob: Wow. Bill Andrews: I kind of fought that one out anyway. Dr. Bob: Yeah. Bill Andrews: Flipped a little bit. Dr. Bob: You faced your mortality, right? You had no choice but to face your mortality at that point. Bill Andrews: Correct. Dr. Bob: You were what? Bill Andrews: Oh, there is no choice. Dr. Bob: Yeah. You were in your 40's? Bill Andrews: Yeah. Absolutely. Dr. Bob: With children that were young. Right? Bill Andrews: Right. Correct. Dr. Bob: Certainly not grown adults. Bill Andrews: They were there in the doctor's office with me, yeah. Dr. Bob: Yeah. Bill Andrews: Right. Dr. Bob: I think you were sort of alluding to this and assuming that, maybe assuming that some of the people out there who are listening know what we're talking about.  But I don't think we actually discussed what the option is that you are taking to handle things the way that you feel best. Can you share a bit, share that? Bill Andrews: Sure. I, you know, kind of put a box on the board. I'll kind of equate this back to my melanoma. With the melanoma, I was given ... The doctors said, "Well, you kind of have three choices. 1: You do nothing because it appears to be fairly advanced melanoma and just see what happens. 2: You look for some miracle cure somewhere. Go to Haiti or somewhere and find a miracle cure. Or 3: Let conventional medicine dig in, and I took the third choice and I'm still here. With the ALS the choices seem to be kind of the same. I can just sit back here and wait until I can no longer breathe or eat. Or I can be kept alive by breathing tubes and feeding tubes and stuff. Or I can do with this choice that I'm making now, which is to go through the end of life in a peaceful happy way with ... I mean, I feel good about this, doctor, I really do. As long as my family's on board with me it's spectacular. I really don't think there's ... The choice for me, and this is easy, you know. This is the time and I'm not going to be kept alive. I watched a Stephen Hawking film on TV years ago and there was a lot of recrimination and stuff about, anger and stuff, by keeping him alive and I don't want that to happen with my family. Nor do I want it to cost eight trillion dollars to keep me alive. There're  factors that went into my decision. Dr. Bob: Many factors and the decision is still being made every day. Bill Andrews: Every day. Every single day, Doctor. Dr. Bob: Yeah. Bill Andrews: Yeah. Dr. Bob: For clarification, Bill is exercising his legal right in California to go through the end of life option act. To receive Aid in Dying, which means that he's made requests of his physician, who's me in this case, to prescribe a medication that will allow him to end his life if he chooses to take it on his terms at the time and place of his choosing. A second doctor who knows him well has concurred that Bill is of sound mind and has a condition that's terminal. Bill has submitted a written request saying basically the same thing. Four days from the date of this recording, Bill's plan is to get this prescription filled and take this medication with his family around him, his loved ones, and he will peacefully, quickly, and in a very dignified way, stop breathing and die. As I said, Bill's making this choice each day because there's no requirement. He doesn't need to take the medication. He can choose at any time not to, and it's just fascinating to be having a conversation with a man who has the presence of mind, the courage, the support from his family, and knows that there's a very good chance and in his mind an absolute chance, that his life will be ending in four days. I am completely honored and awed to be able to have this really frank conversation with you about what you're thinking and feeling and I remember our last conversation you just kind of blew me away when you told me that you're excited. This whole thing is in some way exciting to you. Are you still feeling that way? Bill Andrews: Oh, absolutely. No, this is a ... No. We're, you know we're ... You, I mean… It's great talking. Let me just kind of preface. You have this really kind way of speaking that most of my other doctors haven't had quite the effect on me that you have. Yeah, I'm enjoying this. I've kind of been a pioneer in a lot of things and this is just ... I'm really enjoying this and let me tell you, Doctor, the thing that's the most incredible thing to me, and this is more of a, really a spiritual and emotional thing, is being able to choose when you're going to die. I've always thought if I were to die the most noble way, for me, would be to be protecting my family, my loved ones, or even a dog in the street or something. If I were going to die, would be doing, I guess maybe doing good, but you never know when it's going to hit, but with this, I get to say the goodbyes. I get to do whatever unfinished business. I get to finish any unfinished business and it's unreal, kind of. Very interesting. I think this can do a lot of good. I was telling somebody this morning that if one were suicidal, the worst way to end one's life would be by suicide by cop or something. Where you actually in one's selfishness at ending your life, you end others. Dr. Bob: Mm-hmm (affirmative). Bill Andrews: Where I think that's horrible and I have friends who have done that, but for this, you know, I'm choosing the time. I'm choosing the place. I'm choosing the environment. I'm choosing the company and for me, this is by far, I can't think of anything better. I've almost drowned a couple of times. I've been in car accidents and all that but this is almost soothing. I hope it really works in the way that it's been intended to work and doesn't get prostituted or something in some way that it goes off track. Dr. Bob: You mean the whole idea of the ability to support people in this way with terminal illnesses and the physician aid in dying? You're worried that it could somehow get off track? Bill Andrews: I hope it doesn't is what I'm saying. Dr. Bob: Yeah. Well, there's a lot of protections in there and if I have anything to say about it, it won't. There's enough. You know? Bill Andrews: Yep. Yeah. Well, I know. That's why you know, you guys at the beginning are the ones that are going to chart the course and that's I think, really, really important. Dr. Bob: Yeah, and I think it's important for people to consider, to understand that this is so far away from suicide. When I hear the word physician-assisted suicide I understand Bill Andrews: Yeah. Dr. Bob: It irks me because I think that there's nothing remotely like the suicide that most people think about, which is to end, you know, your life because of some emotional suffering or situation that you're in. People who are using this option, like you, are dying. I mean, you would choose. I'm sure that you would give anything, anything, to be able to not be in that position. Right? In which case you would be— the furthest thing from your mind would be taking a medication and ending your life. Bill Andrews: Absolutely. That's absolutely true and I know sometimes I throw the word suicide out and that's only because maybe because it's simple to say that word but I certainly like your definition a heck of a lot better than mine. Dr. Bob: I guess I took that opportunity just to insert my bias on that. Bill Andrews: Well, I agree. I think you're absolutely not. Dr. Bob: This is your experience and you can think about it or talk about it Bill Andrews: Right. Dr. Bob: Any way you want. Bill Andrews: Yeah. Dr. Bob: Bill, I have the advantage of having a little bit more knowledge of your background and who you are and I think this whole conversation becomes more poignant when people have a sense of what you've done. Could you share a little bit about your background? Bill Andrews: Oh boy. How much time do we have? Dr. Bob: Let's do the Reader's Digest version. Bill Andrews: Well, we'll do a real quick one, yeah. My grandfather's a general in the army. The Air Force. My father was in the military. I was born in Chicago. We moved to California in the '50s and eventually, my family ended up in La Jolla. I grew up right across the street surfing and enjoying the ocean at La Jolla Shores. Graduated from La Jolla High School. Got a scholarship to the University of New Mexico as the United States was preparing for Vietnam. I didn't do real well with that experience with the military side of my education. Anyway, I kind of did an odd thing. I just worked. I have a very broad, broad work history. Not very deep. I know a little bit about a lot of stuff. I've done engineering. I've done clothing manufacturing. I've made garments overseas. I did some advertising programs for Pepsi-Cola. I was on the cover of Surfer magazine if that makes any big deal. I used to motocross motorcycles. I used to race motorcycles. An avid sportsman, fishing. Loved education so this is why this program that you're doing is so fascinating to me. I'm absolutely enjoying every second of watching this go through the process. Raised three beautiful children. Actually, their mother did a much better job at raising them than I did. I just love learning about this and I am so thankful that we've progressed to a state where we can talk about these things. Dr. Bob: Yeah. Bill Andrews: You know, maybe my kids have a one- sentence thing they can say. Not something too bad. Dr. Bob: I would love to get a little bit of the insight from them if they're willing. No pressure though. Brian: Hello, this is Brian and just—my dad's always been a real go-getter in life and wants us to be the very best we can be and always wanting us to be improving and really to be exceptional. Of course, it's been very difficult to watch him go from a very active person and suffering through the loss of being able to use his body. Back on that comment about the suicide, I'm finding a lot of comfort from knowing that you know the cause of death is ALS and that we're able to make this choice. The aid in dying is just fabulous for us that this was passed in California and we're getting the help to do this and your guidance. It's either, you know, going to be that path or watching him really suffer and go through a long and much more difficult process, having a result in a very short time from now that we get to avoid with this. Dr. Bob: Yeah. Brian: Feeling very fortunate and very proud of my dad and very thankful we have this choice. Dr. Bob: Wonderful and I have to tell you, you know, that giving him the gift of supporting him is incredibly powerful. I've had the opportunity to be with many of the family members. The children, the spouses, parents of people who have done the end- of- life option and they are all so at peace knowing that they gave that gift and it didn't always start out— they didn't start out feeling supportive or comfortable with it by any stretch of the imagination but having come through that together, recognizing how desperately important it is to the person who's dying to have that support and to have people with them at the time, you get to go on the rest of your life knowing that you gave that ultimate and last gift. Brian: Yeah. Yeah. Dr. Bob: Good for you and thank you. This might be helpful for people. When your dad first—and Chris, if you want to chime in too—When your dad first approached this with you, what was your initial reaction? Do you remember? Brian: Well we actually brought this forward ourselves in working with him. We were looking at researching ALS and talking about what we wanted to do in the time ahead from diagnosis and we decided we were going to really come together as a family and we took a great trip together, a road trip, and we spent a lot of time together and had a lot of great conversations. Dad's friends from surfing—he's got hundreds of friends— threw him an amazing party. It was a celebration of life while he was here and that's the way Dad wanted to do that versus waiting until he was gone and having a big service and paddle out after he was gone, so that was an amazing day. We had a band, amazing food. It was a beautiful day at the beach. Dr. Bob: Wow. Brian: His friends made this happen down in La Jolla. We've really just taken this time to come closer together and have these great experiences. We were thinking about how this was all going to come to an end and we were going to ALS meetings and just really learning about it and part of that was just researching. I remember reading about it online and then we talked about it as a family and then, you know, it kind of went from there. Dr. Bob: Okay. Brian: Yeah, just exploring the options. We all have felt really good about it from day one. Dr. Bob: Great, so it kind of happened organically and a lot of times it's the individual who finds out about it or comes to that kind of decision, sometimes having been thinking about it for quite a while and it does take some finesse sometimes and time to get families onboard, so I'm glad that you didn't have to go through that. You were able to just, from day one, be united and working together, which is great. Bill Andrews: Yeah, I think in general we were 90 to 95% onboard in total from day one. My decision was I did not want to be kept alive and if it came down to not eating, not drinking or whatever, that was my chosen course. I wasn't going to put my family—I didn't want to put my family through a whole bunch of torture but a torture for me would be breathing help and eating help. Dr. Bob: Mm-hmm (affirmative). Bill Andrews: And selfishly watching my bank account go from a very small amount to negative numbers. Dr. Bob: Mm-hmm (affirmative). Bill Andrews: A lot's played into my decision, selfishly, on what I was going to do. Dr. Bob: I hear you. Bill Andrews: I appreciate them that they're going along with this. Dr. Bob: Yeah. Chris: This is Chris. I have one more thing to add to that. Dr. Bob: Great. Chris: I think in the beginning we were very curious about the disease and that curiosity led us to read a lot and also like Brian said, they started going to meetings. I was living in New York and I was pretty far away, so for me, it was more of like an academic research. Like what can I read and what can I understand more of? Once you start to dive into that space and you get like ... If you don't have a disease you need proximity to it to understand it and once you do, it sort of is like "this is awful" and you want to do everything you can to help. I think that for other families that might be going through this, I imagine there's a lot of avoidance of kind of really want to think about the end or "I don't really want to know too much about it”.  But for us I think having, throwing ourselves into it, it gave us a lot more strength, I guess, to just keep moving through this process with him. Dr. Bob: Mm-hmm (affirmative). Chris: Because we know what's on the other side of it. We don't know how he's feeling but we're able to paint a picture of it by seeing how other people, what it's done to other people. Dr. Bob: Yeah. Now other people will be able to look and have, hopefully, hear this conversation, and the conversation can continue in various forms, but to see how powerful it can be to plan. Right? Not to avoid but to see what's coming, what are the alternatives, how do you make sure that at the end you feel like you have the control you need, that you always would want. The disease takes pretty much all control, at least physical control, away. I imagine knowing that you're going to be able to make this last decision for yourself, Bill, gives you a real sense of control back that's been missing. Bill Andrews: Oh, it absolutely does. I just want to add one more thing too. When I first was diagnosed I wanted to learn more and more about the disease. I'm reading, reading, voraciously and you know, it's all over the place of what it is, what causes it, what doesn't cause it and on and on and on.   So I kind of, I started writing originally about my experiences on my blog and then I thought, eh, if people want to learn about the disease they can go to Wikipedia or something. People had asked and they go, “Well, how are you feeling today? You're moving your toes.", or something. I go, “Well, you know, maybe you ought to learn more about the disease yourselves and then maybe you'd understand where I'm coming from a little easier." Because it's all kind of basically the same, so rather than explaining to the same people every other day how I'm feeling, just, you know, make your own calendar and chart it yourself and they can make their own timeline or something. Dr. Bob: Mm-hmm (affirmative). Mm-hmm (affirmative). Brian: Yeah, my dad's real quick as well. Dad would always say, "Hey, if this is where it would stop, I could be okay. Where I still can stand up and take a few steps with my walker or be able to feed myself and go to the bathroom. Yeah, okay, I'm okay." Then every day we'd get progressively worse and you hit a new level and it'd be like "Wow, I didn't think I'd keep going with this but now that I'm here I could keep going a little more.", and it was just like, and I'm going where is the line? You know? Where is the final level where it's not going to be okay anymore and then it becomes a— there is a point where ... Because as Chris said, "Dad, we're researching." In the end Dad, he was consistent from day one. "I will not be in a feeding tube. I will not be in on a respirator. I don't want to be kept alive. If I have to be fully cared for and bedridden, that's not the quality of life I want to have and that's when I'm ready to go." So always trying to think about, well, at some point we're going to hit a point where you can't move your arms at all. Today he can't move his legs and he doesn't have the strength to do anything with his arms other than lift something that weighs just a few ounces. Pretty soon he won't have the ability to use his arms at all and that's very close so we're trying to stay ahead. We know that there're only a few decisions left. You know, at the very end he's going to starve to death and go through a [inaudible 00:33:26. A difficult process or take this option, so it's been just always trying to stay ahead, but as the years evolved, choices and the days and the weeks and the equipment we need and choices to make has been—it's all in Dad's own journey. Dr. Bob: Mm-hmm (affirmative). Brian: But here we are and now we're all feeling really good about this choice. You know, given where we are. Dr. Bob: Yeah. Thank you. That was really awesome to hear and it's Dad's journey but you're a team and the obvious connection and bond that you guys share in his knowing that this isn't—it's not going to tear you apart, it's not going to destroy you. That you are so together on it and seeing this is the compassionate option. I mean that's going to allow him to slip away so peacefully with that feeling of I don't know, completion or this ultimate sense of connection so that's really powerful that you've been able to create that for him together, all of you. Bill Andrews: Yeah, it's the compassion I think that is so important. You know, everybody can have sympathy or they can have empathy, but all I ask from people is you don't even have to understand it, just accept it as it is and when I tell you how it is, that's what it is. If you need any more information, go to Wikipedia. Go to WebMD or something, I don't know. That's the way I feel. Dr. Bob: All right. Hey, I have two more questions if that's okay and then I'm going to let you go. Bill Andrews: Okay. Dr. Bob: One of them is do you have any fear at this point? Is there anything about this that is causing fear or anxiety for you? Bill Andrews: Absolutely not. Not a drop of fear. Dr. Bob: Awesome. Great. Bill Andrews: No. This is like, you know— Dr. Bob: Oh, go ahead. Bill Andrews: Just a new adventure. A new adventure. Dr. Bob: Okay. That's beautiful. Bill Andrews: Anticipation, not fear. Dr. Bob: Great. I guess the last one is what would you like to share? I know it's not like you're out shouting from the mountaintops to the masses here but Bill Andrews: Right. Dr. Bob: Can you distill down your message? Bill Andrews, Big Pink. Bill Andrews: Surfing. Surfing nickname, no less. Dr. Bob: It's a surfing nickname. Bill Andrews: I guess now that I'm looking back, obviously you can't make every move the right move and just a couple of things. I think if you kind of put your life on autopilot— this may be a little weird but, kind of set a course if you can. You know, get a point A to point B and of course, then obviously by judgment is the right course. You know, a good course. Like a righteous course, and try to stay to that and every once in a while get, but because of your autopilot and that comes internally or God or your friends or whatever, kind of knocks you back into ... Excuse me. Back on course so you're not out there one month, two months, three months. You know, kind of lost out there and then you're looking at time bandits and everything. I think it's very important to make as much effective use of your time as you possibly can, and there again, you know I'm preaching to the choir and all that stuff, but I look back at my life. You know, you only have so many minutes in your life and, gosh, if you could just make 60% of those minutes effective and doing good again, all by definition, that would be my—that's my message to my kids. Kind of pick that course, stay on that course, and you'll look back and go, "Gosh, I've lived a good life and I'm proud of what I've done." Dr. Bob: That's beautiful. Thank you. That's really phenomenal. You guys, Brian, Chris, do you have anything you'd like to say about your dad or anything regarding this before we close out? Brian: Just that we love Dad very much and we're proud of him and proud to be your son, Dad. Bill Andrews: Thank you. Dr. Bob: All right, guys. Bill Andrews: Okay. Dr. Bob: Hey, thank you so much for your time and thank you so much for all you know, Bill, all you've brought to the world. I will be seeing you soon and looking forward to every moment that we have together.

The Teal Chair, a film that was nominated for the Future Filmmakers Award this year at Sun Valley Film Festival was the brainchild of Kimberly Ouwehand. Find out why the hospice community outreach coordinator wanted to create this film and how its impacted her life and others. Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Contact Treasure Valley Hospice website Transcript Dr. Bob: Kimberly Ouwehand is a passionate Community Outreach Coordinator for Treasure Valley Hospice in Nampa, Idaho. When Kimberly got the inspiration to videotape people answering the question, "If you knew you had a limited time to live, what would you do," amazing things started to happen. She collaborated with a local group of high school students, and what came out of it is an extraordinary documentary called The Teal Chair. The film was nominated for the Future Filmmakers Award at the 2018 Sun Valley Film Festival. In this podcast, Kimberly shares how the film came about and how its creation has impacted her life and the lives of many others in her community. I hope you enjoy it. Share with me, the listeners, a little bit about your journey, your working in hospice, and how long have you been part of hospice? How did you get into hospice, and kind of where are you in that, in the course of your career? Kimberly Ouwehand: Well, I started out in clinical. I worked in internal medicine for about 10 years, 10 to 12 years, and kind of fell into hospice, because, and it's kind of a different animal, because you're in people's homes, and you're dealing more with people than you are the clinical side of things, and so I've been doing hospice for about seven years now- Dr. Bob: Okay, and in what capacity? Kimberly Ouwehand: I love it. I do outreach, and communication, and education, so kind of I'm a marketer for it, but I do a lot of hands-on and outreach. Dr. Bob: Got it. Kimberly Ouwehand: A lot of education. Dr. Bob: I think probably a lot of people don't realize ... Well, a lot of people don't realize a lot of things about hospice, right, but- Kimberly Ouwehand: Yeah, that's for sure. Dr. Bob: When they hear "marketer," they probably don't understand how much that involves being with families, and patients, and kind of in the thick of things, because I know I've been associated with hospice for a while now, and sometimes the marketers develop such incredible relationships, because they're the first point of contact for a lot of these folks and people who are in pretty somewhat desperate situations or very vulnerable. It's a really important role to be playing, don't you think? Kimberly Ouwehand: I do. I wish sometimes we didn't ... I mean, I hate to use the word "marketer," because traditionally it's pushing sales and things like that. I find myself making connections and building, like you said, building relationships so that people know, like, and trust you, and they'll call you whenever there's question, and they don't understand something. I feel like my reputation should be built on trust, and I feel like I've done a pretty good job of that so far. Dr. Bob: Good. Well, you've expanded beyond just doing the hospice marketing to take on a whole 'nother realm and project, so The Teal Chair. Tell us how that came about. Kimberly Ouwehand: Well, actually, it started out with just a very simple question. I was getting frustrated that people were waiting way too long to use hospice services. I mean, hospices, it is medical, and palliative and comfort care all at home, but hospice traditionally, especially for the older generation, feels like you're signing off on a death wish. They were missing out on a lot of other services, and I loved that hospice was all about surrounding the family with the patient and making it ... Well, it is one of the most important things you do in your life is die well, but I was getting frustrated, because it's a hard subject to bring up, and people were afraid to talk about it, and doctors were putting it off way too long. I wondered if we'd made it more of just a simple question, "If you knew you had limited time, how does that change the way you live today?" That question seemed a little bit softer, so I thought to myself, I thought, "Well, I have this teal chair," and I was just going to plop it in the middle of some public area and pull people off the street and just ask them a question, record it. It was going to be kind of a short YouTube video, but what happened was, I realized I had no video skills whatsoever, and my son had taken a video class at the high school, and I just liked the rawness of it. I didn't want it to be a production. I wanted it to be real. I didn't want it to be ... I just wanted it to be honest, and so I went and asked the teacher over at Eagle High School if he had a couple students who would do a YouTube video. He said, yeah, he had a couple students, and so he kind of ... I found out later he kind of coerced them a little bit to do this death video. Dr. Bob: They were resistant. You think- Kimberly Ouwehand: That's kind of- Dr. Bob: ... that there was resistance- Kimberly Ouwehand: Yeah. Dr. Bob: ... initially? Kimberly Ouwehand: There was a little ... Yeah, but he got five incredible students to ... Sorry. Incredible students to take part in it. The outcome was phenomenal. It took legs very quickly. Dr. Bob: Yeah. I can imagine if you get the support and you get sort of the passion of youth, and it's a creative process that the school could support. It's one of those things that if someone takes that initiative and puts the pieces in place, people want to talk. Right? They want to talk about these issues, and they just need to, it just needs to be presented to them in a, I guess in a safe way, maybe an inspired way that you're going to do good for other people. That's what I've found. When was the, like how long did it take to produce, and what's the status of the film, and I have a lot of questions, but- Kimberly Ouwehand: I know. It is an amazing story. We started out at a venue called JUMP downtown. It was a great collaboration. They were doing a Day of the Dead event, and I thought it was colorful and fun, and festive. The more I learned about the Day of the Dead, the more I appreciate it, and so I thought it would be visually stimulating for the students, so we went down there, and it just grew into one team did events, did the filming of the event on the outside, people looking at the altars. There was, a Before I Die Wall was set up there. I don't know if you know about that, but it's an amazing exhibit. Then the other half went up into the studio, and they were so excited because it was a professional studio. They had the green, and all the lighting and everything, and we were able to take 22 people off out of the event and bring them into the studio and ask them this question. "If you knew you had limited time, how does that change the way you live?" We interviewed people from eight years old up to I think the oldest we've interviewed that day was about 89. It was just, it was interesting. It wasn't scary. It was thought-provoking, and one thing led to another, and I said, "Well, why don't you submit it into the Sun Valley Film Festival for Future Filmmakers?" We made it instead of just a YouTube, to a 10-minute one that would fit the criteria, and submitted it, and out of about 120 across the nation, we were nominated. There were, I think, 12 nominations. We went to the Sun Valley Film Festival, and then since then, we're, it's going, we've sent it to Washington, D.C., to the National Hospice and Palliative Association, and I'll be submitting it into the American Public Health Association- Dr. Bob: Awesome. Kimberly Ouwehand: ... for educational pieces, because what happened is, it just started this huge conversation, and it's not only about dying, but it's about the different seasons you are in your life and what that looks like and having those conversations, because you never know if you're going to die suddenly or if you're going to have a chronic illness that will take a long time. Dr. Bob: One of the things that came to you when you were just posing the question to people, "What would you do differently, or how would you live, if you knew you had a limited time," did people ask you like, "What do you mean by a limited time? Like are you talking about days or months?" Did that seem to be an issue, or did they all sort of feel like they could take that and speak to it without getting more clarity? Kimberly Ouwehand: That's a really ... I mean, nobody's asked me that question, but some people did, like about how much time, but most people didn't ask. They just thought, "Okay. Where am I right now, and what's important to me?" Like the eight-year-old said he wanted to have a pizza party, and you just realize that the shorter, the younger you are in your life, your life doesn't expand very much, and then the teenagers, the college, they wanted to experience life as much as they could. They wanted to get out and just learn as much about the world and everything around them, and then it seems like, and I'm kind of stereotyping it a little bit, but the career, your middle-aged people would be more focused on balance of life, realizing really what is important, not working so much. The family becomes important... Working so much, the family becomes important. And then older people got it was usually something to do with a memory, revisiting a place or a person, or for sure it was all about family. Dr. Bob: I imagine some of them would want to have a pizza party. Kimberly Ouwehand: Yeah, I mean, and the conversations that's come out of it. When I set it up, I set up interviews, and we interviewed doctors, and we interviewed a couple of professional people. And we interviewed a hospice patient and a family who had hospice. When we were doing the interviews, I would think to myself; these kids are going to think it's stupid, it was a waste of time, they're not going to pull anything off of this interview. But what they did, and pulled, and put together, I was amazed. I thought he knows it's boring; they're not going to think it's exciting, they're kids, you know. But they pulled stuff off that I would never have thought of. Some of the pieces that I thought were really long, I had people come up and say that really spoke to them. So you really can't make it into one topic, it's a super broad topic that hits people in all different areas. Dr. Bob: Yeah, it's so personal. That's part of the idea of how do we spend our time, what's important to us, what do we value most? That's what we're getting at, and everyone has such a unique experience. So, I don't want to put you on the spot Kimberly, but what would you want to do if you knew that you only had a limited time? Kimberly Ouwehand: You know what, that's- Dr. Bob: Did you answer it? Were you interviewed? Kimberly Ouwehand: No, I was not interviewed. And I don't know if I really know what I would do because I feel like my life is centered around that already, that everything I do today, it matters. So I hope that when I do die, if I die suddenly, that people will look at my life as I've lived it, and the things that I've done, that I was nice, and that I was kind, and that I was just a good person, I think. But I don't have any bucket list things. I wouldn't do anything differently, really. Dr. Bob: I agree with you. I'm in that same place, and it really feels good to feel like I don't really need anything else. I probably would want to just be with my family, and have friends. I think about it, you being in the hospice world and me being, caring for people at the late stage of life and many of them in their final days and weeks of life, I think about it often. Like, where am I? Am I complete? Am I good? It's a really gratifying feeling to feel like I'm good to go. I would hate not seeing my son grow up and all these things. But I don't feel like there's anything undone or unsaid at this moment. It feels powerful to me. It sounds like you're sort of in that same place. Kimberly Ouwehand: Yeah, and I agree with you too, in the film, I asked one of the interviewers, what would he do? It was interesting because really, and I can see this with a lot of parents that they would hope that they had left enough of them with their children, that their children wouldn't forget him, and his values and what he was like. I think for parents, and I'm a parent too, but my kids are getting older now and more independent, I feel I've done a pretty good job. But I just would want everybody to know that I did love them. The parent thing is a little hard because you're leaving something that you can't follow up with, I guess. Dr. Bob: Kind of unfinished. You feel like you're not, you feel like there are a little bit more unfinished business and a gap that be left more ... I agree with you more so than if the kids were already adults and launched. Was there anything you can think of that was really surprising, that people said, that you, "Wow, that was really interesting," or crazy... Kimberly Ouwehand: Yeah, there was a lot of things that people that I took away from there, just with a little bit of different perspective. One person said, and I thought this was really interesting, and I think I live my life a little bit differently because of it, was, "If you give up one thing if you focus on one thing, sometimes you have to unfocus on another thing." In other words, you can't have it all. You can't focus on everything because then it doesn't, you don't hit the bullseye, basically. I thought that was interesting because I think sometimes we try to do too much, and we forget that you can't. And it's okay not to do everything. And we can't do everything well. And that's why we have people in our lives. That's why we have people like you doing podcasts that are reaching out to a whole different demographic that I can't reach, and I'm doing my thing that you can't reach. I think that put a new perspective on a stressful job, to be honest with you. Dr. Bob: I'm sure that the gift of being involved in that, I'm sure there were many gifts, but one of them was this new perspective and the wisdom that came out of people speaking from their heart, from this place of a different awareness than they would otherwise have. I wonder if, how many of the people that were interviewed, who were able to share what they would do if they had limited time, started doing more of those things. If the impact is not just on the people who watch the film, but the impact on the individuals who got to reflect on that. Kimberly Ouwehand: I feel like the interviewers that I knew, all said that they had conversations later, because their families ask, "What are you doing?" I don't know about the other interviews, that we did at the jump event, the Day of the Dead event because I kept that anonymous, so I didn't want to put names or tag any links on that. So most of them, I never really heard back from. Dr. Bob: It'd be interesting if there was a way to come back and interview those people again. Kimberly Ouwehand: That would be, I know. Dr. Bob: I think we talked a little bit earlier. I think it's so important to get the conversation about life and death, and preparing, and living intentionally, to the younger demographic, into college age kids, and high school age kids, and even elementary school kids. I just feel like we have become such a death-phobic culture and we don't allow ourselves to promote these conversations. I think it just continues to, this fear continues to escalate as we get older, and no one's having the conversations. Do you feel like the film, I haven't seen it, I'm looking forward to seeing it, do you feel like it's something that could be used in schools to help open up the topic and stimulate conversation and sort of a structured format? Kimberly Ouwehand: I really do. At this point, because it really only got finished, there's a 30-minute documentary, and that really didn't get finished until May. So we'll be doing more screenings, but we're talking with BSU, Boise State University to implement that as part of their curriculum in their nursing program. And then also, with the Boise State Center of Aging and their social workers, we will probably be doing a couple of presentations with that. The biggest resistance that I found interestingly enough is with the medical professionals, the ones that are already doctors and physicians. And that one, I've been very surprised at how resistant they have been in having it be presented as a topic. Dr. Bob: And why do you think that is? Kimberly O.: I think number one, they are busy, and they don't necessarily have the time, or maybe even the energy. I think a lot of times, after you get through medical school, you feel like you're an expert in whatever you're doing so you don't think anything outside of that, except for your bubble, I think. I don't know; I'm not a doctor. Dr. Bob: Yeah, no, well I am, and I think those are accurate. But you said there's resistance to actually them coming out and viewing the film, or somehow allowing it to be shown in different venues? I'm curious, it would seem to me that this is the kind of thing that anybody would benefit from seeing, and watching, and taking the teachings. I apologize on behalf of the medical specialty. Kimberly Ouwehand: Oh no, and I don't mean... Dr. Bob: I do. I find myself doing that. I find myself doing that all the time. I hear people talking about all the challenges they have with the medical- Dr. Bob: On all the challenges they have with the medical system and with physicians in particular, and I mean, I'm diverging a little bit, but I do see all the challenges, and I see physicians being stretched and very narrowly focused, and people suffer because of it. Both from when the medical care, as well as the physicians aren't open in many cases to thinking outside the box and supporting something like this project. Anyway, I do find myself apologizing on behalf of physicians [inaudible 00:22:39] to patients. Kimberly O.: I sound like I'm bashing doctors and physicians, but I really am not. I mean, again, it goes back to the focus physicians who are specialties. They need to focus on that. They can't be looking at every other angle, because they'll lose their focus. They'll lose their specialty. I think too; they are asked to do a lot. They're busier now than ever; the paperwork is crazy. Covering your bases all the time. Healthcare, in general, is just getting more complicated. I don't necessarily feel that they're being resistant, but I do feel that they can only handle what they can handle, and one more thing, even if it is outside of the box a little bit, might be just a little bit ... Until they understand it, I just think it might be harder for them to grasp. Dr. Bob: Right. I think you're being gracious, and that's nice, because these are the kinds of things that, yes, it's important to focus on your area of expertise and your practice and to try to maintain balance in your life, but this is the kind of thing that helps to further our humanity, right? Kimberly Ouwehand: It does. Dr. Bob: I mean, this is the stuff, every physician needs to work on their humanity, on their compassion, and on their empathy. It doesn't matter what you do, what specialty you're in, this kind of project is something that everybody should be at least open to bringing in and supporting. That's my thought. Kimberly Ouwehand: Yeah, I appreciate that. I think too; I think sometimes physicians need to stop and think about their own mortality. I think they forget that they are ... They're going to die someday too, and it might help them center what's important to them a little bit too. I would hope, I hope it's one of those films that people take and just apply it to where they need to apply it, you know? Dr. Bob: Yeah. Kimberly Ouwehand: I think too, you mentioned earlier about the younger generation, the high school students, and the college students, and when we had started filming, we started filming the first week of November, and later that month, one of their classmates died in a tragic car accident. At the end of the school year this year, one of the students at the high school committed suicide. Death is around them. It's interesting how they handle it, though. I don't know how they handle it, quite frankly. I don't know if adults put what we know onto kids or if kids just know how to ... It was interesting, 'cause there was hardly any talk about it at school. Dr. Bob: It's hard to imagine that that's healthy. You would think at least you want to have an opening for the kids who feel like they do need to talk or to ask questions or to come together. You'd like to think that they would put that in place to give an opening for those who may be struggling with it more. Kimberly Ouwehand: Yeah, I agree. I think they made it ... I mean, I think the students know they have a counselor that they can go to. I think some of the friends, the girl that died in the car accident, they had a vigil, but it was done just through her girlfriends. It wasn't really ... They didn't talk about it at a school level, and I just thought that was interesting. Especially when it comes to the suicide. There have been several suicides in high schools here, and they don't talk about it. I don't know if that's for the family's sake, or how they handle that in the schools. They don't really tell us, so it's interesting. Dr. Bob: Yeah. It's scary. It's also I think more than people realize, there's also a lot of suicides in medical school, and physicians. It's increasing in numbers. Kimberly Ouwehand: I think that's true, and there is a lot of emphasis on physicians and mental health care, taking care of their mental health. I think you're absolutely correct. Dr. Bob: I want to take it back to the film, and how do I get my hands on not a copy probably, but the ability to get it and show it and potentially have an event around it, or do a showing? Kimberly Ouwehand: At this point, the 30-minute documentary, we're editing it just a tiny bit, and it will be available by link. The 10-minute one that went to the Sun Valley Film Festival will be on our website, at TreasureValleyHospice.com. It's not up yet, but we're working on that. I'm happy to send you a link so you can see it- Dr. Bob: Awesome that'd be wonderful. Kimberly Ouwehand: ... before then. Dr. Bob: Well good. I'm excited, and this is the kind of thing we need to do more of this, and it's cool, 'cause this is taking a softer approach, right? It's not a death café; it's not in your face. It's taking the backdoor approach to are you really living your life intentionally? And doing the things that truly matter, and not ... Go ahead. Kimberly Ouwehand: I'm sorry. I keep interrupting. Dr. Bob: No, that's okay. This is your interview; we're here to hear you. Kimberly Ouwehand: I think the film really almost mirrors a little bit what hospice is because hospice is taking what's really important to you in your life, and everything that surrounds your life at that moment in time. I feel like it's a very softer approach to really what hospice does and is. I hope that's what the message is, in the end. Dr. Bob: Yeah, that's nice. You're right. Many people don't get that. Society, until you've had a personal experience with a really good hospice team, the perception out there still for many people is hospice is basically just where you go to die, and we know that that is ... There are times when that's true when somebody's dying, and they're in their last stages, and hospice comes in and helps facilitate it and make it more comfortable. But there are so many people who spend months on hospice, and they live so much more richly, and so much more peacefully, because of that support. It really is about living well until you die, as opposed to just dying, and I- Kimberly Ouwehand: And the family, too. Dr. Bob: Yeah, that family support. I can see the film helping to further that concept and that philosophy. I'm looking forward to it, to seeing it and sharing it, and who knows what other projects you'll be getting to next. I did an interview not long ago with Michael Rossato-Bennett, who directed the film "Alive Inside." Have you seen that? Kimberly Ouwehand: No, but I'd love to- Dr. Bob: Wonderful film. It's about music and bringing music to people with dementia, and people who are isolated. It started out as just a little project that someone asked him to come and do some filming, and out of that, he has now created a foundation, and there are iPods and headphones being given out to people all throughout the country, and it's launched into something beyond what anyone could ever have imagined. Who knows? Something like that could be happening with you as well. You never know. Kimberly Ouwehand: I hope so. You never know. Thank you so much, Dr. Bob.

For decades Kathryn Tucker has been supporting people's rights to have a peaceful and dignified death. She's fought to protect the medical aid in dying laws. Listen to learn more about the End of Life Liberty Project. Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Contact End of Life Liberty Project Dr. Bob: Katheryn Tucker is an attorney who's dedicated almost 30 years to supporting the right of individuals to have a peaceful and dignified death in a manner that's consistent with their values. In this work, and in this effort, she and I are very aligned. She helped initiate and protect the medical aid in dying laws in Oregon and Washington State as well as California, and has continued to be a fierce advocate for this right on a state and national level. Katheryn's a graduate of Georgetown University Law School, and she's currently serving as the executive director of the End Of Life Liberty Project, which is now based at the UCSF/UC Hastings Consortium on law, science and health policy. Katheryn is recognized as a national leader in spearheading creative and effective efforts to promote improved care for people who are seriously ill and dying. And on this episode, Katheryn is discussing her passion for supporting and protecting people's right to a peaceful and dignified death. As well as her views on the current laws in place in certain states that allow terminally ill people to access physician aid in dying or otherwise known as death with dignity. I personally found this conversation to be highly informative, a bit provocative and incredibly interesting. I hope you do too. Well. Katheryn, I am so happy to have this conversation with you. And I really appreciate you taking time. I know you're a busy lady, and involved in lots of important things. So, again, thanks for sharing your time and your expertise with my listeners. Kathryn Tucker: Well, thank you for having me. My pleasure. Dr. Bob: Yeah. I feel like we have so many different things that we could talk about that are important, but I'd like to start out, you're a passionate advocate for people having the most peaceful, dignified end of life as am I. We have we approach it from different angles, but with the same kind of general mission, which is to allow people to be self-determining and have more control. You've been doing this for a long time, how did you become such a passionate advocate for this? Kathryn Tucker: I started doing this work when I was a brand new lawyer back in 1990, and I was the outside counsel to the first initiative campaign in the country to put before voters the question of whether dying patients should be able to receive physician assistants in dying. So, my work started that year with that campaign. I did become passionate about empowering patients with information and choices as a civil liberty, and one of the most profoundly personal decisions a person can make in a lifetime. Dr. Bob: So, was this something that you ... Is this a direction that you chose at that time back in 1990, or did it just fall into your purview based on where you were working and what you were doing? Kathryn Tucker: I was a young lawyer in a big law firm in Seattle, Perkins Cooley that supported its lawyers taking on pro bono work. So, I actually was casting about for some public interest work and came upon the campaign, Washington Citizens For Death With Dignity, and just volunteered to provide some legal support. Right at that moment, the initiative was being drafted. So, I got involved with that drafting. Then we had a long campaign that involved the defense of the ballot title in court, that's the words that the voters will see when they go to make their vote and is very important to the outcome of the vote. So, we had litigation about that. We had litigation around false political advertising because some of the claims that were being made about what the law would allow were so outrageously wrong that we challenged those in court. So, it turned out to be a year and a half working to get this in front of the voters. And it very nearly passed even though it was quite a broad measure, much broader than what was passed in Oregon a few years later. So, my work on that then rolled forward into doing some work on the Oregon Effort in 1994. But also the orchestrating of two federal lawsuits that were seeking to have the federal courts and ultimately the United States Supreme Court recognize that the choice of a dying patient for a more peaceful death with physician assistants was an interest that should be protected by provisions of the United States Constitution. So, that work then got underway, and 25 years later I'm still doing this role. Dr. Bob: You're still doing that. Do you ever wonder what would have happened if you never were asked to participate in that back in 1990- Kathryn Tucker: It would probably have been a less interesting and satisfying career. I think that this question which is that the intersection of law, medicine, bioethics is very fascinating, and there are so many perspectives and so many complexities that 25 years later it says interesting as it was when I first got started. So, I'm very grateful and privileged to be able to do this work.Dr. Bob: I completely get that. This work has been part of my life only for the past couple of years since the end of Life Option Act passed in California, but it's so complex, and it makes me feel so, I guess, alive and invigorated to be able to provide such a high level of support at such an incredible and vulnerable and intense time in people's lives. Kathryn Tucker: Right, absolutely. Dr. Bob: So, I commend you, and you're partly responsible for what's transpired and what's now allowing people to have this kind of control and peace. And so I thank you for all the efforts that you've put in. I know that you've gone way above and beyond, you've created a nonprofit to additionally provide support. So, 25 years after you began, what are you currently focusing your energy and attention on right now? Kathryn Tucker: Well, one of the things that I constantly try to do is have some perspective on whether the efforts that we have been engaging to expand end of life liberty are actually achieving that. My current view is that while the work we did with the Oregon Death With Dignity [inaudible 00:07:50] which became the first statute to permitted and dying, enacted by voter initiative in 1994 by the Oregon voters. But then subsequently followed in many other states that have essentially what's referred to as the Oregon model. Which is a very heavy-handed government regulation of the practice of medicine with regard to aid and dying. That very heavy-handed government regulation may have been appropriate and necessary in 1994 when no state had an open practice of aid and dying. And there were many unanswered questions about how an open practice would impact patients and the practice of medicine. So, the Oregon enactment was designed first to actually be able to run the gauntlet of the political process. So, it needed to have a tremendous number of what are referred to as safeguards. You'll recall that the Oregon measure followed a failed attempt in Washington State in '91, and then a failed attempt in California in '92. So, by the time we were working in Oregon in '94, it was the kitchen sink approach to protection, regulation and safeguard so that the contentions of opponents that this would be dangerous could be effectively combated by showing how many safeguards, in fact, were in place. So, that's the backdrop of why the Oregon measure has the multitude of restrictions, requirements, and constraints that it does. Following Oregon's enactment. Other states adopted virtually the same but in some cases even more burdensome measures. Because at that point they could say well, the Oregon approach has worked well. So, everyone in this forum can feel comfortable voting for this. That's been effective. We saw Washington State and Vermont and Colorado and California and Hawaii adopt what are called Oregon style aid in dying measures. The problem is we're now more than 20 years later; we've got abundant data that shows who chooses aid in dying and why, and how it impacts patients in the practice of medicine. So, we now know a lot more than we knew in the early '90s. I think it's time to move away from the Oregon model because what we have also seen, and a multitude of studies are starting to report is that very heavy-handed government regulation comes at a tremendous cost. It creates barriers to patient access, which I know you've seen in your practice. And it creates tremendous burdens for physicians, which of course you're also aware of, which means few doctors are willing, and patients find difficulty finding doctors, and it's very problematic. So, the advocacy that I am embarking into now is really to move the practice of aid in dying into a standard of care approach, which is how all of medicine is practiced Dr. Bob: Awesome. You are really gifted at articulating all of that, and I think you did a great job of sharing how things got to be as they are today. Could you go a little deeper into what the heavy-handed government regulations you're referring to are? Kathryn Tucker: Sure, and I know you know them very well. Dr. Bob: Right? I want our audience to be aware of what we're talking about. Kathryn Tucker: Right. Well, so, on the eligibility side, and I don't really quibble with this because I think this is where our culture accepts the practice of aided dying. The patient must be diagnosed with six months or less life expectancy. They must be mentally competent. So, this is a decision that can only be made by a patient who has the ability to make their own informed medical decisions. Then the physician involvement is limited to providing the prescription for medication which the patient can self-administer. Those three bright lines, terminal illness, mental competency and patient self-administration, I think are what this culture accepts and are appropriate however the practice is conducted. Whether it's subject to statute, or standard of care. But then beyond that, what these regulatory statutes require is a tremendous amount of process and procedure. The patient must make multiple requests. It must be oral and written; they must be witnessed. They must have a minimum 15-day waiting period, although in the case of Hawaii that's now been extended to a minimum waiting period of 20 days. There's a tremendous amount of requirement for the collection and recording of data. And all of that is apparent to the practice of medicine. And most medical practices, even practices that result in the death of the patient and in fact, can be anticipated to precipitate the death of the patient are practice subject to standard of care. Which means the practice and procedures that govern are those that have been shown to be most efficacious and to deliver the best care to the patient. That is something that can evolve over time as clinicians discover what is most efficacious. So, it's an evolving standard, which best serves the patient. Here, just to bring it into a concrete example, I think we can all see that a 15-day mandatory state regulated waiting period causes a tremendous amount of suffering that standard of care would likely not impose. Clinicians free to determine whether there should be a waiting period would likely have it be much shorter. They might say to the patient, and Dr. Bob, you can say what you might say. You might turn to your patient and say, "Why don't you sleep on this, and we'll talk about it at our visit next Tuesday, or we'll talk about it tomorrow on the phone." It wouldn't be an additional 15 days. Because remember, patients come to this choice when the cumulative burden of suffering is so horrific that they feel that achieving death is their best option. So, they're in tremendous suffering when they're ready to make that choice, and then mandating waiting another 15 days, which many patients don't even live long enough is just cruel. Dr. Bob: Agreed. I completely agree. So, that does seem to be the most significant burdensome aspect. It's interesting, I hear about how often people have these multiple struggles trying to find a physician who will support them. Once they do find somebody, often it's because they're part of a hospital system, and they've been referred to so and so, or their own doctor has finally agreed to. But they also have these processes in place that mandatorily referral to an ethics counselor or a psychologist or psychiatrist even though they've never had any hint of mental illness throughout their entire life. But when people find me, and I know there are other physicians, Lonny Shavelson, and there are other physicians who are truly focused on providing support and honoring the patient and not primarily focused on protecting themselves and worrying about the liability or the hassle factor. The process really can be very streamlined. It doesn't feel in many cases for the patients that we care for, overly burdensome aside from the 15-day waiting period. So, I know we've had conversations about that- Kathryn Tucker: You are to be commended for your willingness to put up with so much procedure. Because doctors are busy people, and to create additional burdens on the clinician as these statutes do, well beyond what would be done for example, with the provision of palliative sedation, of course, is another medical choice that patients can make, and physicians can provide. Where death is the certain outcome after some considerable period of time, while the patient essentially dehydrates to death without any of that paperwork, without any of that reporting of data. It just happens within normal medical practice, which I think is where most physicians are comfortable practicing. That's a difficult enough job as it is without layering a tremendous additional level of process procedure and second-guessing on top. Dr. Bob: Yeah. I'm in agreement. What I've come to discover since becoming willing to participate and support patients and families is, I have concerns about this becoming a more ... About having a lot more physicians support participating. I want patients to have easier access, and not struggle to find the support that they need. But knowing how much time and energy goes into providing that support, the questions the patients have, the families have, the multiple, multiple phone calls and emails and communications as this is moving forward, I'm very concerned that most physicians in a traditional practice don't have the mechanism or don't have the wherewithal to provide that support. So, we would certainly have to be able to address that. Because otherwise, people are going to be struggling not having the information they need, not having the support they need. What are your thoughts about a process that can be put in place to ensure that that's happening? Kathryn Tucker: Well, I certainly think that clinicians who are willing to expand their practice to include aid in dying are going to be those that are highly motivated to respect their patients autonomy and to want to make sure that the patient is able to make the journey to death in the manner that is most consistent with their very personal preferences and values and beliefs. So, this is a fairly unusual subset of clinicians that will feel strongly about that. I think that they will take the responsibility of ensuring that the patient's request is voluntary and considered and enduring. I think they will take that all very seriously in a standard of care practice. Those clinicians will provide it. So, it will self-select. Certainly, not everyone is going to make this part of their practice. And we know that, for example, 20% of surveyed physicians in a New England Journal of Medicine survey were unwilling to discuss palliative sedation with their patients. That's an option that is clearly accepted by both law and medicine, and it should be available to patients in all 50 states. Yet, a fifth of doctors don't inform their patients about it. So, we know that physicians self-select what they're willing to provide in terms of care, and not all physicians would provide aid in dying. I'd like to see the model that we've been able to open the door to in Montana, considered by other states. And that's the one state that now has nearly a decade of aid in dying practice subject to standard of care, not subject to statute. I think that that model should be more closely looked at by other states and by advocates. Because it's much more normal in the practice of medicine than to have statutory governance. Dr. Bob: Yeah, it's an interesting model. Do you know how ... Of course, Montana is not a very populous state. Is there any data on the numbers of patients that are taking advantage of that right in Montana? Kathryn Tucker: Right. Well, you asked the question that we all ask, and the answer is no. Which is as it should be, because, absent a statute, clinicians are not required to collect and report data to a state agency, which then publishes the data for public review. So, we don't know the answer to that question. We do know anecdotally, from talking to clinicians who have embraced aid in dying in their medical practice, that some clinicians are practicing, and some have been very public about that, and have been willing to talk about their experience in other forums, including in lawsuits, trying to expand and have life, liberty and other states. So, we have the experience and the testimony of participating clinicians, but we don't have survey information. And in fact, I've been working with some researchers who do research into the practice of aid in dying in various states and published studies that you'd probably read about that practice. To encourage them to embark into the kind of surveying that would allow us to answer that question in Montana. It's really, they're excited to do it, it's a question of finding the funding to support their work, and we are also planning a symposium in the state of Montana to bring forward the experience there, and hopefully interested clinicians and patients and health policy researchers from around the country will come to that symposium to learn more about the Montana experience. Dr. Bob: Great. Do you know when that's going to be happening? Kathryn Tucker: We have just chosen the date. It will be September 6, 2019. Dr. Bob: Okay, so about a year plus in the planning. Sounds good. I'll put that on my calendar. Kathryn Tucker: Great. Dr. Bob: Another model that I find interesting, we were talking about the concern about physicians, if more physicians were participating in supporting aid in dying, do they have the wherewithal to truly support the patients? I did an interview with Robert John Keir in the Netherlands, and we talked about the model there, which of course allows euthanasia, in a much broader scope. But they allowed physicians to serve as an attending physician without any specialized training or background. But every patient is required to be seen by a specialist in this infield. There's a select number of physicians who are trained to be able to do the assessment and to provide the guidance and support. So, they provide support for not only the patient but for the physicians who have the relationship with the patient. So, what it does, is it assures that every patient has the adequate support that they would need, which would be an interesting model to be looking at here as well. Because one of the reasons that physicians, many physicians are reluctant is because they were concerned about the burden. They're concerned about the time involvement that they don't know enough to make sure that they're doing everything properly. So, what are your thoughts about that? Kathryn Tucker: Yeah, I don't favor having an extremely specialized small cadre of physicians who do this work. I much favor that the patient can turn to their own physician in the context of hopefully, a long-standing doctor, patient relationship, which can be very rich in terms of what the doctor knows about this individual, and their values, their beliefs, their preferences, and that that can inform the care the physician is able to provide the patient. Rather than having the patient come into contact at a difficult, vulnerable, burdened time of life to meet a new professional, and try to ramp that person up in explaining who they are, and why this is important to them. That's a complex dialogue that one would hope has gone over some period of time. And I think that's why it's so difficult Of course, to extrapolate cross-culturally. But I think it accounts for when you take a look at the data from the Netherlands where it is common that there are these long-standing doctor-patient relationships. And that that then allows the clinician to feel comfortable actually administering life-ending medication to the patient, which is not permitted in the States. But when you're in a situation with a very long-standing relationship, and there's a lot of clarity and understanding about the patient's wishes, the clinician then feels comfortable doing that, and the society feels comfortable supporting it. So, I tend to favor the physician assistants coming from a position with a long-standing relationship with the patient. Dr. Bob: I couldn't agree more. I absolutely believe that that is the ideal version and the ideal scenario. But realistically, I'm also aware of what life is like for physicians, and what that relationship has become. And unfortunately, it would be a long time, which I think many things would have to change for that to become reality. And I think we're both aware of that. That's the idealized version, which would be phenomenal, and it does happen at times. There are times when I have a physician who will contact me and say, my patient is requesting this, I want to support them, I don't really know what to do. It's my first time, and they request my support in guiding them to allow them to be the attending physician, and I may become the consulting physician, but providing additional guidance and support. Kathryn Tucker: That's exactly as it seems it should be, which is that's how standard of care and best practices are established, is clinicians who are new to a practice will look to peers for guidance. That's the beauty of standard of care governance is, hopefully, the more experienced clinician helps the beginner understand what best practices are. And those can, in a normal environment be allowed to evolve as the clinicians learn in providing care. So, I think that's the direction we should be moving, and much of my work now is oriented toward bringing that about. Dr. Bob: That's wonderful. I'm fully supportive of that aspect. I'd like to ... Again, we could speak for hours and just barely scratch the surface of all the things that we might want to talk about. And I am hopeful that you'll be willing to come back and do another podcast with me at some point in the future. But before we close, I just want to give you an opportunity to share whatever it is that's bubbling up for you, if there's something that you want to make sure that you articulate to the listeners, I'd like to give you that opportunity. Kathryn Tucker: Well, I will close by thanking you for offering me this opportunity to share some insight into the work of the End Of Life Liberty Project. And for any listeners who don't know the work with that project, you can find out more by visiting our website, which I hope you will do. We are based out of the UCSF/UC Hastings Consortium on law, science and health policy. But if you just Google End Of Life Liberty Project, you'll come to our website where there's information about our work. There's also a handy donate button. Because of course, this work is the work of a nonprofit and can only happen when donors support the work. So, if any of your listeners are in a position to support this work, we're always grateful and make tremendous mileage out of every dollar donated. You can also like us on Facebook, and get updates on the work of the project through following us on Facebook. Dr. Bob: Fantastic. And we'll make sure that the links for the sites and the Facebook page are on the website where we post all the podcasts. And that's at integratedmdcare.com/newsite1. Again, this was fascinating. I'm always fascinated and grateful to speak with you. I feel like we are in partnership in something incredibly meaningful. The patients and families that we get to care for are benefiting from your tireless efforts. And again, thank you for giving us some of your time and wisdom. Kathryn Tucker: Thanks for the opportunity Bob, and for all of your good work as well. So, congratulations to you.

Bill Palmer has dedicated much of his life to helping people get comfortable with death. Hear why he has hosted more than 75 Death Cafes and what he's learned from them and the people who attend. Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Contact Death Cafe website Transcript Dr. Bob: My guest on today's podcast has been on a really interesting journey over the past several years. Bill Palmer is a successful executive coach and management consultant who lives in Oakland, California. After a personal experience with a loved one who died while being supported by an excellent hospice organization, Bill was inspired to come home to Oakland and start volunteering with other people on hospice. And then he began hosting Death Cafes. To date, Bill's hosted over 75 Death Cafes for members of his community up in Oakland. If you're not familiar with Death Cafes, you will be after listening to this very informative podcast. Bill has had incredible insights through many, many hours spent with hundreds of people openly discussing death and dying. From the very practical aspects to the emotional and spiritual issues. On this podcast, he shares some of the insights that he's gained with us. I believe this can help you become more comfortable having those meaningful and really important conversations that you should be having with your loved ones and with yourself. I hope you're as grateful for these insights and reminders as I was, as I was speaking to them. Bill, thank you so much for being willing to spend some time with us and share a bit of your experience and knowledge with the listeners. Bill Palmer: Sure you're welcome. Dr. Bob: You have an interesting life, I'm assuming. For some reason, you have chosen to dedicate yourself to helping people get more comfortable talking about death. How did that come about? What was the ... My understanding is that you're a business coach and that you're coaching people through different aspects of business and leadership. How do you become a Death Cafe leader from that place? What was your journey? Bill Palmer: The journey really started actually, quite a few years ago when my mother was admitted as a hospice patient in Florida. She received incredibly good care at the Hospice of Palm Beach County where she lived at the time. As a business coach, and as an organizational development consultant, I was struck mostly by the wonderful care that she and my family received, but I was also struck by the incredible business alignment and sense of higher purpose in that hospice. At the time, I thought it was unique. And since then I volunteered in several different hospices. I found that to be more the rule than the exception. Somehow, rather, and I don't recall exactly how I came across a guy named John Underwood who lived in London, and who was the founder of Death Café. It just seemed like a great idea to me at the time. I became a hospice volunteer because I wanted to give something back. It didn't especially require any special skill to be a hospice volunteer. Sometimes just sitting with somebody, visiting, doing a respite visit something like that. But Death Cafe appealed to me because I could bring to bear some of the skills that I feel I have in terms of leading groups and speaking with individuals in an open and honest and kind of free, willing environment. So, I decided I would take John's advice and example and do a Death Café, which is actually pretty easy to do. Dr. Bob: You have the model, right? He shared the model with you and ... From my understanding ... Tell us what a Death Cafe for people who don't really understand it. Bill Palmer: Well, first of all, there's a website called www.deathcafe.com, and it gives a full explanation not only of what a Death Cafe is but how to start one if you want to in your own community. A Death Cafe is simply a free and open ... Free meaning there's no fee to attend, a group meeting of people, whoever wants to come, who want to talk about any aspect of death that interests them. That could be anything from where do I get a will to, deep philosophical and religious concerns to, what are the regulations about scattering ashes to, my companion died 40 years ago and I'm still grieving to, my spouse died last week and I feel nothing. There's an incredible richness of experience and this is going to sound really strange, but they're actually fun. There's a lot of laughter in a Death Cafe. Some of that laughter is just nervousness about speaking about a taboo subject, but some of it is just appreciation of life. If I could make one generalization about the Death Cafes, people leave feeling strongly that what they're doing in their lives right now, whether they're close to death or whether they feel like they're very far away, takes on an added significance if they can find a way to accept the fact that we're all going to die. One thing that surprised me about the 75 Death Cafes I've led is the number of people who apparently, intelligent, responsible, normal people who actually don't really think they're going to die. Dr. Bob: They certainly act like that, right? Bill Palmer: Yeah. Like I said, responsible, taxpaying, voting, civic-minded people who don't have a will, who don't have an advanced care directive, who've never discussed their wishes for their care towards the end of their lives. It is just an indication of the power of the taboo that people who in most every other aspect of their lives behave quite responsibly. But in this one area, even after they see and hear about the chaos that ensues if you die without a will, if you die without an advanced care directive, if you die or become disabled, even after they hear stories about that, it doesn't seem to get them. Dr. Bob: Do you think that people are denying that they're going to die or that they just think somehow things are going to work out? They just don't want to ... They don't feel like they need to do the preparation because things just have a way of working out? Bill Palmer: Well, I guess on an intellectual level, of course, they know they're going to die. But I think on some kind of emotional level, like a child, they don't really believe it. But I think it's probably a little bit of both, is just if you've never sat down and filled out an advance care directives, and you're using a good one, I'd ask some pretty tough questions. For example, if you don't really know what resuscitation is like, you might think sure, resuscitate me. And if you find out what resuscitation is actually really like in many cases, you might decide something very different. Dr. Bob: Right, in most cases. I think people, they watch TV shows, they watch ER or St. Elsewhere, these shows that depict somebody having a cardiac arrest. They do a couple of things and then a few seconds later they sit up and everyone's relieved, and it doesn't depict the absolute horror that ensues when somebody's doing chest compressions and ribs are breaking, and there's virtually no chance of survival in the vast majority of cases. So, yeah, are those kinds of things discussed even at that kind of graphic level? Are people open to hearing those kinds of things when they show up for the Death Cafes? Bill Palmer: Yeah, I think so. Anyone who leads a Death Cafe, including myself, leads it with a very light touch. There's no schedule of activities. There are no small groups. There are no icebreakers or anything like that. It's just open conversation. If somebody brings that up, people listen, and I think people are affected by it. There is a great deal of information that gets shared. A common statement is, my family won't discuss my death with me. I will or someone else in the group will say, "Well, here are some great resources." The conversation project, for example, can give you some tips and guidelines and do's and don'ts for, how do you have this conversation with people that don't want to talk about it? It's not an easy thing. So, I think there's that and there's a sense of comfort and community and that people find out well, gosh, I'm not alone in this. Other people feel this way too, or are afraid of the same thing, or have had a similar experience. I think it's comforting to people. Dr. Bob: Yeah. Oh, it's rich, and like you say, it's a safe space. Interestingly, I haven't been to one for a bit, but when I went to a few Death Cafes here in San Diego, and they did break up into small groups like four people and then there were some sample questions to stimulate conversation. There was a little bit of discussion as a group. I think as I remember, representatives from the small groups talked about some of the insights that came out. But I felt like there were so many people in the room, there were maybe 50 to 60 people in the room, and I felt like we missed getting the insight from more people in that space. So, I feel like maybe the open format like you're describing could be even more effective if everybody who wants to speak has a chance to. Bill Palmer: Well, anyone who's interested in starting a Death Cafe can read on the Death Cafe website, very specific and clear instructions for leading one. I think that if someone is fortunate enough to get 50 or 60 people at a Death Cafe, that's nice, but I think it's an unwieldy number. I know that I've always limited the attendance of Death Cafe to 20. Even at 20, it can be a bit unwieldy. So, I think the smaller group dynamic works. I know I was asked to help with a Death Cafe that was being sponsored in a retirement community here in the East Bay in California. 40, 50 people showed up. Yeah, we split up into small groups, but it just wasn't as satisfying. It is just really difficult to manage. If anybody's considering doing it, I would strongly recommend that you limit the attendance. You can use a website like Eventbrite which is a free ... It's like Evite, or Eventbrite, one, they're pretty much the same. You can invite people to purchase free tickets, or just sign up for registration. Then you can limit it to 15 or 20. Dr. Bob: How did you go about finding a location? Because if you're there's no fee, I'm assuming you've done 75 of these, I'm assuming that you're trying to avoid spending a lot of your own money on these. Is there money available from any organization to help defray costs of putting these on? Bill Palmer: Actually, to be specific, The Death Cafe, you can charge a fee if it's to reimburse the cost. For example, if you rent some space or if you provide some refreshments, you can recoup the cost with nominal fees. I was very fortunate. There's a funeral home here in Oakland called Chapel of the Chimes. They have a long, long history of community involvement and a beautiful setting. They have a lovely acreage and their buildings are fantastic. They have a high commitment to community service. So, I called him up and I said, "Would you sponsor a Death Cafe? I.e. give us free publicity, give us free space?" They said, "Yeah, we'll do that, and we'll also provide coffee and cookies and donuts for you. Because it's right in line with the way that we want to be involved with the community." Death Cafe Oakland gets free space and a little bit of free publicity. They get 20 people a month walking in there who maybe otherwise wouldn't know about Chapel of the Chimes. They've just been great to us. Churches are likely spots, community centers are likely spots. Synagogues are likely spots, and funeral homes I think. There's an obvious disincentive for certain people, well, I don't want to go to a funeral home ever for any reason, but it's worked for us very well. Dr. Bob: Right? Well, my sense ... So, a great alignment, it seems like a great partnership as long as everybody's approaching it with the right intention, and it's comfortable. You don't want to partner with somebody who's going to be pushy and pushing their services. It sounds like that's clearly not happening. But the people who are coming to Death Cafes are probably the same people who don't mind walking into a funeral home. Bill Palmer: That's probable. Dr. Bob: You've got a bit of a self-selected group. Well, that's helpful. I appreciate that. So, you've done 75 of the Death Cafes. When was your first one? Do remember- Bill Palmer: March, of 2013. We actually had our 76th last night. Dr. Bob: Fantastic. So, you've spent 76, and then they're probably what, an hour and a half to two hours each? Bill Palmer: Two hours, yeah. Dr. Bob: Okay. You've had a lot of time to hear people sharing. I'm sure that you are well aware of some of the gaps and the challenges and the struggles around living and dying. Can you share some of the top insights that you've gained from the experience, and offer some of those to the listeners? Bill Palmer: I've thought about this a lot. Something that jumps out at me is that how we die in America is largely a function of race and wealth. Death Cafe in Oakland or the part of Oakland that we're in is a very different thing than a Death Cafe might be in a very different part of Oakland. That jumps out at me constantly. Another thing that jumps out at me is, we live in a secular world, many of us do. Certainly, here in California, at least in the East Bay, in the Bay Area. I'm not sure that that's a bad thing but another thing that jumps out at me is that the loss of rituals, of customs, and community, most religions supply ... Things are taking their place but if you look at the Jewish religion, or you look at Islam, or you look at Catholicism, really any of the major world's religions, Hindu, there are very specific rituals and customs around death that are a comfort, and that allow people to navigate or at least help them to navigate through what is painful and difficult. So, I think that a lot of the interest in Death Cafe and in the conversation around death, it's much larger than Death Café, is around some of the loss of those rituals and the lack of replacements for them. Dr. Bob: I started to write down the statement because I'm sure it was going to be something really valuable. Could you finish the statement, the loss of rituals, customs and community around the time of death has- Bill Palmer: Left a vacuum where people are alone. They don't have a way to navigate through that first, terrible few days, weeks, months. I just think it makes it harder. Dr. Bob: It's a vacuum, I can see that. So, people were coming to the Death Cafes in part to help to fill that void, that vacuum, or because they're afraid that that will be there? Bill Palmer: Yeah, I think on two levels. One is simply, what are rituals that I could participate in that I no longer an observant and fill in the blank. Catholic or Jew or Muslim or whatever. There are rituals that people have created in this country or reinvented in this country about dying at home, and how to care for the body of someone who has just died, against the medicalization and hospitalization, and institutionalization of death. So, I think it's both those things. Some of it is just information. What am I supposed to do? Where can I go to find some community around it? Dr. Bob: The practical issues that can really lead to a lot of stress and anxiety if they're not addressed or planned for. Bill Palmer: Yeah, exactly. Dr. Bob: Any other big insights that are jumping out for you? Bill Palmer: Unfinished business. I can't tell you. I haven't done an exact count, but probably in the 75 Death Cafes, we've had, oh gosh, 500, 600 people come through there. What I constantly hear is five years, 10 years, 20 years after someone died, that the unfinished business that I had with that person haunts me. I never forgave them, or they never forgave me. I had a sister, brothers, spouse, father, mother, son, daughter, and I never resolved what it was that drove us apart. To me, unfinished business in our relationships is the gasoline that gets thrown on the fire of grief. It just makes it all that much worse because you can't fix it once they're gone, they're gone. So, that's something that I hear over and over again. Dr. Bob: Do you offer resources ... it seems to me like ... I think one of the things that felt a little bit dissatisfying for me about the Death Cafes, was that there were people who are clearly looking for support and needing additional help and resources, and there wasn't ... Because it's not promotional, you're not giving out pamphlets or directing people specifically to resources. It feels like there would be an opportunity to bring in some experts and to have people bring in their specific questions to get that kind of guidance. What's the thinking on that? Bill Palmer: Well, I think the thinking is, and it may be flawed is that, above all, John Underwood the founder of Death Cafe did not want to commercialize. I've had any number of invitations from perfectly respectable, fine people who have a book, they have a program they have this, that or the other thing, and they want to come in and in effect, make a sales pitch. Under normal circumstances, I'd say that'd be fine. But I think it leaves us open to having to vet them, having to know what they say. My solution has been to, I've created a Facebook page for Death Cafe Oakland. I post resources there. If somebody says, "Well, gee, how do I start this conversation with my spouse?" I can mention the conversation project. I can also tell people to look on that Facebook page, which is open to the public. You don't have to have attended Death Cafe Oakland to see it. You can find wills, you can find an Advance Care Directive. You can find lots and lots of research. So, I agree with you that the one thing I do specify is that, and I say this at the beginning of every Death Café, is this is not grief counseling. So, if you're grieving, what I say is, please talk about if you want to, we will support you, but it's not grief counseling in the sense that I personally cannot offer you continuing support. Dr. Bob: Yes, it's not a support group. It's a forum, right? With a lot of people coming for different reasons? Bill Palmer: Right. I can refer them ... They can do a Google search as easily as I can on bereavement groups. There's many of them. But I agree with you, my solution is a bit of a compromise, and hopefully, it's workable, but probably every single person who ever came to Death Cafe Oakland who wanted a specific resource for a specific need sometimes didn't get it. Dr. Bob: You're staying true to a mission and that's honorable and it makes sense because you could open it up for all kinds of challenges if you don't keep the boundaries clear, and you're providing ... Again, you're doing this all as a volunteer, right? You have a career and you have to divide your time between things that allow you to pursue that and to ... I really applaud you, commend you for your passion and commitment to this. It's really remarkable. Bill Palmer: The irony is I get more than I give. I appreciate you for saying that, thank you. Dr. Bob: Just to quickly follow up on that, what have you gotten? How has it changed you to have this experience and to be part of this movement? Bill Palmer: Well on a very practical level, to avoid any hint of hypocrisy, I have filled out every form known to humanity with regard to my death, and I'm closer in terms of age, I've got a lot more behind me than I do ahead of me. I think that what I've gotten, the most valuable thing I've gotten about that is, if not an acceptance of it, but a clear idea of, if I have my way, how I want it to go to know exactly what I think is right for me in terms of end of life care. If I'm not able to make decisions or to be mentally competent, a great deal of faith in the agreements that I have with my family, specifically my daughter and my son, who I 100% trust will carry out my wishes should I not be able to act on my own. So, that's a huge gift, that really is. Just the incredible richness and variety of the people who show up, I'm always interested in groups of people. I'm never bored in a group because I'm always watching to see and hear and feel what's going on, and they never disappoint me. It's always fascinating. Dr. Bob: Yeah, I couldn't agree more, especially when they're talking about issues that are so vital and important to them. Do you still have any fear or concerns about what lies ahead for you? Bill Palmer: Sure. I think the idea of gradually losing capabilities is what bothers me and bothers most people that I talk to. Not that I'll be dead, but that I won't be able to move, or I won't be able to speak, or I won't be able to hear, or see, and then that gradual loss of capability, of mobility. Of course, I'm afraid of that. I've also been a hospice volunteer and seen people who seem to live with a quality of life, whose lost a lot. So, I take a little comfort in that. But yeah, that scares me. Dr. Bob: That is such an interesting awareness, right? That some people when they lose certain capabilities, certain degrees of independence, when they're dealing with challenges, some people are ready to die because they've lost these things and it's intolerable for them and they're ready to check out as soon as possible. Then there are others who just handle it with such grace and acceptance and even joy. I don't know what the secret formula is, I'm looking for it. Because I want to be able to A, have it for myself, and B, be able to prescribe it for my patients. But it's such a unique individual, I guess, a way of being in the world. I try to figure it out, but I haven't been able to, and I'm still working on that. Bill Palmer: Let me know when you do. Dr. Bob: Yeah, I will. You'll be one of the first ones. As far as ... I think most of us share a little bit of the fear of the unknown of what's coming. I guess one of the things that I'm really passionate about now is helping to give people a greater sense of understanding, a greater sense of control over the circumstances that they may find themselves in. Part of that is by doing all the right preparation, filling out all the right paperwork, having the conversations with those who will be responsible for making those decisions if you can't. But also, I think ... Do you feel like you have a medical team, do you feel like you have a physician who if and when things become really challenging or intolerable for you, will engage at the level that you need to support you through that difficult challenging last journey? Bill Palmer: Yeah, I do. I am a Kaiser Permanente member. And one of the criteria for my primary care physician that I insisted on was somebody who would not only understand my wishes about that but who would act upon them. The interviews that I did, I found a physician who I'm reasonably certain will honor my wishes. My advanced care directive is scanned into my medical record there... it's a crapshoot a little bit- Dr. Bob: A little bit, it always is. Bill Palmer: You fall down on the street and nobody knows who you are, and they take you to whatever hospital, the ER people are bound by law and by custom to do everything that they can to resuscitate you. Is there a chance it could all go sideways? Yeah, but I feel like ... I've taken every precaution I could to try to make it go the way that I want, and my physician she seems like she's just fine with it. So that's important. Dr. Bob: Well, let's hope whenever it happens, many many years in the future, she'll probably be retired, and you'll have to have a new person who comes on ... I guess that's a good reason to try to find younger doctors so that you connect with. Well, this has been great. I feel like we've given people a great overview of what the Death Cafes are designed to do, and hopefully given some insight into where some of the challenges and struggles people face are, and how to try to mitigate those. I appreciate your time. If you have any burning thoughts that you want to share before we sign off, I am all ears. If you feel like you're complete with what we've discussed, that's totally cool too. Bill Palmer: No burning thoughts, but I want to thank you for the time, and for your thoughtful questions and statements. It was great to connect with you and someday, some way I hope our paths will cross. Thank you again. Dr. Bob: Thank you, Bill. Bill Palmer, founder and curator of Death Cafe Oakland, and I'm sure our paths will cross hopefully fairly soon.

Lydia Lombardi Good is a licensed clinical social worker. She shares the importance of self-compassion, what it is, and how to get comfortable with it and how it helps the grieving process. Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Contact Lydia Lombardi Good, Pier View Counseling Transcript How Self-Compassion Helps The Grieving Process Dr. Bob: Yeah. That's my pleasure. This is a Life and Death Conversation, and we talk about things that we can do to enhance life and bring more joy and peace to life, and of course, we talk about death. We don't shy away from the topic of death. We always explore a bit about how our guests feel about the whole end of life, death and dying, what experiences they've had, how the awareness of death seems to show up in your life. For people who come on and have these conversations, most of the time they're pretty comfortable speaking about death and sharing their experiences and thoughts about it. I'm just going to open it up and let you share a little bit. I know that you do a lot of work in grief and loss, and you've been in hospice, and have a lot of experience. So share a little bit about what the idea of death and dying means to you, and how it shows up in your life. Lydia Lombardi Good: What I learned from my experience with death and dying, working with clients, having my own personal experience losing close loved ones, is the more we think about death and understand that it is inevitable, and we are all dying a little bit every day, I think the richer a life we are able to live, and we are more mindful of the choices we make, and the people we choose to surround ourselves with, and the life we want to live, knowing that nothing is permanent. Everything is impermanent. And if we live a life without regrets and can be more present to our lives instead of staying maybe stuck in the past, or focused too much on the future, we can look back and say, "You know, I fully experienced all that. I don't wish to be back there again. I wish to be right here, right now, to live my life fully," knowing that we really only have one shot at that. So that's how it's changed me a lot in terms of my own choices, the way I live my life, the way I try to stay compassionate. A lot of it's talked today, and what I really am passionate about is teaching people to embody self-compassion and treat yourself kindly, the way you would treat a close friend. And the more we can do that, the better life we can have. The more chances we take, the more we can just fix up things as they are, instead of always wishing things to be another way, or for us to be another way. And when we do that, we're missing what's happening right now. Dr. Bob: Yeah. That's beautiful. And I think it's pretty common to hear people share that when they contemplate death, when they recognize, like you say, the impermanence of everything, it really allows us to stay more focused on what's happening right now, and feel gratitude, and just feel very present. I want to talk about the mindfulness, the self-compassion, and the mindfulness, because mindfulness meditation, self-compassion have figured prominently in my life and I've done my work there, I've gone through courses in mindfulness. And it's so interesting what you said, to treat yourself the way that you would treat a close friend. Do we do that? I mean, do we really do that? The stuff that we lay on ourselves, and the way that we diss ourselves, which is so common. Like, if we were doing that to a friend, would they stick around? Would we still- Lydia Lombardi Good: We wouldn't have any. Dr. Bob: We wouldn't have any friends. Share a little bit more about that, about how you came to that, what your journey has been to become a teacher of self-compassion and mindfulness. Lydia Lombardi Good: Yes. Yeah. So, I was working in hospice since about 2007, 2008. Right out of graduate school I started this work, and I think I understood it to the best of my knowledge. I'd had a lot of loss in my past, and a lot of trauma that I thought I had worked through and had done a lot of healing around and was in this work. And I think I had as much compassion for the experiences of my clients and patients as I could have at the time, for that point I was in my life where I was at and what experiences I had been a part of at that point. And then it was 2012; I lost my dad to cancer. He died of prostate cancer and endocrine cancer. So the three years prior to that, we were taking care of him, and it was a real aggressive form, so it was a really difficult dying process. So that following year I was in charge of settling what I call closing out someone's life. That process of closing up his home, preparing it for the next chapter, getting his belongings and setting up beneficiaries, that kind of thing, and doing my grief as best as I could, as much as I knew how at that time. And then, shortly before the one year anniversary, I got a call from the medical examiner's office that my uncle, who was one of my father's primary caregivers aside from myself, had taken his life. So then I embarked on that next journey. I was his only family here, so helping to then close out another person's life. And then two months later, I get a call. My husband's out of state at a bachelor party. And I get a call that he's had an accident and I need to fly out immediately to Arizona and be with him because he's had a traumatic brain injury. So I fly out there and spend 10 days in ICU with him until we were basically told that we need to consider letting him go because he was not going to recover at that point. So my real journey I think began there. I could make sense that my dad was in his late 70's, although for some that is still young, but he had lived a really full life. My uncle, I wasn't as close with. It was a different type of grief, but losing my own husband was a total ... knocked me off my feet. It was a total life-changer. So basically, learning about self-compassion and mindfulness started the year before, when my dad was going through his dying process, but really kicked into high gear after I lost my husband, simply for just survival. I was in survival mode- Dr. Bob: Yeah, self-preservation. Lydia Lombardi Good: ... trying to figure out, yeah, how do I survive all this. Three in a row, I'm totally alone, feeling like I'm totally alone. How do I keep going? How do I keep going? How do I make sense of ... if this can happen to my 32-year-old husband, what's going to happen to me? This feeling of just total lack of safety and security and anything that I once knew. So that's when things really, really kicked into high gear for me. And a couple of years later I ended up leaving hospice. I was working out as a bereavement manager, and I decided to start my own practice, focusing on grief and trauma. A lot of it because of all the work I did with amazing clinicians, and spiritual healers, and energy healers, and the amazing, amazing people that supported me through my past, inspired me so much that I felt I really needed to do this myself and work with individuals again, and step away from the program planning and go back to pure clinical work. And it's been amazing. Dr. Bob: I bet. Wow. And like many people, your journey has taken you someplace because of your own personal experience. I mean, you have the training, you have the structure of having worked in a company, but once you had your own personal experience and were down in the depths, and then figured out what you needed to do to survive, and then I'm assuming beyond surviving, starting to thrive again, you recognized that you needed to be in a position to share that on a deeper level. Lydia Lombardi Good: Yeah. It's been tremendously healing, although I didn't jump into it necessarily to do it for my own healing. I wanted to make sure that was taken care of on its own, so I wasn't coming to work with clients doing my own work. But feeling complete and on a really steady path with my own healing empowered me to know the tools that work for people, and to empower others to consider some of these healing modalities. And mindfulness and self-compassion were right up there. They were the primary methods for me in terms of my healing. A lot of people as what does that mean. When I heard, "Self-compassion," I frankly, four, five, or six years ago I never knew what that even meant. It's not a term a lot of people in western culture understand or use. So really learning what that meant, and practicing it for myself, so I could know how to show others to do that. Dr. Bob: So why don't you try to explain it and let people know, because there's probably a lot of people here who ... you know, the self-compassionate conjures up some images and some thoughts, but I think you could probably do a really good job of helping people see what it really is to learn self-compassion. Lydia Lombardi Good: Yeah. So, self-compassion defined more is bringing yourself to the same attitude and understanding that you would do for others, or a beloved friend. So asking, how can I care for and comfort myself at this moment, instead of judging and criticizing. How can I bring kindness and understanding, and patience, when I'm confronted with a personal feeling or loss, instead of beating myself up. And then honoring and accepting your humanness. And with grief, I think where I see a lot of people, and I did this myself, we put ourselves in a timeline immediately. I was talking to a woman the other day, and she said to me she just lost her fiance a week ago. And she said, "I'm trying to be happy. I know I need to be happy, so I'm just going to be happy, and I cry when I need to, but I just want to be happy." And I said, "You know, why do you have to be happy? You just lost your fiance. Can you just honor what's really happening with you? You're sad, you're angry, you're all these feelings ..." that she was telling me before she said she felt she had to be happy. We try to pressure ourselves to move faster than we actually it's reasonable for our healing. And this is actually what stuns our healing when we try to pretend it's another way. We try to pretend that ... you know, you'll hear people saying, "In a year you should be better. Just give yourself that year." Well, for some people a year it's just begun. The trauma is just starting to settle, and now all of the sudden there is space for grief. Or the realization or the beginnings of acceptance begin to occur after a year, for some people longer. None of that's wrong; it's just is. But with self-compassion, we can give ourselves that space to say, "Whatever's happening is just right for me. As long as I'm not hurting myself or I'm hurting another person, this is what I need to do in order to move forward and to heal, step by step." Dr. Bob: So how does that happen? How does somebody learn self-compassion? How do you go from having the normal chatter, the typical berating and judging that most people have ... has become sort of their pattern, to having this self-compassion, and what's the process? Lydia Lombardi: I think the first part is learning you're being able to become aware of the voice inside you and what it's saying, so really listening to that. So if you start to notice your pattern of self-deprecation, or being really hard and punitive with yourself in difficult times, starting to become an observer of those thoughts instead of allowing yourself to become hooked to them. The problem is, a lot of us, me included again, we get so used to those thoughts, they just become ... we get on autopilot with them, which becomes kind of a way of being. But by practicing things like mindfulness, or meditation, we allow ourselves to slow down a little bit, take a breath in between thoughts, and start to notice the thoughts instead of getting hooked. For example, I used to notice I would get really frustrated with myself when I would get really, really down. Like, a year or two after my husband had died, I would all of a sudden have a really bad day, a really bad grief day, and I used to think to myself, "Gosh, where is this coming from? What's going on? Why am I feeling this? Gosh, I've done all this healing, and I've done all this work. Why am I sobbing now? Something must be wrong with me. Maybe I'm just not doing enough work to heal." And all these questions, instead of just catching the thought and saying, "You know what? There I go again. Can I just have the feeling that I'm feeling and let it rise and fall naturally, instead of resisting?" Because we find, when we push against it, and we create this resistance, we actually create more suffering for ourselves. And this is a real Buddhist concept as well, that pain is inevitable, but pain with resistance equals the suffering. When we can just settle into the pain and just feel it, it's like when we have a good cry. When you're stuffing it down, and it's that nod in your throat, it hurts so bad, it's so uncomfortable, but then when we just let ourselves ball, all of a sudden you notice you come out of it and it's like, wow, I feel so much better. Why didn't I just let myself do that before? Dr. Bob: It's a catharsis, yeah. Lydia Lombardi Good: Yeah. Dr. Bob: I think we need to allow for more of that. So, a big thing that's coming up for me as you're describing this process is awareness, self-awareness. That's the first step, right? Because if you're not aware, if you don't have an awareness of what's truly taking place, there's no way that you can influence it, or impact it. Lydia Lombardi Good: Exactly. Dr. Bob: And again, going back to this, sort of the analogy of treating yourself like you would treat a friend, imagine if you were with somebody and they said something just kind of off the cuff, and your response was, "Well, you're an idiot. Like, what a stupid thing to say." Or, "There you go again, making a fool of yourself," those kinds of things that people are so comfortable saying to themselves, thinking to themselves, that if they were being said out loud to a friend, they would never tolerate that. Lydia Lombardi Good: That's right. That's right. That's exactly right. Why is that okay to do to ourselves? Dr. Bob: Yeah. It's not, but we do it, and we keep doing it. And I think we just believe that this is the way that it is. People become so accustomed, and I think it deflates you just like if you have a teacher who's always telling you how stupid you are, or a parent who's always telling you how disobedient you are, or sloppy, or whatever. That has an impact, and it will keep us from really feeling the depth of I guess the beauty and the magic of life. Lydia Lombardi Good: Yes. And it holds you back from that experience that you deserve to grief. And sometimes that sounds really strange when I say that to people, the love you had for that person needs to be expressed through your grieving process. Someone told me years ago grief is the twin of love. You can't have one without the other. So, why are we suppressing this grief expression if it's simply an expression of our love? And whatever that grief presentation looks like. For some it's crying, for some it's sharing stories with family, or memories, or whatever that looks like, memorializing, ritualizing the person. But you're entitled to that experience. That's how we're able to move forward. But when you don't allow that experience to yourself, it's still there; it's still going to be there. A lot of people will say time heals everything. It's actually time and attention. Time alone doesn't do a thing if we're not giving it the attention that it needs to do the healing that we deserve. Dr. Bob: Time can actually just cause more festering and the wounds to deepen. Lydia Lombardi Good: Right. Dr. Bob: Yeah, if you think about it kind of like an infection in your system, yes, there are some self-limited infections that will get better over time, but there are some that if they're not addressed, if you're not aware of them, and deal with them, they'll eventually cause incredible suffering and ultimately kill you. Lydia Lombardi Good: Exactly. Exactly. I use that wound example a lot. Dr. Bob: Yeah. Interesting. And one of the other things that came up, and I'm sure that this is something that's very much in your awareness and in some of what you teach, is the concept of the gap, the space, that most people just remain unaware of. So we go back to awareness. And I think it was Victor Frankl who originally made this quote. I actually saw it in one of Steven Covey's books, but it's a quote about between stimulus and response, there is a gap, there's a space. And it's within that space that our freedom and our power come from. And the fact that we have that space to choose what to do with, how to respond, if we're going to respond, what to do with that stimulus, that feeling that came, the words that someone spoke, if we recognize that we have this power, everybody has this power to take a space, take some time, and choose what to do with it, it is too incredibly empowering. Most of us are just reacting all the time without giving any honor to that space. Lydia Lombardi Good: You're right, you're right, and that space is where all the magic happens ... Dr. Bob: That's where all the magic happens. Lydia Lombardi Good: ... where physiologically we can settle our nervous system, we can move into a more parasympathetic nervous system and really think critically, shift those thoughts to a different part of the brain and be more skillful in our actions, exactly. Dr. Bob: Yeah. Lydia Lombardi Good: And maybe that just means that we still don't know what to do, and maybe skillful means stepping away and just taking a break and thinking more about what to do next, instead of jumping right in and just making a reactionary decision that could actually lead to more harm. Dr. Bob: Right. Yeah. That awareness, and it's something that I've tried to teach with my children, with others, and of course I forget. I still at times react ... Lydia Lombardi Good: Sure. Dr. Bob: ... and then when I realize that I've given up my power, I'm giving up my power to choose a response, then I actually exaggerate it, where I start ... I'll give it a full two or three seconds, when somebody says something, rather than having an immediate response prepared and going right into it, I will exaggerate the space. And sometimes it can almost be a little awkward. People wonder what you're doing and why you're not answering, but it just kind of reminds me and allows me to feel empowered and to feel a sense of peace and control again. That's a really great exercise. Lydia Lombardi Good: Absolutely. Absolutely. We're not used to that in our culture. You're very right. We always feel like we need to fill the space. And I think that's a big part of the problem too; even when we're consoling a person who's grieving, we have a hard time just sitting with their raw emotion or the feeling, or just saying nothing and just being present to their experience. We have a hard time with that. We feel like we have to say the right thing, or jump in and fix it, or push the tissue box to them real quick, to make sure their tears don't get out of control. We can be messy and just sit with snout rolling down our face. Just say it's okay. This is what's happening right now; it's okay. We don't have to fix it; we don't have to talk over it and make it pretty, put a bow on it. Dr. Bob: That's one of the things that's been such a gift for me, working with people, especially at end of life, people who are approaching the last days or weeks of life, is I get to visit them in their homes and spend time with the patient, the family, the person. And sometimes I will just be there. The conversation will stop, and as you say, so many people want just to fill the... it's uncomfortable, so they just want to fill it and find something to say, and think that that's going to make it better. But what I'm recognizing is, people will want to know that you're comfortable just being present, and just holding that space, maybe holding their hand, having a head on the shoulder, or just being in that space so you can feel what it is that's happening, and maybe reflect back just some concerns, some love and support. As an ER doc, for the 20+ years, I was an ER doc, you don't have much time to do that. But now being in people's own home, it has been such a gift. And it's a gift for me, and I think it's a gift for them to know that there's a certain comfort with just being present. Lydia Lombardi Good: Yeah. Yeah. Absolutely. And it's so humbling for you as the individual, to just allow yourself that humility to know that you don't have the right answer. And people really respect that I find. They can tell when you're just trying to fill the space, or trying to fix it. But when you have enough humility just to say, "You know what? God, I don't have the answer to this. Maybe there isn't an answer to this." Dr. Bob: Right. So let's just be together for a moment. Lydia Lombardi Good: I'll just be here. Dr. Bob: Yeah. Let's just be. Lydia Lombardi Good: Yeah. Dr. Bob: Yeah. That's powerful. Lydia Lombardi Good: Yeah. I'll tell you just a quick story. My husband died in November, and a month after I was [inaudible 00:25:17] mother and it was Christmas night. And my neighbor comes. This is a neighbor who I grew up on that street with for my whole life, and he had a son who had died. I think five years prior, in a really tragic accident. And he showed up at the door, and I open the door, and I said, "Paul, what are you doing here?" And he opens his arms, and he said, "There are no words. There are no words." He says, "I just came here to give you a hug." And every time I tell this story I get teary-eyed again because I just think, I'll never forget that. I'll never forget that. Tons of people told me all sorts of stuff, but that simple act of just, listen, I'm just here to give you a hug and to hold you. I don't have answers; I don't have anything to tell you what to do or not to do. I just want to be here, was so profound and I'll never forget that. I try to remember that very clearly, to remember of my own action, how to be with others, how important that was. We forget. We forget the importance of that simplicity, that human connection. We're looking for the next intervention. Dr. Bob: Yeah. And that goes back to a little bit of that self-talk. It's like, "I don't know enough words. I can't be consoling or comforting. My presence isn't ... that's just not enough." So it's complex, and I think it takes time for someone to learn this too. It's not innate. For some people maybe it is, but for most of us, it's learned over time. And sometimes it's through those personal experiences as well. Lydia Lombardi Good: Right. Right. And what we do know is that actually the more we practice it, it actually can restructure parts of our limbic system in our brain and help us ... it's like building a muscle. The more we practice, the better we get at it. Or we're making new neural connections, and over time it becomes easier to tap into. But you're right. It takes time. It's a skill. It's a skill. Dr. Bob: It's an interesting thing. I was just realizing that some of what has changed for me, some of the learning that I've had through being with people in this state, in this condition, it spills over into other parts of your life, where I now feel more comfortable in other relationships with silence, with just being present and not always thinking that I have to fill the space with my wife, or with my children, that there's a deeper connection that can exist just by sharing a space together, which is interesting because a lot of time I'm someone who has kind of felt like if we're together, we should be talking. Like, we should be communicating about something in some way, and if not, then it's because we don't have anything to say. Lydia Lombardi Good: Right. Right. Dr. Bob: So I'd become much more comfortable, which is nice. Lydia Lombardi Good: Yes. Yeah. It's so beautiful that when we get better at this in our work, it does spill over and makes all of our relationships and experiences, as I said in the beginning, so much richer. Yeah. Dr. Bob: So you're in San Diego, right? Or in San Diego County. Do you have an office where people come to see you? Or do you go- Lydia Lombardi: Yes. Dr. Bob: ... see people at home? How does your practice work? Lydia Lombardi Good: I have a practice in Vista, North County San Diego, Pier View Counseling. Pier like the pier in the ocean. And I specialize in supporting people who are experiencing grief, trauma. And my subspecialty is really working with partner loss. But all ages. I actually have a group as well in Vista, at Vista Library, the second Saturday of every month. It's a grief support group. Anyone's welcome to come. We've been going on for about almost three years now, and people come and go and use the space as needed, and it's a really nice complement to some of the individual work I do, where people either who just aren't interested in individual work right now, or just looking for others who are going through a same life transition they are and are just, again, wanting to tap into that common humanity, which is part of that self-compassion piece, knowing others are experiencing what you're experiencing too, although it looks a little different, we're all going through something. So yes. People come to me at my practice. And I do some Saturday hours at another office in Oceanside, but mostly Vista. Dr. Bob: All right. Great. And I'm assuming that you have some resources for people on your website, that can help them get a little more information about you, and a little bit about some of the topics that we've been covering? Lydia Lombardi Good: Yes. PierViewCounseling.com. Dr. Bob: We'll have links for that on the podcast as well, integratedmdcare.com. So there are lots of ways for people to find you, which is wonderful. Lydia Lombardi Good: Great. Dr. Bob: I have a feeling, now that we've had a chance to connect, for me to learn more about your background and how you approach things, I certainly feel that there will be opportunities for us to collaborate with some of the patients and families that we're supporting as well. Lydia Lombardi Good: Well, I'd be honored. Dr. Bob: Yeah. I look forward to that. I really, really appreciate you taking the time and sharing some of your experience and your wisdom with our listeners, and I'm hopeful that maybe there will be another opportunity to bring you back on and revisit some of this in the future. Lydia Lombardi: Thank you. And thank you for everything you do. So important. I could say that from working in the field, but then when you actually have it, when my dad was dying, having that experience in our home, it changed everything. I saw it from a whole another light, how critical that support is when a family member is dying. So thank you for what you do. Dr. Bob: It's my honor, and I imagine having you there for your father who was an incredible gift for him. So he was very fortunate in that. Lydia Lombardi Good: Yeah. Grateful. Dr. Bob: Yeah. Thanks, everybody for tuning in, and we'll talk with you very soon. Have a great day.

Please Note:  This was recorded as a Facebook Live earlier this year prior to the recent ruling to overturn the California End of Life Options Act 2015 by Riverside County Superior Court Judge. In response, California Attorney General Xavier Becerra filed an emergency appeal seeking a stay of Superior Court Judge Daniel Ottolia's ruling that invalidated the less than two-year-old medical aid-in-dying law.  "It is important to note the ruling did not invalidate the law or the court would have said so explicitly in its order, so the law remains in effect until further notice," said John C. Kappos, a partner in the O'Melveny law firm representing Compassion & Choices. If this law and the right to die with dignity is important to you, we urge you to learn more from Compassion and Choices the organization that helped get the law passed.  Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text.  We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Need more information? Contact Dr. Bob for a free consultation. Transcript Dr. Bob: On this episode, Elizabeth Semenova and I speak very frankly about what it's like to support people through Medical Aid and Dying. We explain the process; we discuss who asks for this kind of support and why there are still so many barriers. This was originally captured as a Facebook Live and repurposed as a podcast because this information is so vitally important. Please share the podcast with everyone and anyone you feel would benefit from listening. Thank you. Dr. Bob: I'm going to do a little bit of introduction for myself, if you're watching this and you have been on the integrated MD Care site, you probably know a bit about me. I've been a physician for 25/ 30 years, somewhere in that range. Over the past several years I've been focusing on providing care for people who are dealing with complex illnesses, the challenges of aging, the challenges of dying. During these few years, I've discovered a lot of gaps in the health care system that cause a lot of challenges for people. Dr. Bob: We developed a medical practice to try to address those big challenges in those big gaps that we've encountered. It's been really remarkable to be able to do medical care in a way that is truly sensitive to what people are really looking for and what their families are looking for that is not constrained and limited to what the medical system will allow. It's not constrained by what Medicare will pay, what insurance will pay. We allow people to access us completely and fully and we are there to support them in a very holistic way with medical physician care, nursing care, social working care and then a whole team of therapists. Massage therapists, music therapists, acupuncturists, nutritionists. Dr. Bob: So that has been really fascinating and phenomenal. Elizabeth came along in the last several months. Really, she was drawn primarily to the true end of life care that we deliver and has been truly surprised how beautifully we are able to care for people who aren't necessarily dying as well. Elizabeth: Absolutely, yeah. Dr. Bob: So we can talk about all the different aspects of that, but we are here today to really talk about Medical Aid and Dying. Because, shortly after we started this practice, back in January 2016 California became one of the few states in the United States that does allow physician-assisted death. Dr. Bob: It allows what is also known as Death with Dignity, Medical Aid in Dying. The California End of Life Option Act passed in June 2016. At that point, a person with a terminal illness, an adult who is competent, had the ability to request a prescription of medicine from their physician, from a physician. That if taken, would allow them to have a very peaceful, dignified death at a place and time of their choosing. Since June 2016 we have become essentially experts and kind of the go-to team in San Diego for sure and actually throughout a good portion of Southern California because other physicians are reluctant to participate or because the systems that the patients are in make it very difficult or impossible for them to take advantage of this law. There is a lot of confusion about it. It's a very complex, emotionally charged issue. We as a team, Elizabeth and I, along with other members of our team have taken it upon ourselves to become true experts and guides so that people can get taken care of in a way that is most meaningful and sensitive. In a way that allows them to be in control and determine the course of their life leading up to their death and how they are going to die. That's why we are here. We want to educate; we want to inform, we want people to not be afraid of the unknowns. We want to dispel the myths. I'm passionate about that. We work together, and I think we do a very good job as a team, of supporting patients and families. I'd like to have Elizabeth share a little about why this is so important to her and then we are going to get into some more of the specifics about what's actually taking place, the requirements, how the process works and if there are questions people have we are going to answer those as well. We are going to go for about 20/ 25 minutes, and if it turns out that we don't get through enough of our material then we will have another session, but we don't want to make this too long. We want to make it concise, meaningful and impactful. Elizabeth: Okay. Dr. Bob: All right. Elizabeth: Okay. I started as a hospice social worker, and I became an advocate for Aid and Dying because I learned about the law. Learned that there were not a lot of options, policies, procedures in place, in Southern California when I started working in hospice for people to take advantage of and participate in the End of Life Option Act. Elizabeth: There were very, very, very few resources. There were no phone numbers to call of people who would answer questions. There were no experts who, well not no experts, who thoroughly understood the law but it was very hard to access that information. Elizabeth: I did my best to find it and became connected with some groups and some individuals who were experienced with and understood the law and became really passionate about pursuing advocacy and allowing as many people to have access to that information as possible. I started working on sharing that information and being a resource and learning everything that I could so that other people could have that. How I became connected with Integrated MD care and with you, I found you as a resource for another client, and we started having conversations, and I learned that it was possible to be supportive of people through this process through the work you were doing and I took the opportunity to become a part of it. We have done a lot to support a lot of people, and it's become a really special part of our work and my life. Dr. Bob: Why is it so important to you? Why is it so important to you for people to have access and the information? Elizabeth: I really believe that every life can only be best lived if you know all of the options that you have available to you. So how can you make choices without information? Right? So when it comes to something like this which is a life and death situation, quite literally, there are limited resources for people to make informed choices. What could possibly be more important than having access to information about what your legal rights are to how you live and die? With California only having begun this process of Aid and Dying. Exploring different perspectives and legal options and philosophical positions on the subject, I think it's really important to open that conversation and to allow people who support it as well as people who are against it to have those conversations and to explore how they feel about it and why. Then of course for the people who want to participate, who want information, resources, support in the process they have every legal right to it, in my opinion, they have every moral right to it and if there are no other people who are willing to support them I feel it is my duty to do that. Dr. Bob: Awesome. And you do it well. Elizabeth: Thank you. Dr. Bob: Yeah it's kind of crazy to think we have this legal process in place. People have spoken up and said, we want to have access to this, and we believe it's the right thing. Despite the fact that we have a law in place that allows it, it was so difficult, and it's still is to some degree, but especially in the beginning, it was like a vast wasteland. If somebody wanted to find out how to access this process, no one could really give them adequate information. There were organizations that would tell them what the process is and how it happens but there was no one stepping up to say 'I'll support you.' There were no physicians, and there was no one who was willing to give the name of a physician who was willing. It was very frustrating in the beginning of this process, in the first, I would say, the first year and a half. Still, to some degree, getting the right information, getting put in touch with those who will support it is difficult or impossible. Even some of the hospital systems that do support Medical Aid and Dying their process is very laborious, and there are so many steps that people have to go through that in many cases they can't get through it all. Our practice we are filling a need. Our whole purpose in being is to fill the gaps in health care that cause people to struggle. One of my mantras is 'Death is inevitable, suffering is not.' Right. We are all going to die, but death does not have to be terribly painful or a struggle. It can be a beautiful, peaceful, transformative process. We've been involved in enough End of Life scenarios that I can say that with great confidence that given the right approach, the right information, the right guidance, the right support it can always be a comfortable and essentially beautiful process. Elizabeth: Something that is important too also is to have people who have experience with these processes these struggles that people have. Not just anyone can make it an easy process. Not just anyone can make it a smooth process. You have to have it those obstacles you have experienced what the difficulties are and where the glitches are and in order to be able to fill those gaps you have to know where they are. Dr. Bob: Right. Elizabeth: Sometimes that comes from just falling into the hole and climbing out which is something we have experienced a few times. Dr. Bob: Having been through it enough times to... and of course we will come across- Elizabeth: More... Dr. Bob: Additional obstacles but we'll help...and that doesn't just apply to the Medical Aid and Dying it applies to every aspect of health care, which of course, becomes more complex and treacherous as people's health becomes more complicated and their conditions become more dire, and their needs increase. Hospice, yes it's a wonderful concept, and it's a wonderful benefit, but in many cases, it's not enough. Palliative Care, in theory, great concept, we need more Palliative Care physicians and teams and that kind of an approach, but in many cases, it's not enough. What we are trying to do is figure out how to be enough. How people can get enough in every scenario. We are specifically here talking about Medical Aid and Dying. In California, the actual law is called The End of Life Option Act. It was actually signed into law by Governor Brown in October 2015, and it became effective June 9th, 2016. I'll note that just yesterday the Governor of Hawaii signed the bill to make Medical Aid and Dying legal in Hawaii. The actual process will begin January 1st, 2019. There is a period of time, like there was in California, a waiting period, while they're getting all the processes in place and the legal issues dealt with. Elizabeth: Which you would think, that would be the time frame that health care intuitions would establish policies, would determine what they were going to do and how they were going to help. Dr. Bob: One would think. Elizabeth: You would think. Dr. Bob: Didn't happen here. Elizabeth: That didn't happen here. Dr. Bob: So maybe Hawaii will learn from what happened in California recently when all of a sudden June 9th comes, and still nobody knows what to do. What we are becoming actually, is a resource for people throughout California. Because we have been through this so many times now and we have such experience, we know where the obstacles are, we know where this landscape can be a bit treacherous. But, if you understand how to navigate it doesn't have to be. Elizabeth: We have become a resource not just for individuals who are interested in participating or who want to find out if they qualify but for other healthcare institutions who are trying to figure out how best to support their patients and their loved ones. TO give them without the experience that they need without having the experience of knowing what this looks like. Dr. Bob: Yup. Training hospice agencies. Training medical groups. At the heart of it, we just want to make sure that people get what they deserve, what they need and what they deserve and what is their legal right. If we know that there is somebody who can have an easier more supported, more peaceful death, we understand how incredibly valuable that is, not just for the patient but for the family. For the loved ones that are going to go on. So let's get into some of the meat of this. I'm going to ask you; we can kind of trade-off. Elizabeth: Okay. Dr. Bob: I'll ask you a question. Elizabeth: Okay. Dr. Bob: You ask me a question. Elizabeth: Okay. Dr. Bob: All right. If you don't know the answer, I'd be very surprised. In general who requests General Aid and Dying? Elizabeth: A lot of the calls we get are from people who qualify. So I don't know if you wanna go over the qualifications... Dr. Bob: We will. Elizabeth: Okay. Dr. Bob: That's the next question. Who is eligible. Elizabeth: Sorry. A lot of the people who call are individuals who are looking to see if they qualify and want to know what the process is. There are people who are family members of ill and struggling individuals, who wanna support them in getting the resources they might need. There are some people who just want the information. There are some people who desperately need immediate support and attention. Dr. Bob: Do you find, cause you get a lot of these calls initially, do you find that it's more often the patient looking for the information or is it usually a family member? Elizabeth: It's 50/50. Dr. Bob: Oh 50/50. Elizabeth: I think it depends a lot on where the patient is in the process and how supportive the family members are. Some people have extremely supportive family members who are willing to make all the phone calls and find all the resources and put in all the legwork. Some people don't, and they end up on their own trying to figure out what to do and how to do it. There are some people who are too sick to put in the energy to make 15 phone calls and talk to 15 different doctor's offices to find out what the process is. A lot of people start looking for information and hit wall, after wall, after wall. They don't even get to have a conversation about what this could look like, much less find someone who is willing to support them in it. Dr. Bob: Great, thank you. So who is eligible? Who does this law apply to? That's pretty straightforward, at least in appearance. An adult 18 or older. A resident of California. Who is competent to make decisions. Has a terminal illness. Is able to request, from an attending physician, the medication that if taken, will end their life. Pretty much 100% of the time. The individual has to make two requests, face to face with the attending physician and those requests need to be at least 15 days apart. If somebody makes an initial request to meet and I determine that they are a resident of California, they are an adult, they are competent, and they have a medical condition that is deemed terminal (I'll talk more about what that means) if I see them on the 1st, the 2nd request can happen on the 16th. It can't happen any sooner. The law requires a 15 day waiting period. That can be a challenge for some people, and we will talk a bit about that as well. In addition to the two requests of the attending physician, the person needs to have a consulting physician who concurs that they have a terminal illness and that they are competent to make decisions and the consulting physician meets with them, makes a determination and signs a form. The patient also signs a written request form that is essentially a written version of the verbal request and they sign that and have two people witness it. That's the process. Once that's completed, the attending physician can submit a prescription if the patient requests it at that time to the pharmacy. Certain pharmacies are willing to provide these medications, and many aren't. But, the physician submits the prescription to the pharmacy, and when the patient wants to have the prescription filled, they request that the pharmacy fill it and the pharmacy will make arrangements to have it delivered to the patient. The prescription can stay at the pharmacy for a period of time without getting filled, or it can be filled and be brought to the patient, and at that point, the patient can choose to take it or not. The patient needs to be able to ingest it on their own. They have to be able to drink the medication, it's mixed into a liquid form. They need to be able to drink five to six ounces of liquid, and it can be through a glass or through a straw. If the patient can't swallow, but they have a tube-like either a gastric tube or a feeding tube as long as they can push the medication through the tube, then they are eligible. The law states that no one can forcibly make the patient take it. They have to be doing it on their own volition, willingly. Okay. So, that's pretty much the process. Is there anything that I left out? What is a terminal illness? That is a question that is often asked. For this purpose, a terminal illness is a condition that is likely or will likely end that person's life in six months if the condition runs its natural course. Most of the patients that we see requesting Medical Aid and Dying have cancer. They have cancer that is considered terminal. Meaning there is no cure any longer. It's either metastasized, or it involves structures that are so critical that will cure them. In most cases, there is no treatment that will allow them to live with a meaningful quality of life, past six months. Of course, it's difficult to say to the day, when somebody is going to die, but there has to be a reasonable expectation that condition can end their life within six months. We also see a number of people with ALS, Lou Gehrig's disease, amyotrophic lateral sclerosis. That's a particularly sensitive scenario because those people lose their ability to function, they lose their motor function, and as it gets progressively, further along, they lose their ability to swallow. They can lose their ability to speak and breathe. The time frame of that condition can be highly variable. We see people with advanced heart disease, congestive heart failure, advanced lung disease other neurologic diseases. Elizabeth: The gamut. Dr. Bob: We see the gamut, but those are the majority. We've talked about who's requesting this for the most part, who's eligible? A patient who is competent has a terminal diagnosis and is an adult resident of California. We talked about the requirements, what's the process. Let's talk a little bit about the challenges that we've identified or that other people have identified. At the very beginning of this process, I became aware that the law was going to begin taking effect just a few months after I started my medical practice at Integrated MD Care and I figured great this is progressive. We are kind of like Oregon, we are going to have this option available, and I felt like it was the right thing. I've always felt like people should have more control and be able to be more self-determining. Especially at end of life. Who's life is it? Right? Who are we to tell somebody that they have to stay alive longer than they want to. That never made sense to me. I think if you're not in this world of caring for people at end of life or you haven't had an experience with your family. Most people figure when people are dying they get taken care of adequately. Hospice comes in, and they take care of things. IN some cases that's true. In many cases, it is the furthest thing from the truth. People struggle and suffer. Patients struggle and suffer, families suffer and if we have another option, if we have other options available wouldn't we be giving them credence? My answer is yes, we should. So when the law was coming into effect, I figured physicians would be willing to support patients because it's the right thing. I just assumed people would go to their doctors and say 'we now have this law, can you help me' and the doctors would say 'of course.' It didn't quite work out that way. Now I understand why I see it more clearly. People started calling me to ask for my support, and I started meeting with them and learning about what they were going through and learning about all of the struggles they've had through their illness and trying to get support with what is now their legal right and they were getting turned away by doctor, after doctor, after doctor. I learned what I needed to learn about the process and I started supporting a few patients here and there. As time went on, I saw A)what an incredibly beautiful, beautiful process it is. What an extraordinary peaceful end of life we could help people achieve and the impact that it has on the families was so incredibly profound that I know that this was something that I needed to continue supporting. With the hope that other physicians would come on board and there wouldn't be such a wasteland and so much struggle because I can only take care of some many people. Well, it's a year and a half later, and I do think things have- Elizabeth: Improved. Improved some. Some of the hospital systems in San Diego certainly, have developed policies and process to support patients through the Aid and Dying, sometimes it can still be laborious and cumbersome, and hiccups occur that create great challenges and struggles. But what we've developed is a process that is so streamlined. Like Elizabeth mentions, we've come across so many of these obstacles and these issues that couldn't have really been anticipated. That have to do with hospice agencies not wanting to be supportive. Of not being able o find a consulting physician for various reasons. Coroners and medical examiners not understanding anything about this process. So we've had to be educating them to make sure that the police don't show up at somebodies house in the middle of the night. It's become a real passion for both of us and our whole team. To be able to do this and to be able to do this really well, as well as it could possibly be done. More doctors are coming on board and being open to this. I'll tell yeah, I'm not so sure that's the right thing, and we have thoughts about that. I've been talking a lot, so I wanna sit back and let you talk, take a sip of my coffee and I wanna hear your thoughts on- Elizabeth: Other doctors. Dr. Bob: Other doctors and how they perceive this. Why we may not just want every doctor- Elizabeth: Doing it. Dr. Bob: Doing it. Elizabeth: I think it's really important that other doctors be open to it. Especially open to the conversations. I think one of the things that has been the most important for me is to help people start those conversations with their doctors, with their families, with other healthcare providers. A lot of the doctors are restricted by policies where they work or by moral objections or just by not really being familiar and being concerned that they might misstep. I think that having doctors come on board first in terms of conversations is fantastic. Then also learning the process is important. As simple as it is in the way that you described it it's more complex than that. There are a lot of small details, paperwork, and requirements. Things have to be done a certain way in order to be compliant with the law. There are aspects of supporting the family. This is a very unique experience. If you as a physician don't have time to have longer conversations with patients and families, if you don't have time to provide anticipatory support and relief for the grieving process or for the dying process, it can be a struggle for the patients and families to go through this even if they have the legal support that they need. I think that that's one of the things you were referring to in terms of why it's not necessarily good for everybody to come on board. Dr. Bob: Yeah. Because if they say that they will support a patient and be their attending physician through this process, they could start the process and then come across some of these hurdles that they don't know what to do with and it could completely derail the process. It's too critical when patients finally feel that they now have this option available to them, that they see the light at the end of the tunnel, every little misstep and every little delay, is- Elizabeth: Excruciating. Dr. Bob: Excruciating. We see that happening over and over again. So when people find us and we assure them, we will help you get through this without any more hiccups, without anything getting derailed, they are very cynical. We tell them- Elizabeth: They've been so many doctors, they've been to doctors who've said... Dr. Bob: They've been screwed, they've... Elizabeth: We will help you, and they haven't gotten the help that they need. Dr. Bob: There is nothing that's more painful for somebody, an individual or a family member who's finally come around to wanting to support mom or dad or husband or a wife or a child and then to have it be taken away from them or threatened. We make ourselves available. There are times when we say we are available for you anytime, day or night; you can contact us. They start calling us; I've gotten calls at 2 in the morning from somebody just to say I just wanted to make sure you were really there. That you really would respond. They can't wait to get to the endpoint. Not even because they are ready to take the medication but because they are ready to have the peace of mind and the security of knowing that they have an easy out, rather than have to struggle to the bitter end. Elizabeth: This is really about empowering the patient and the family. This is all about providing them with the opportunity to do what they want to do with their life. To live it the way they want to live it and to end it the way they want to end it. Not in a way that is incongruent with their moral, ethical, spiritual life choices. In a way that supports the way that they've lived, the principals they've lived by and the things that matter to them. I would also say that the difficulties that doctors have had and the struggles that we've had in working with other physicians it's not because they don't care about their patients. It's not because they don't want the best thing for them. Maybe they disagree with what the best thing is, or maybe they feel that they are not able to provide sufficient support. There are a lot of really good doctors who aren't able, for whatever reason, to do this. Dr. Bob: That's a great point. I think a part of it is that sometimes they work for organizations that won't allow them to, and that happens often. Then they don't understand the process; they are intimidated by it. They don't want to mess it up. And, they are so busy that they feel like it's going to require too much time out of their day. Elizabeth: Which it does. Dr. Bob: Which it can, and they don't have any way to bill for that. They feel like they are going to be doing everybody a disservice. But unfortunately, that often leads to the patients being in this state of limbo and not knowing where to turn. Elizabeth: Thinking that they maybe they have started in the process and Dr. Bob: Not, we have certainly seen that. Elizabeth: Discovering later that they haven't. Dr. Bob: So we are going to close it down here shortly. One of the things, and you spoke about empowerment, and how really important that is, both for the patients and for the families. One thing that I've recognized, so now I've assessed and supported well over a hundred patients through this process. I've been with many of these people when they've taken the medication and died. So, I've seen how beautiful and peaceful it is. It literally in most cases, a lot of times there's laughter and just a feeling of incredible love and connection that occurs with the patient and the family in the moments leading up to that. Even after they have ingest the medication we have people who are expressing such deep gratitude and love and even laughing during the time because they are getting freed. They are not afraid, they are almost rushing towards this because it's going to free them. Most of the time they fall asleep within a matter of minutes and die peacefully within 20 to 30 minutes. Sometimes sooner. Occasionally a bit longer. But, if anyone is wondering if there is struggle or pain or flopping around in the death throws. None of that. This is truly...this is how I want to go when it's my time. The one thing that seems very consistent with the patients that I've care for through this process is, they have a physical condition that is ravaging their bodies. Their bodies are decaying, they are declining, they are not functioning. Their bodies are no longer serving them. But their spirit, is still strong. They have to be competent to be able to make this decision. Most of the time they are so determined to be in control of what happens to them, their spirit has always been strong. They have lost control because their bodies no longer function and that is irreconcilable for them. They cannot reconcile this strong spirit in a body that is no longer serving them and that is only going to continue getting worse. That's the other important part of this. These are people who are dying, they are not taking this medication because they are tired of living. They are taking this medication because they are dying and they don't see any reason to allow their death to be more prolonged and more painful, than it needs to be. They are empowered, and we are empowering people to live fully until their last moments and to die peacefully. My last little note here is, why do we do this? Well, that's why we do this. Elizabeth: Yeah. Dr. Bob: Because people deserve the absolute best most peaceful, most loving, death. This is in many cases, the only way to achieve that. I think we are going kinda wrap it up. We obviously are passionate about this topic. We are passionate about wanting to share the realities of it. We don't want there to be confusion, misconceptions, misunderstandings. Aid and Dying is here; it's not going away. It's going to continue to expand throughout our country. We are going to get to a place where everybody has the right to determine when their life should end peacefully when they're dying. I'm very happy and proud to be on the forefront of this. I know it's controversial, I imagine there are people who think that I'm evil and I'm okay with that because I know. I see the gratitude that we get from so many patients and families. When we go out and speak to groups about this the vast majority of people are so supportive and Elizabeth: Sort of relieved, even the professionals are so relieved. We have a patient, we have been helping another doctor support that patient, and he's so relieved and so friendly and so grateful just to be able to provide the support that he wouldn't otherwise be able to provide. It's not just the patients; it's everybody we engage on this, it's really amazing. Dr. Bob: Thank you. It really is an honor to watch you engage with the patients and families and to be as supportive of what we're doing. It's remarkable. Elizabeth: Thank you. Dr. Bob: We will talk about some of the options that people have when they don't qualify for Aid and Dying because there are other options. We wanted to address some of those options as well but not on this live; we'll do that maybe next time. Thanks for tuning in, have an awesome day, and we will see you soon, take care. Photo Credit:  CENTERS FOR DISEASE CONTROL AND PREVENTION/WIKIMEDIA COMMONS PUBLIC DOMAIN  

  Jami Shapiro helps seniors transition from homes with her company Silver Linings Transitions. Learn why she is so passionate about this work and how she can help you or your loved ones. Contact Silver Linings Transitions Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text.  We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Transcript Jami Shapiro: Thanks for having me. Dr. Bob: Yeah. It's great to have you here. Jami Shapiro: This is exciting. I was really looking forward to this conversation, so I'm glad to be here. Dr. Bob: Yeah. Why is that? Jami Shapiro: Well, death and what you do, it has just really become ... I guess I should describe what it is that I do so that it can set the stage for people. Dr. Bob: Sounds good. Jami Shapiro: Okay. I own a company, as you mentioned, called Silver Linings Transitions and we started as a senior move management company, which is actually part of a National Association called The National Association of Senior Move Management, and I have to step it back a little bit because about 13 years ago, I was diagnosed with thyroid cancer, and I was 34 years old, and it was life-changing for me to have to wait on the diagnosis and at the same time, one of my closest friends died of ovarian cancer. When you look at cancer as a 34-year old, you realized, "Oh, this is borrowed time." A friend of mine who had cancer as a freshman college said that getting cancer was like getting a front row seat to life. Dr. Bob: Wow. Jami Shapiro: Right. I started to look at my own life, and I knew that what I was doing wasn't fulfilling for me. I ended up moving to San Diego from Florida with my now ex-husband, when he took a dean position out here, and it was an opportunity for me to explore what it was that I wanted to do and the first job that I had was actually working at a cancer foundation started by a family who had lost their daughter at 39 to gastroesophageal cancer stage four, and no one knew because we weren't talking about it or what the symptoms were. I loved that they took their tragedy and they turned it into something, which was really very close to who I was. Around the time that I needed to put my daughter into private school, a friend of mine approached me about starting a business selling things for seniors on eBay. That was how we were going to start. Then while she was researching that, we found out about The National Association and they were going to be having their conference in San Diego two months later, and went to that conference, and that was that light bulb that everybody hopes to get, and it was like, "This is what I'm meant to do," and the people that do the work that I do, which is helping seniors when they're transitioning from their homes. It can be the home they've been in for 60 years. It can be the condo that they've moved into, but going into a senior community typically or sometimes into a smaller space is actually very ... It's a tough transition. It's medically identified as relocation stress syndrome, and they say that it is the most difficult transition a person will make in their lifetime. I don't know compared to what you're helping them transition through, but it's tough. Dr. Bob: It's significant. Jami Shapiro: It's significant. Dr. Bob: It's significant, and it's probably under-addressed and under-recognized in general. Jami Shapiro: Absolutely. Right. Then, what their staff represents to them. That's what we're doing is we're helping them go through the mementos of their lives, so I started it that way with a partner. Then, things happen the way life does, and my partner ended up going to work with her husband because he had actually started a business as well. Then, I had to look at how am I going to do this business by myself because I planned on having a partner. I've got three children. Anyway, I ended up shortly after that, putting something on Facebook that I was looking for help because I'm actually as great as my company is, and you have to be very organized to do the work that we do, but I'm not organized. I knew I had to find somebody that was. Initially, I was looking for a partner, couldn't find the right partner. Then, I put something on Facebook in a group of women that I, in San Elijo Hills, we have a little women's site. I posted something, and the first person that responded to me was a woman who had been a stay at home mom for 18 years, and she couldn't find anyone that would hire her. That was when the second epiphany happened, and that was women when they're transitioning back into the workforce whether they're going through a divorce or their kids are going to school, it's tough for women to compete with the younger women and then to have the flexibility, so that became my team and that was women transitioning back into the workforce. Then, right after that, I started, my marriage ended. It was like I'm starting a business simultaneously and going through a divorce. Then, I realized that women including me, if we walk away from careers and even though I worked, we didn't find my retirement. We find it his, and even though I'm getting half of his retirement, I'm starting at a lower level than he is. Then, you've got the issue of benefits. My long-term objective is actually to help the seniors and the other clients because we now help divorcing clients. We help when there's a death, and we go into the home, but it's also to provide meaningful work for women, a platform that will give them to get the confidence to get back up into the workforce, but I see this really ... In my vision, it's national. That's where I'm going. Dr. Bob: That's awesome. That's really great. It's like a trifecta. You're helping several populations that clearly have needs. Many of those needs are unmet, and you're doing it from a place not ... It sounds like, not necessarily because you want to be a billionaire, but because you want to have meaningful work. You want your life to mean something, and you were fortunate to have that wake-up call at 34 when you realized that, "Wow. There really is a limit to all of this," and you needed to do something now. That's awesome. Jami Shapiro: Yeah. Dr. Bob: That's pretty wonderful. Jami Shapiro: Well, that's actually why I called the company Silver Linings Transitions because I would never have gotten to that place if I haven't had that experience. Dr. Bob: Yeah. Well, I love that. It really resonates with me because for me, I've been accused of being an eternal optimist and even in the phase of situations where it really seems like it wouldn't be the appropriate response, I just have this sense of optimism that things are going to work out and I always look for the silver linings, and I talked about that because there always is one. Jami Shapiro: You're absolutely right. There's always a lesson to be learned. Dr. Bob: Yeah. No question about it because we can't control what happens in life. Jami Shapiro: Yeah. That's exactly right. Dr. Bob: What we can control is our response to it. Jami Shapiro: I just wrote a blog about that yesterday actually, and it ended exactly that same way. Absolutely. Dr. Bob: Good for you. Jami Shapiro: Yeah. Dr. Bob: I love the fact that ... We talked about this before we started recording that there's definitely some similarities and alignment in our ... Not just our chosen, I guess career path. Jami Shapiro: And who we're serving, right? Dr. Bob: And who we're serving, but I think what we're trying to accomplish. Jami Shapiro: Our why? I think we both talked about the fact that we both feel like this is a calling. Yeah. I'm also an eternal optimist and I'm so grateful actually that I am because I have a lot of family members with depression, and I know that it's really difficult, and I feel like if I can talk about God because that's really helped me with everything that's gone on is to know that He's given me these talents and there's some reason that I have them, and there's something I'm supposed to do with them. Dr. Bob: Yeah. If you didn't, well, then you wouldn't be fulfilling your reason for being here. Jami Shapiro: That's exactly right. That's right. Dr. Bob: Right? It's so cool because there's ... In your work as well and in mine, we come across people who are in really difficult circumstances often, and they're going through challenges, and it's fascinating to see how people respond to those challenges because I can be talking with a person who's in their 80s, 90s or over 100 who's struggling, and looking at uncertain future, but likely challenging, but they don't feel victimized. They still see the positives in life, and they still feel grateful for what they've had and what life has been for them, and even what's coming. Jami Shapiro: That's right. What they can do. Right. We need to identify what it is we still can do. Dr. Bob: There's such an opportunity, I think, we're not a psychologist. We're not a psychiatrist. We're not the therapist, but in everything that we do, I think there's an opportunity to help to share this sense of the possibilities. Jami Shapiro: Absolutely. Yeah. Dr. Bob: Right? That there is a silver lining to everything. Sometimes people don't want to hear that in the moment, but I think representing that, living it by example is very important, and it sounds to me like you're doing that. Jami Shapiro: Right. It's interesting because I do get to work with seniors when they're going through the mementos of their life as I mentioned, and so we actually ... I have a partner, Bryan Devore, he's a realtor, and we worked together now. He does his own Silver Linings Transitions, but most people who are selling a home ... Well, everyone selling a home will have to move, and a lot of the clients that we come across are seniors who will also need to sell their homes, so we offer that as a bundled service, but we ended up working with four clients together last year. Two of them embraced moving into a senior community. One of them had his name tag on when we met him, and he was excited about going, and he was going to have his meals there, and the other woman put herself on a waiting list and brought my company in, so we could get her ready for that transition, and those two are thriving. Then, there were two situations where we were called in, and they were kicking and screaming going there, both had put deposits down, but neither one of them wanted to be there. Both of them pass within a month of moving, and it just shows like you're right. You don't have a choice in a matter. The only choice you have is your response to it. Dr. Bob: Yeah. It's powerful. Jami Shapiro: We started a TV show actually that we're going to start filming in March, and I'm really excited about showing people what senior community really is and following people who are transitioning into those changes. Dr. Bob: The communities that you're helping people transition to, is it any size? It can be a large assisted living or independent living or small residential care homes? Jami Shapiro: Sure. We've even done an 8,500 square foot ranch in Santa Fe home into a smaller three bedroom house. Anytime there's a downsize and we actually ... I don't want to plug the business because that's something the conversation is about. Dr. Bob: Please do. You're plugging something that's needed, and valuable. Jami Shapiro: We're working with a family now, and there's a little bit of health stuff going on and they are needing to move out of their son's school because there are some issues going on and there are some boundary changes, and so my team is going in and getting the home organized and helping them move because people would say, "Well, do you have to be a senior?" I said, "No. We don't discriminate based on age." We really help, and Bryan is selling the home for them, and as I mentioned, if he sells their home, then he provides Silver Linings Transitions free for our clients. We actually have a website called packedforfree.com, and we actually created a little thing that looks like a Reese's because what's the best combination in the world? Chocolate and peanut butter and next is selling your home and moving. Dr. Bob: Right. Helping someone transition. Jami Shapiro: Right? Move services. Exactly. Dr. Bob: Well, I just moved a little over a month ago, and we're pretty good at moving. We moved a number of times. I think we just changed. Jami Shapiro: Me, too. Me, too. Dr. Bob: ...When I was looking at the website, and the idea that really appealed to me is you get up in the morning, you leave your bed unmade, you go out, you enjoy your day, you go back to your new place, and everything's in place. The idea of that was just like incredibly overwhelming to me. Jami Shapiro: Yeah. For us ... Dr. Bob: I wish I would have known about you. Jami Shapiro: You know what? I wish that every time somebody said that, I got a dollar because I'd be a wealthy woman. Dr. Bob: I know. Me too. Yeah. No doubt about it. Jami Shapiro: Yeah, exactly. Dr. Bob: For me, and probably for you too, it really makes me sad when I hear somebody say, "I wish we had known about you when my mom was ill, or a few months ago when we were going through these challenges." Jami Shapiro: Right. I think one of the things that also we are different than a moving company because the women that I'm hiring are so compassionate, and it's funny. Most of them have found Silver Linings Transitions. One of them when I was first starting the business, and I wanted to take credit cards, I had to have my ... My home was where I was going to work out of the company or work, and she came in to look at my home and make sure I was legitimate, and we've got into a conversation and her father had just passed away, and she was helping her mother go through all of his belongings, and she's actually my head manager now. That's how she found me coming into my kitchen, and then I have another woman whose husband was on jury duty, and he happened to hear somebody talking about the company, and she approached me. People are coming because I think they feel that calling too, and I think it's so evident when our clients work with us that we are just really compassionate and ... Dr. Bob: That's what they want. That's what people want. Jami Shapiro: Yes. Dr. Bob: They don't want someone who is just going to come in and handle the transaction. Jami Shapiro: Right. They would be heard. Dr. Bob: At this day, for some people, yes, it's about cost, and they have to be conscientious about that, but I think for more people at that stage of life, it's about trust, knowing that they and their things are in good hands and that it goes smoothly. Similarly, I think there's alignment there as well that there's such a ... The norm is that things don't go smoothly. The typical situation is people struggle. They try to find the resources, and they're searching, and they're getting recommendations and they piecemeal it together. To be able to say that anxiety, time, frustration by having a teen that they can really trust and feel good about working makes all the difference in the world. Jami Shapiro: Right. I noticed that about your team as well, and it's having a comprehensive solution. I know when I had thyroid cancer actually, I was very fortunate that I lived in Jacksonville, Florida and there was a Mayo Clinic, and the leading person who dealt with thyroid cancer endocrinologist happened to be in Jacksonville. Then, it ended up that we couldn't go because the insurance have that goes. Dealing with Mayo where everything was in one place, and as a patient, it was so comforting versus them having to leave that system and then have to exactly piecemeal it together. There's nothing worse than going through something really tough, and then having to manage all the pieces too. Dr. Bob: Right. The situation itself is stressful, and then to add on top of that all the frustration that comes with trying to get the right support. Jami Shapiro: Right. Dr. Bob: The healthcare system is the prime example of that, which is why we exist. I would be very happy if there was no need for us. Jami Shapiro: Oh, no death. I say [crosstalk 00:15:34]. Dr. Bob: Well, I would be wonder ... People were going to die, right? Jami Shapiro: Yes. [crosstalk 00:15:39]. Dr. Bob: We're not going to stop that, but if everybody has the right support and the right guidance. Jami Shapiro: Absolutely. Dr. Bob: Because the medical system acts like death is not going to happen. They don't talk about death. Jami Shapiro: Right. I'm not supposed to talk about it either. I was telling you we go out and we give talks. The talk that I've done lately is, "Do you own your stuff or does your stuff own you?" Because so many people are prisoners to these rooms, they're not even living in because their stuff is there. They're not even enjoying their stuff, and that's a whole conversation that I still want to address, but when I talked about it, and we're talking about downsizing and going through the mementos of their life, I've been told not to talk about death. We want to bury our heads in the sand. I actually went to ... An attorney was giving a talk on advance directives, and he said that only 10% of people even have a discussion with their spouse about what their wishes are. It's just like we just want to bury our head in the sand. Dr. Bob: Yes, we do, but we're trying to do something about that. Right? Jami Shapiro: Yes, absolutely. Dr. Bob: And people like us, which is why we're having this conversation, which is why people like us who, for some reason, somehow had become comfortable with the concept. It's so important for us to be out there leading by example and encouraging the conversations. I think that there's a shift happening. There's a movement underway, the death cap phase, and maybe I have a warped sense of things just because I'm so immersed in that. Jami Shapiro: Yes. Dr. Bob: But I do get the sense that when I'm out speaking with people, and they learn what I do, it opens up this flood sometimes of wanting to talk about the experiences they've had. You and your team find yourselves in situations where you're having intimate conversations, and people are in a vulnerable time, so you're probably experiencing some of this as well. Jami Shapiro: Absolutely. Dr. Bob: I'm amazed how freely people talk about the experiences that they've had in their life around death of a relative or a friend, and I would say it's probably equally divided between people who talk about how difficult and challenging it was and their frustration with the system and fear about what might happen next time, somebody that they love or they become ill, but there's another group of people who want to share what an incredibly transformational experience it was because they somehow found the resources they needed. They had a great hospice team. They have advocates, and so it seems so ... The goal really seems to be to try to get those people who have had those scary, challenging, frustrating, horrific experiences to not have to deal with that but to be able to be in that other camp where it is a beautiful, peaceful transformational experience. Jami Shapiro: Right. You said something that you're noticing, and you think it's because of the work that you're doing, but I also am ... I've sort of become, I would say more spiritual, and sort of realizing a collective soul now. I actually had read back in my 20s the book, "Many Lives, Many Masters," by Brian Weiss, and ended up having a conversation with somebody about Akashic records, which is probably something I can't even interest, but I reread the book now in my 40s, and so, now I see this time on earth, they call it earth school, which ties back into the whole silver linings thing, which is what lessons is my soul supposed to learn? That has given me some peace because I'm actually one of those people whose always been really afraid of death too and it was one of the reasons I wanted to talk to you because it's really addressing something that I myself not wanted to talk about. As I'm starting this business and realizing that for me anyway, and I would say most people, we are going to leave this earth. There's no debate. We both know, and we're on the same side of the coin, that's going to happen, but what's your legacy going to be? What is it that you're going to have done? What's your imprint? I think when you are ... [inaudible 00:20:03] the word "aligned," but it is, when you are aligned, when you are listening to that voice or however comes to you, meditation or the light bulb moment, then you realize you're part of something bigger. Dr. Bob: That has brought you more peace? Jami Shapiro: It has. It has. Now, I'm reading "Journey of Souls," and that one's a little bit more challenging for me. I read the Brian Weiss one in a day, and this one, I've been struggling with, but it talks about our souls and the way that our souls evolve and that some souls don't even come back to earth, and that they are so ... They love where they are, so that gives me peace. Actually, when I was in my 20s, I worked with a couple ... I was in a different line of work, but they lost their adult sons, both of them within a period of two years, and I told them about this book. Then actually, recently, I was in yoga, and I was really getting frustrated because I wanted to get into the class and there was a woman, and she was talking to the woman that was checking everybody in, and, "Come on, come on, come on." Then, the one woman said, "I've been thinking about you. My daughter passed away last week." Then, it was just like ... That changed where I was at completely, and I told her about the book because for me, just thinking that this isn't a final conversation, that this isn't a final place and I remember too like that whole class, I felt called to hug her. I just needed to hug her. That's not something I'm just going to like, "Hey yo." Then, I walked up, and I said, "I just have to. Is it okay?" It just was such a ... That collectiveness that we are this one thing. Dr. Bob: You could sense that there was a bond of some sort or you wanted to bring her some comfort? Jami Shapiro: Right. Right. Yeah. Dr. Bob: It's fascinating, and I love where you're going. I love this path that you're on. Do you bring this into ... Obviously, it influences everything in your life and your work. Do you incorporate this into the relationships with your clients and your team? Jami Shapiro: Yes. That is a great question. Actually, when we have had clients and the tears start to come because they do, and I'll say to them, "I was diagnosed with cancer at 34." The idea of being a senior when you're 34 years old, and you don't know ... At that point, I didn't know that I have thyroid cancer. Actually, they call it "the good cancer," but I had to wait 10 days for my pathology to come back to even know that that's what it was, so I had that opportunity to look at my life and my mortality. I say to my clients, "You're so lucky because whatever life threw at you, you get to be here making these decisions. Let's own it." Kind of embracing going into a senior community like starting a new school or I remember we had a client, and she had a ton of hats. Some of these hats had never been worn. They still have the tags on them, and we're going through her belongings and trying to figure out what's going to fit. I said, "Why don't you take the hat? Somebody known as the crazy hat lady? You can change it." It is just like you said back in the beginning; it's attitude. I think when I can say to them, "I faced it, and you're so lucky to be here." That really turns it around for them. Yeah. Dr. Bob: Yeah. Well, we have a shared experience there as well. Yours was a little bit more intensive, but the day before my 50th birthday, which was a little over five years ago, I got a phone call from a doctor telling me that I have prostate cancer because I've been having issues and MRI was done. A month later, it turned out that we found out that that was not correct, but I spent a month with this belief that I have a fairly aggressive form of cancer, and it changed things for me. I already felt like I had a fairly healthy outlook on life, but at that point, I just saw things differently. I started seeing things through a little bit of a different lens, and I realized it's okay. That was a big piece for me. I realized that no matter what happens, no matter what life threw at me, it was going to be okay. I was prepared. I had pretty much said to those I love and those in my life what I want them to know. I didn't feel like I had any relationships that needed to be fixed, which was wonderful. I think it was a gift, but I would love for people to be able to have that gift without having to have that diagnosis or that fear of the diagnosis. Jami Shapiro: Absolutely, right. Dr. Bob: To be able to have something that allows them to do ... Just to check in to do a big-time check in with where they are, and essentially answer the question, "Are you ready?" If you're not, what do you need to do to be ready? Jami Shapiro: Right. Dr. Bob: Get on it. Jami Shapiro: Right. Absolutely. I also see that too as the brick that was turning your path because you're dealing with people when they're going through this time, and when you're in that space, I think it gives you ... I think you're already an amazingly empathetic and compassionate, but now maybe a little more empathetic because you sat there. Dr. Bob: Then, subsequently in the last few years, both my parents going through terminal lung cancer and dying in my presence and my family's presence has added to that. We don't want everyone to have to go through these personal experiences in order to get the lessons, which is I think partly why we're putting ourselves out there and creating opportunities for other like-minded folks to come in and provide support and guidance. Jami Shapiro: Right. Yeah. Sure. Dr. Bob: Yeah. You've had a number of experiences that have influenced your journey and your path and kind of the attribute. I know that you've also experienced death in your life. Jami Shapiro: Yeah. Yeah. Actually, my grandmother was, I think the person that I was closest to in the entire world, and I'm actually wearing her pin today because I'm going to be starting filming on this show and I wanted to have her a part of her with me, and I will sense her sometimes, not necessarily like feeling her, but finding a letter that she wrote that was exactly what I needed to read in that moment or on my 47th birthday, I was going through a divorce. I just had a breakup with the boyfriend, and I was not expecting much of the day because no one to throw a party for me, and I was an only child. My birthday is a big deal. When you have cancer too, you need to celebrate birthdays, but I ended up totally by fluke, I had my three daughters. It was my birthday, so nobody could say no. I'm going to sit in my bed with me, and we're going to look through this box and mementos. I have had this box and some of the things in it for years, but there was a jewelry pouch that had been my grandmother's, and she had these pins that I knew about, and I knew that her wedding ring was there, but there was a little brown pouch, and it was flat. It was a felt pouch and had I not been a senior move manager, I would have tossed the pouch, but something made me put my finger inside, and I found a diamond earring. Then, I couldn't find the other one, and I was searching the whole box, and then I put my finger back in and found the other earring. I'm wearing them. It was funny too because I had gotten this second holes when I was 16 years old and didn't want to wear them, and I was thinking, "Maybe I should get a small earring." Really, this is so true. Then, I found my grandmother's earrings and have been wearing them every day since because I think she meant for me to find them. Dr. Bob: Yes, absolutely. Jami Shapiro: That's my experience with death. I wasn't there when she passed, but it's interesting because she ended up dying from a pulmonary embolism, and I got a call that she had passed, and my husband at the time was going to drive me to the hospital, and my daughter was two months old at the time, and we got stuck in traffic. I needed to get there, and so I got out of the car, and I ran into her room, and she was still there. That was the only time I've ever been close to anybody who had died, and part of me wishes that I had been there to hear that last breath that I hear so peaceful. I've not experienced that, so it's just me seeing this woman that I loved laying there, and I couldn't touch her. Still, it scared me. Dr. Bob: Did you feel like she was no longer there? Did you feel like her spirit, her soul had left the body at that point? Jami Shapiro: Yeah, I didn't sense her. I will say my mom would feel her presence a lot because my mom was actually there when she was dying, and it was a very traumatic death because she was gasping for air, and it really was with my mom and still is. I'm sure I don't even like to talk about it with her because it brings up that for her, but I didn't. I don't feel her the way people talk about feeling energy or I don't feel her, but I know that she's looking out for me because of these little things that keep happening. There are so many synchronicities in my life that are just ... I have no other way to describe them. Part of this is her, but just also I don't know. God is just leading this path. Dr. Bob: Yeah. I think many people feel that. They feel the synchronicities. They feel the signs, messages, but you need to be looking for them, right? Jami Shapiro: Oh, you absolutely have to be open to it. Dr. Bob: I think if you're not, you can just keep blinders on and if that's the case, I guess you could still be hit over the side of the head with a two by four sign. Jami Shapiro: Or cancer diagnosis. Dr. Bob: Yeah. Exactly. Maybe being aware and receptive and looking for those things, maybe that's a health benefit. Jami Shapiro: Sure. Dr. Bob: If you're getting what you need, maybe you're not going to get the things that you don't want because you're not paying attention. Jami Shapiro: Yeah. That's another interesting thing that you brought up. There's another book. I do a lot of reading a lot, and there was a book by Jen Sincero called, "You Are a Badass," and just very inspired by ... I see on your bookshelf, "Think and Grow Rich," but she has an exercise where she says, "For the next minutes spend, look at everything you can find that's right. Count as many things that you can find that are red." You spend a minute counting red, and then she says, "What do you see that was yellow?" Right? We are going to see what we're looking for. Dr. Bob: What we're paying attention to. Jami Shapiro: Absolutely. Dr. Bob: Right. If you look at my bookshelf, when I moved, I took some of the books from home and brought them here. "Think and Grow Rich" could be next to "Many Lives, Many Masters." I have a whole array. I guess I want people to know how to find ... I want people who are potentially going through these transitions or know people who are going through transitions and looking for support. Tell me who are the people who are your ideal clients who really need you, and what's the best way for them to get a hold of you? Jami Shapiro: I feel like my answer is going to make me sound like a transition queen, but as I mentioned ... Dr. Bob: I think you are becoming the transition queen. Jami Shapiro: As I mentioned, Silver Linings Transitions is my company that we started as a senior move management company, and then going through my own divorce and I don't know if I shared it in the interview, but I was having a consultation because my ex and I ... Really, it was a pretty amicable divorce as these things go, but we got to a point where we didn't agree on the house and the attorney that I consulted with said that if we couldn't come to an agreement, that we were going to go before a judge and the judge was going to make us put our house on the market in 60 days, and I looked at her and I was like a deer caught in headlights and like I said, "You're going through one of the most difficult transitions in your life, and now you have to sell your house?" In the middle of my own consultation, I looked at her, and I said, "Do you think divorcing couples would benefit from the services we're providing for seniors?" We started an offshoot, even though it's still Silver Linings Transitions that goes in, but it's called Divorce Home Solutions because I don't think someone going through a divorce is quite ready to hear Silver Linings. You know what I mean? Then, actually my grandmother passed unexpectedly, and my family and they say weddings and funerals bring out the worst in people, descended on her home, but also had to deal with clearing it out when we were grieving. We were having to deal with the physical part of that while we're planning a funeral and grieving this amazing woman. I tear every time I talk about her. I do. I just love ... Anyway, sorry. I remember the items that I didn't get. You know what I mean? One of the things that we do also is we'll go into a home, and we will do a sentimental auction, and we will help the families rather than fight with each other, you come to an amicable solution and then if Bryan Devore who I worked with sells their home, we'll come and we'll clear the whole thing. We can bring the appraiser in to figure out if there's anything of value. We can help divide the belongings. We ship things to people. We just make that another easy transition, and we started meeting with funeral home directors, and a lot of them will keep our brochure and again, that doesn't say Silver Linings Transitions either, but it's really just us going in, and I'm helping anybody and people say, "Do you have to be a senior?" "No." Moving is one of life's top five stressors. If somebody wanted to find me, they could go to my website, Silver Linings Transitions, not just me because I would not be where I am if I haven't had this amazing team of people who found their calling too, but silverliningstransitions.com, and that would give them an opportunity to reach out. Dr. Bob: Are you looking at ... Thank you. Hopefully, that will bring some peace to folks knowing that this exists. I know that when we have patients who die, this is a very common need that everyone is left with so many things that they have to be worrying about and thinking about, and one of them is, "What do we do with all this stuff? What do we do at the house? What do we do with all these things?" It's really the last thing in the world that they really want to be focusing on. Jami Shapiro: Right, or should be. Dr. Bob: Having a compassionate team of people that come in and support that is phenomenal. Are there other companies that you know of that have the same breath of service that you do? Jami Shapiro: Well, as I mentioned, I am part of the national association, The National Association of Senior Move Managers, and people can find it. It's nasmm.org, and they could find other people who do the work that I do and honestly, anybody who chooses to join an association where we're not regulated is already ... As far as I'm concerned, having to learn how to work with seniors and taking that level of commitment to the work that we do. There are other senior move management companies, but I don't think there are any other Silver Linings Transitions, and again, one of my callings is also to help the women who are transitioning back into the workforce. Yeah. Dr. Bob: Are you looking for additional team members? Jami Shapiro: It's a great question. Yes, I am. We're growing, and we're getting to the point where we don't have enough hands. Dr. Bob: Okay. We'll keep that in mind. Jami Shapiro: Yes. Absolutely. In fact, when I go and talk to divorcing people, especially these women who've been at home and are still getting support, I said, "This is the time to start building your resume in that platform," but of course, my vision is to grow and to not just be in San Diego, and rather than doing franchises where you've got to come up with money to pay for a franchise, I want to build this business where we could go in and train people in different cities and give them the tools that they need to run Silver Linings Transitions out of their cities. That's when I think of the whole "Think and Grow Rich," that's the picture of it that's in my head, and not because I want to grow rich but because I just feel like it has to be done. Dr. Bob: Well, you want to grow, and you want to make sure that your life has meaning, that you want to be the example of creating a legacy and doing something that is clearly going to bring value to people. Like us, the need is huge. The gaps are immense, and we want to try to fill that need in the most, I guess, organic and beautiful way possible. Jami Shapiro: Yeah. I can see, by the way, why you coming into someone's home when they're at this point because there's very calming presence about you, and I love the people I have met in your office and that you have this team that can go in and supports them with massage or acupuncture or ... I saw the aromatherapy, I see have been going right now during the interview. Yeah. If it's going to happen, let's make it as gentle as possible. Dr. Bob: Let's make it beautiful. Right. Jami Shapiro: Exactly. Dr. Bob: Because I think back to your grandmother and that struggle, and I don't know how long that went on for those circumstances, but truly I believe that there is a way aside from a very sudden traumatic type death or an incident that is just unanticipated or unexpected, the vast majority of death's cannon should be peaceful and beautiful, and that's not happening routinely, which means that we're doing something wrong, and we have opportunities to make a huge impact because your mom shouldn't have to live with that, right? Jami Shapiro: Oh, no. No. Dr. Bob: That's my why. People shouldn't have to live with fear when we could be there making sure that every last breath is peaceful. Jami Shapiro: Yeah. I just got chills. Just beautiful work that you're doing. Dr. Bob: Yeah. You as well. Jami Shapiro: Thank you. Dr. Bob: I have a feeling that we're going to be collaborating more and this will not be our last conversation. Jami Shapiro: I have a feeling that might be the case. Dr. Bob: Thank you so much for being here. It's a pleasure. Jami Shapiro: Thank you so much.   Weak adjective: difficult by→for in→at , and , I→; I Repetitive word: home the good Undo GENERAL (DEFAULT) 7386 WORDS 3 CRITICAL ISSUES5 ADVANCED ISSUESSCORE: 99 Style checking has been disabled

Dr. Tim Corbin joins the Integrated MD Care team. He shares his experiences as the Director of Palliative Care at Scripps Health and why working with terminally ill patients is so meaningful to him.     Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text.  We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print. Transcript Dr. Bob: Welcome back to A Life And Death Conversation. I'm Dr. Bob Uslander, and I'm here today with my good friend, Dr. Tim Corbin, who has recently joined the ranks of Integrated MD Care after working for many years in various capacities as a hospitalist, a palliative care and hospice physician. Tim, I'm excited to have you on the show, and I'm excited to have you as part of our team, Tim. Dr. Corbin: It's good to be here. It's been a journey to get here, and it's a really exciting future for me. Dr. Bob: Well, we've been talking about working together for quite a while now, and timing is everything. Just so listeners are up to speed on you and what you bring to our team, tell me a little bit about your background, your training, and the work that you've been doing up until now. Dr. Corbin: Sure. Well, I'm internal medicine trained through my residency and became board certified in internal medicine. I went into private practice for a few years. I had the romantic vision of being able to take care of my patient completely in my office at home, in the hospital. I realize in the changes of healthcare that that just wasn't practical. It became more difficult at that time to make a living doing that, believe it or not, with insurance changes, and the evolution of HMOs, and all those sorts of things. What I really loved, being in the hospital, taking care of patients who were facing more serious illness and ultimately became a hospitalist as that movement was developing, so spent over 10 years being a hospitalist and taking care of patients in the hospital. But all along I've been doing hospice medicine. There was just a part of me that identified with patients, and I saw that need, and it was very meaningful work, so always a percentage of my practice evolved around caring for patients on hospice and at home. Palliative care became one of the fastest growing specialties in medicine, you know, kind of in the last 10 years. Having done hospital-based medicine as well as hospice work, I was in a position to really gravitate towards that, and it really spoke to the style of medicine that I like to practice, and I again saw a huge need, and so began developing really hospital-based palliative medicine services, and started one in 2008, and then ultimately became the director of the palliative care service at Scripps Health for four or five years. Dr. Bob: It seems like you were in a really well positioned for palliative medicine, being internal medicine trained, having all that experience in the hospital, working with hospice. I think, like me, what you recognized was there's a gap, right? Dr. Corbin: Absolutely. Dr. Bob: There's a gap between treating people aggressively in the hospital and then sending them off to hospice, where the entire focus is comfort and essentially waiting until the end of life. There's this big gap there, where people still need more care. Dr. Corbin: Having done so much care at home, I think I would see in the hospital what patients were often missing. You know, they were receiving their care in the hospital setting, and I always thought about the possibilities of doing some of this at home, where patients prefer to be and can be more comfortable if we had the abilities to do that. That was clearly a huge gap that's been improving, but in my careers, that was a huge gap for families and patients, so I recognized that pretty early on. I always used to joke that hospital medicine, you know, being a hospitalist and internist, strengthened my care, caring for patients at the end of life, but the opposite was true. Me doing hospice medicine and caring for so many patients when they were dying really strengthened my ability to be a better doctor upstream, as an internist, seeing patients in a hospital or even in a clinic setting. Dr. Bob: So, can you expand on that a little bit? Why is that? What do you think that results from? Dr. Corbin: I think for myself, if I'm effective as a palliative care physician, I'm guiding patients through the process of end of life, if patients and families don't recognize that there was a possible issue that could have caused more pain, or suffering, or difficulty, but I've been able to help guide that that never becomes and issue, because I have kind of a prospective insight about what may be coming, and so part of it is a skill of anticipating when we may not have good outcomes or beneficial care and not providing care that doesn't provide that. The way you set what beneficial care is and what quality is is really having those conversations with patients and families so that you gear your care towards what best supports them as a patient and a person. Dr. Bob: Yeah. What they want, what their goals are. Dr. Corbin: What they want. Dr. Bob: It's so true. I think that most physicians who don't take care of people who are dying or who don't see them in their homes, the traditional office-based physician, really have no idea what those challenges are and what's happening with people once they're no longer able to come to their office. I don't fault them for it, but there's a certain amount of ignorance or just lack of experience. They can't anticipate it, which if they can't anticipate it, they can't do anything about it. ` Dr. Corbin: You can take a history and a social history and ask patients, but when you're in the home, and you see for yourself, you see aspects that will affect patients' medical care. Now we're getting in the realm of talking about the social issues and the emotional issues, even spiritual issues. You go in a house, and you can tell a lot about what's important to a patient, and you can immediately identify conflicts and what we're doing medically that don't align with that. Dr. Bob: Right. That don't support that. Sure. Dr. Corbin: In fact, many times I would say, "You know, let me come see you at home next week," and patients laugh out loud, or they're taken aback. They say, "Well, I can come see you in your office." I say, "No. I really want to come see you at home," because I anticipate that later I will need to come to their home–in a fair amount of time–but also, again, it gives me that insight, and there's something about being in a home environment, where you break down some barriers of trust. You can be open with each other to really talk about what's most important. I had a very elderly patient who had a lot of medical issues going on. I thought I was going to her home to talk about that, but her cat kept bothering us while we were trying to have our interview. What it came down to, one of her biggest stressors was, "What's going to happen to my cat? Who's going to take care of my cat?" These things were affecting her ability to make medical decisions about what she wanted and what choices she wanted because she was worried about who's going to help take care of her cat. Dr. Bob: If she were coming into your office, she probably wouldn't feel like that was worth your time, right, to bring that issue up. Dr. Corbin: Right. If I were really an astute clinician, I'd notice the cat hair on her maybe, and I would be able to ask those questions, but I'm usually not that good. Dr. Bob: The second part of that is that someone who's in the patient's home may see the cat, and the cat may come up in conversation, but they wouldn't really be so perceptive or be so concerned about that dynamic, so it's not just the fact that you're there. It's also the fact of who you are. Dr. Corbin: Too often what we see as important to physicians and clinicians is medically based. It's disease based. We don't often think about the social dynamic of patients and how that may affect their health and their decision making. I think that is so true in the hospital setting because patients become institutionalized. I mean, you're giving up your freedom in many aspects, because you become a patient, and you become a patient within a hospital that has certain processes, and rules, and you don't have access to your home. This is something that is tolerated, obviously, by many patients, and we give amazing care, but when you start having patients who that's not really the most appropriate place for them to be, then we have to start creating better solutions than using the hospital as a way to kind of take care of patients who really don't want to be there or don't need to be there. Dr. Bob: Right, or don't need to be there, or it's detrimental for them to be there. Let's segue into that. We'll go back and talk more about what you're doing now because you've made a shift, and you're no longer in that position of running the palliative care and hospice program at Scripps Health, much to many people's dismay over there and joy on our side. But I wanted us to talk a bit about the hospital experience, the gaps that people experience, the challenges, because me, having my experience of being an ER doc for so many years, seeing people coming in various states and conditions, you as a hospitalist, palliative care physician, hospice physician, I think we're in a unique position to help people understand some of the challenges and risks that they face when they are in the hospital dealing with complex illnesses. You can I could spend hours, and hopefully, we will, talking about the different challenges and gaps that people face and ways to help avoid being harmed by them. Well, let's spend a little time focusing on what happens in the hospital, what doesn't happen in the hospital, what happens when people are preparing to be discharged, and where are the gaps, and what can people do to help prevent any further turmoil or challenge? I mean, you mentioned when you're in the hospital, you're in an institution, right? You're in their territory, so you lose some of your freedoms. I think that people who work in the hospitals, they lose sight of that. I mean, they're busy. Everyone's working hard. No one's lollygagging around, for the most part. I will make generalizations. In general, I think that people in healthcare really do care. They really want to do the job, and they really want to take good care of people, so it's less of a personal personality issue, and I think more of an institutional system problem, that we just don't have enough staff. We don't have enough people to provide the kind of personalized, supportive care that people are looking for and need, and that's largely a financial issue, right? I mean, what's your perspective on that, having spent so much time in the hospital? Why don't people feel, in general, like they're well cared for? Or do you think that they do? Dr. Corbin: I think in many cases they do, and in many cases, they don't. I think one of my family members, in their personal experience, made a comment that in the hospital they felt like they were a cog in a wheel, where there's this path of workup, and diagnosis, and treatment that is on a course of, you know, kind of standard medical treatment that, again, a patient gets put into. A patient's in a bed. The physicians discuss having, "Well, we need to get a CT scan." It's ordered, and all of a sudden someone shows up to the patient, and they're whisking them to the radiology, and the patient doesn't understand why. When you sign yourself up in a hospital, you're signing yourself up and agreeing to the treatment that needs to be done for your particular issue. As physicians and clinicians, we're trained to treat that condition. You know, there's kind of a process and an algorithm to that, to a certain extent, and we don't often go off course. To not do something could risk missing a diagnosis or risk of there being downstream harm, and physicians are very sensitive to that, whether it's from the standpoint of malpractice or not providing a standard of care. The standard of care becomes doing everything, which is not always appropriate. It's not always beneficial care. I tell you, patients often recognize that, and they understand that and are willing to take that risk, if you will, so there becomes this disconnect between what the treating teams are doing and what the patients really want. The patients, it's not that they don't want to be hospitalized. They may say, "You know, I'm weaker at home. I'm 90 years old, but my quality of life's pretty good, so I don't mind coming in and getting treated for pneumonia, but I'm not really up for getting a bunch of CT scans and being poked and prodded and this sort of thing," so where is that balance? In many ways, it's the physician's job to cure and to treat fully, but we're not always taught how not to do everything, so I think patients need to recognize that. There are many times patients bring up the fact and want to have this conversation. So, in the last 10 year, palliative care teams have developed in the hospitals, which are multidisciplinary teams made up of physicians, and nurses, and social workers, and even chaplains to really address patients' emotional, social, spiritual needs, as well as their physical needs, but really it developed as a support team to help support patients with serious illness through the hospitalization, which is kind of crazy when you think about it. Our technology and ability to treat patients is so, you know, high tech and the ability to keep patients going and keep patients alive is so extended that we need support teams to help- Dr. Bob: To protect them. Dr. Corbin: ... to help fend off, you know ... It's kind of like the ability to turn off your cellphone and ways for patients to connect with you. It's very interesting when you start thinking about the ... I always joke that I hope I don't have a job as a palliative care doc one day because that means that our healthcare system is treating patients with the values and the principles of palliative care that we don't need specialists in palliative care to do this. I think we'll always need our expertise and specialty, but there's so much work to be done in that realm of taking care of patients holistically. Dr. Bob: So, a huge issue that we touched on is that when people are in the hospital, sometimes the care is appropriate, and then there are times when it just goes beyond what they would want or might seem necessary because that's just the way it's done. My sense is that it's the path of least resistance. A person is in the hospital. They've got a condition. Something else might be identified. Then they get a consult with the kidney specialist, and they get a consult by the cardiologist, and a consult by the infectious disease guy, and the pulmonologist. Everybody gets a piece of this patient. Everybody gets paid, but everyone's ordering the tests that they feel are appropriate, potentially the treatments that they feel appropriate, and then before you know it, there are six different physicians treating the patient, and they're now a week into it, and they've been tested and treated way beyond they may have ever wanted, because those conversations are not happening. Dr. Corbin: Let's think about each of those physicians who are seeing those patients, who are amazing clinicians, really good docs, want the best for the patients, want the best outcomes, so intentions are all perfect and good, but in today the chances that any one of those physicians has a long-term relationship with that patient is almost zero. We now have sub-specialists, who do nothing but round in the hospital for their group. We used to have just hospitalists. Now we have cardiologists that are hospitalists. We have GI docs that are hospitalists. We have neurologists that ... when you get admitted to a hospital, you have this new team taking care of you, and no one has had that relationship over time. If you, as a patient, have defined what is most important to you and what your true goals are for your life, what gives you dignity and respect, and how you want your life to go as you become sicker, no one has appreciation for that. That's one reason we have palliative care teams, because we sit there for three hours and try to understand this, so we can affect what we decide to do with patients. If you don't have those conversations, as my family said, you become a cog in a wheel, where we're going to treat whatever's going on as we do everybody, and there are tremendous pressures to then get you out of the hospital. You know, we always want a shorter length of stay. Dr. Bob: We do everything- Dr. Corbin: When I first started as a hospitalist, patients stayed in the hospital five or six days. Now it's down to below four days, three days average length of stay. Tremendous pressure to see patients, make a diagnosis, start treatment, and then get out of the hospital. So, you don't have the luxury of time to sit there and think about what you want, or you don't want, because people are coming up to you constantly saying, "We need to do this next and this next." So, it can be completely overwhelming. Families and patients get in a crisis mode. You know, I tell families and patients, "It's really not a good place, in a hospital, to be making life or death decisions, when you're in a crisis mode, where you're emotionally stressed. You haven't been sleeping well. Family's flying in from out of town everywhere, and you're being asked to make decisions that hugely impact what your future is going to look like. You really need to try to have these conversations earlier." Dr. Bob: Very critical information, the timing of that, when you do it, but a lot of times it's not being done. Dr. Corbin: Absolutely. Dr. Bob: So, we now find people who are facing this. They're in the hospital. They're being asked or kind of demanded to make a decision about what's next for them, which may mean going home with certain treatments. It may mean going home and being in hospice. It may mean going to a nursing facility. But they're being pressured, because of what you were just describing, where there's pressure on the physicians to discharge patients and get them out of the hospital quicker, which in some cases is appropriate, but it puts this new sense of time pressure on families to make decisions, and they're getting it from the hospital discharge planners, and the case managers, and now the doctors. So, what do you do? Dr. Corbin: Yeah. You started this conversation talking about gaps in care. I think the gaps are that, you know, our healthcare system's kind of in silos. You see your primary doctor. You go to specialists. When you're in the hospital, you have your hospital team. When you leave the hospital, you may go to a facility, like a skilled nursing facility, which has its own team. So, the patient needs to speak for themselves. We talk about healthcare now should be more patient-centered and family-centered, where the patient should have the autonomy in decision making to make decisions that are best for them, but they're constantly facing a new team. I once looked at social workers' touches on a patient who had cancer very early in their diagnosis all the way through to the end of their life, and they had five different social workers over the course of like a two year period. You know, they had a social worker, outpatient oncology social worker. They had a home health social worker. They had a social worker in the hospital. The palliative care team had seen them eventually, and they had their own social worker. When they ultimately went home on hospice, they had a different social worker. So, you can see that families and patients sometimes complain about having to tell their story again, because they're constantly having to tell their story again– Dr. Bob: Over, and over, and over. Dr. Corbin: ... and reiterate what's most important to them. You know? It's almost like telling my story fatigue. They just get tired of that. So, there are the gaps where there's not that support. Dr. Bob: The continuous support, the continuity. Dr. Corbin: And often it's about explaining to families and patients what their options are and how to be prepared for those things. It's much easier to do it when you have a little bit of time and space. It's very hard when you're told, "You need to figure this out within two days, because they're being discharged in two days, and we need to know if they're going to a skilled nursing, or are they going to go home with more support, or whatever the case may be." Then patients often, depending on what kind of support they need, they may ... For example, hospice, which is by definition for someone whose prognosis is estimated to be less than six months of life. With that, you get a hospice service, and you get kind of this comprehensive care that's paid for through a hospice benefit. It's great support. You have 24-hour care for nurses, a triage available. They can come to the home as needed. Medicines are often delivered to the patient. You have a social worker, physician's visit, do home visits. I mean, it's an amazing program, but it's for the more very end of life. I see a lot of patients who are kind of really I wouldn't say pushed, but one of the options is to go to hospice when maybe it's questionable whether they may qualify. It's questionable whether that's what they truly want. They're not maybe ready for that, but they get the support because everything else is breaking down, that they're kind of pushed towards that, and then patients get better because there's not another alternative. The alternative home is often home health, which doesn't give the same amount of support. If patients' preferences are to get home, one of the huge gaps is enabling patients to get home with the kind of support they need. By default, if we don't have that, they have to go to a skilled nursing facility many find it very difficult to participate, but they're supposed to participate with a certain amount of therapy. They prefer to be at home. You look at a healthcare system that's looking at ways to be more cost-effective and to give beneficial care. You know, you have a situation where patients prefer to be home. That's where they want to be, yet there's no infrastructure to support that, yet it's inexpensive care when you compare it to a skilled nursing facility, or you compare it to going back in the hospital, and yet we haven't, as a healthcare system, figured that out yet. There have been improvements there, but it's a gap. It's a problem. Dr. Bob: Yeah. I think one of the reasons that it continues is because the people who are making the recommendations and facilitating the discharge, physicians, discharge planners, case managers, they have a hard time thinking outside the box. They're looking at what is the most efficient. They're looking at multiple factors. They're looking at what's in the best interest of the patient, what's going to allow them to get the patient out most efficiently because they have pressure to discharge the patients, and then what they're familiar with. How do you facilitate it? Unfortunately, what's in the best interest of the patient or what's most aligned with the patient's goals and values drops down the list of priorities, and people, patients, and families don't know to question it. They don't question the doctor. When the doctor says, "You need to go to a nursing home," well, that's where you need to be, but many times, as we both know, that's really not what's in the best interest of the patient or the family, and so everyone continues to struggle. Dr. Corbin: We should always question, as patients and families, if possible, just not question, but understand. If I'm going through a test or if I'm being sent somewhere, you know, why? What's the purpose, and what is the outcome, and what's the endpoint? What is my goal? I often tell patient and families, "Let's understand who you are as a person, as a patient. What's most important to you? What gives you the quality of life and meaning? And let's align the medical care we provide and the support we give with those goals." It's approaching the patient from a completely different perspective than what we're really taught in medical school, which is really disease based, you know, history and physical, if you will. Diane Meier, who's a leader in palliative care, had a quote. I don't know her exact words, but basically, she said, "You know, palliative care is about matching patients' goals with the medical care we provide." Dr. Bob: It needs to be driven by that, and it's not. And patients still, especially the older patients that we get to take care of, they're intimidated. They don't feel empowered to question what's going on. They may, in some cases, and sometimes there's a family member who will stand up and advocate, but too seldom does that happen. We, I think you and I recognize these gaps. We're working towards trying to fill them in our way, in our community, but what I'd like to do is to give a couple of, I guess action items, a couple of things that people can do to take away from this discussion when they have a patient, a family member, or themselves admitted to the hospital who is then going to be discharged. What are the couple of things that we would recommend that people could do? I'll start by saying, in general, if possible, you should never allow a family member to be in the hospital alone. Whatever needs to happen. And I know it's not always easy. It can be very challenging. Sometimes it's costly, but when a person is in the hospital, they are sometimes sedated. There's the potential for medication errors. I had just a patient who was a 31-year-old woman, who was on pain medication for an intestinal disorder that made it so that she couldn't eat anything. She was being fed through feedings going through her veins. She got an infection. She was hospitalized. A well-meaning nurse, but a relatively new nurse, instead of giving her five milligrams of Methadone, gave her 50 milligrams of Methadone, which is a huge, potentially fatal error. Those types of things happen all the time. It's not just the errors. It's the feelings of loneliness, of isolation, of needing to get somebody to come in and help you get to the bathroom, to understand what the doctors are saying when they come in on their rounds, which could be whenever. People need advocates, and I will never allow a family member of mine to be in the hospital at any point without somebody there to advocate for them, so I would strongly encourage people to find a family member, friend, or even if you have to to pay someone to be there with you. Dr. Corbin: Yeah. I would agree with that. You know, things in the hospital happen fast. We used to round as a team once a day, get all our tests, round the next day. Now we're rounding multiple times a day on a patient. You'll round, get some tests. You'll round again in the afternoon. Things happen quickly, so for a family to get real-time information is challenging if you're not there. I also tell families, "You know your loved one best. What are you seeing?" Subtle confusion or changes in their cognitive abilities, which is very common when you're hospitalized, particularly when you're older, may be missed by someone who doesn't know the patient. If you treat that early, you can kind of help prevent some of that, so there are lots of reasons to have an advocate for a patient there, for sure. That's one of the risks of hospitalization. I mean, it's well documented, medical errors, and hopefully, there's been an improvement in protocols, but the reality is is that, again, you're institutionalized. There are processes, and as much as there are checks and balances to avoid mistakes, mistakes can happen that can cause harm. It's been well discussed in medicine as an issue in our healthcare system, as well as infection risks, and often hospitalization tends to lead to more treatment. One thing leads to another, so you have to define what your purpose is in the hospitalization. You may know this. What an ER doc told me once, "As soon as a patient comes into the ER, the first question I have, 'Am I sending them home, or am I admitting them?'" I mean, that's the first question they ask. You know, as a hospitalist, I would say, "Okay. When am I discharging this patient?" It was all about the discharge. It's, "What do we need to do to get the patient out?" That doesn't mean we're not concentrating on treating, but there's such pressure to get patients out. So, another thing of having someone be there with the patient, be an advocate, is really advocating for what the vision of the patient needs to be in transitioning out of the hospital, back home or wherever that might be. Dr. Bob: Right. You alluded to this, the experience and the perspective of an emergency physician, and I think another tip for people is really thinking about whether you need to go to the emergency room or not. Give some serious consideration to that, because when an elderly person or a person with complex illness ends up in the emergency room, it's far easier to admit them to the hospital than to discharge them. Whether that's in their best interest or will ultimately result in improvement, or the opposite becomes kind of secondary. Speaking from the perspective of a physician who worked in the ER for 20 years, when an ill or elderly person comes in, ideally we could assess what's going on, determine what needs to happen, and determine if we can safely allow them to go home, which is where they'd rather be, and in many cases that's the safest and best thing for them. But because that takes more time, energy, and puts more risk on us as a physician, the path of least resistance is to call the hospitalist and say, "I've got a 95-year-old who's maybe got a touch of pneumonia and a little fever," and they might fight you, because they don't want to do another admission, but you're going to push that. Then you're going to order all the tests and order all the x-rays to cover yourself. So, there are times when we pick up things, and that kind of a workup and approach is valuable, but there are many times when it's not. Dr. Corbin: Another thing for patient families to realize, is that most physician offices are open from 8:00 to 5:00, but it's often 9:00 to 4:00 or something like that. After hours, and weekends, there's more chance that you're going to have an issue off hours than you are during regular business hours. Our human bodies function or not function 24/7. But one question for patients and families is, "What do I do after hours or on weekends if I have a medical problem?" Unfortunately, by default, if there's an issue after hours, and if you have any kind of significant medical history with advanced illness, no one's going to take the chance that something is missed–so they say, "Go to the emergency room," or, "Go to Urgent Care." That's just what we do. We impact our emergency rooms. It's very expensive care. Most of the time, if you have significant illness, the ER doc's going to feel uncomfortable sending you home, because they don't know you, and it's complicated, and so you end up getting admitted. As a hospitalist, I felt I did a lot of admissions, which were unnecessary. If someone was there to coordinate care at home, and kind of have an oversight, and there was that plan of what to do if it was after hours. That's amazing thing of your service with integrated MD care is that someone who has that layers of care, you know, all this is kind of planned out, and you have that support, and patients are really satisfied because you're not just ... Patients aren't just being sent back to the emergency room, and you get, again, into that cog wheel of treatment, where many patients don't want to be, which is another point. One of the risks of hospitalization is when you go, the medical records, you know, your history, what's been done, there are often duplicated care. You get more imaging tests, and you get more workup that you don't really need. I really advocate for patients and families to take a medical history and have that with them. If you come with a full binder, no one's going to look at it or read it, so it needs to be kind of done by someone with some medical knowledge to very succinctly put the diagnosis and what treatment's been done, so it's well understood, because- Dr. Bob: A summary. Dr. Corbin: We just reinvent the wheel. Again, this new team takes over, and they're kind of obligated to do the workup, and it's probably, in many cases, already done. It doesn't seem like a big deal, until you're in that seat, or you find those tests to be very difficult to get through. You know, to go through an MRI, if you've ever had an MRI, it's not a fun experience. I've had one, generally young and healthy, and it was really tough. Imagine if you're in pain, or have more advances illness, or if you're elderly going through these tests. We don't think about it. We think to go to the hospital; you just do what you need to do. You get these tests, but we don't understand kind of sometimes the physical and emotional toll that that takes on you. Dr. Bob: It's very easy to order the tests, right? It's very easy to order an MRI, or a scan, or another blood test, but even just getting blood drawn, these people, the folks, they're sick. They feel horrible. Dr. Corbin: I used to challenge my ... I used to come in as an attending, whether I had residents or teaching. It was like day number seven of hospitalization, and they had the same blood panel every single day. I'm thinking, "What are you going to see in this blood test that may change what we're doing in management?" I mean, we get in this protocol where we stop thinking critically, and we just start treating patients as a process, and- Dr. Bob: Yeah. And a commodity. Dr. Corbin: It's easy to do. You referenced it earlier, about how when you work in that environment, it's comfortable to you. You know it. When you're not in it, it's over. I remember the first time as a medical student I walked into an intensive care unit. I kind of stood back, and it was just kind of a, "Wow." It was kind of overwhelming. Well, you know, when I was a resident, and I spent a whole month being an attending resident in the ICU, after that month it was ... Even after a month it became pretty routine, and all those bells, and whistles, and machines, and tubes, and everything else became kid of normal, which is kind of scary when you think about it, but you've just kind of normalize to that. We always have to back up and understand it. That's what's so hard to have these conversations with patients and families, to really get them to understand what things may look like as they make different choices about their treatment. I say, "There's no right or wrong answer about the treatment." I think patients need to understand their choices and make the decisions that are best for them, and then we try to support them in that decision. I think to have a good history available with you, be prepared with what your true goals are downstream, so you can share that information with physicians and teams, if you change different healthcare settings, and then really having someone that can really coordinate that care for you. If there's someone in the family that can't do it, and you have the means to have someone else or hire someone to help coordinate that care, just like having someone be with you in the hospital, there's no doubt you're going to get better care. Dr. Bob: Yeah. That's critical. Unfortunately, I think once you're in the hospital, it's hard for outsiders to come in. You might have that. So, for me, we do this high level of in-home care and become very intimately connected with our patients and our families. We do a great job of keeping them out of the hospital, because we are available 24/7, and we address things as they come up, and we really try to encourage people to not just rush to the hospital. In general, we're pretty successful at that, but sometimes people end up in the hospital. Even though I have this very intimate relationship and the patients want me and my team to be engaged, the hospital doesn't want that. They don't want outsiders coming in, and it's very difficult to get much information. I'm able to communicate with the hospitalists with some effort, but you can't coordinate anything. It's very difficult to influence the care that's happening, so you have to be able to work with the families, to spend some time with the patients, and allow them to become self-advocating as much as possible. Then get them the heck out the hospital as quick as possible, right? Let's talk for a moment about palliative care, because it really can add a lot of value to the experience for people in the hospital and save them from some future struggles and help guide things more in alignment with their values and wishes. Is palliative care available for every patient in the hospital, or how does somebody get a palliative care team to work with them and support them? Dr. Corbin: That's a very good question. Palliative care, first off, is really available to any patient at any time in their medical illness. It's a whole-person, holistic approach to care, where we address patients' physical needs, but also, as I mentioned, emotional, social, and even spiritual concerns, and try to align our care with what their true goals are for themselves, knowing that those goals may change with time. So it's a fluid situation. But it's really having those conversations and supporting those patients in that goal. It's a team approach, so it's a physician, and a nurse, and a social worker, and often a chaplain, and also maybe sometimes ancillary services as well, so it's a team approach as well. There's a lot of talk the last year that unfortunately palliative care, someone gets palliative care by chance. We know that palliative care is beneficial. We know it enhances the quality of life. We know patients like it. There's less caregiver stress. There's better end of life experience in death when that time ultimately comes. Patients can tolerate their medical treatments better when they have palliative care involved. We know all the outcomes look really good. Palliative care across the board is inaccessible to all patients in every care setting, and so it becomes who do you know? It's, "Oh. Well, I know my neighbor's Dr. Corbin, who does palliative care. Maybe you can call him," and so, oh, I get involved. It's kind of word of mouth and by chance, which is fortunate. Hopefully, in the future, we get palliative care across the spectrum. Palliative care started in a hospital setting, and now over 70% of hospitals in the country have some sort of palliative care team. For example, Scripps Health has palliative care team at all five or their campus and hospitals. So, patients in the hospital can request palliative care consultation. Usually, it's up to the attending physician, whether that's the specialist or the hospitalist, to request a palliative care consult. Dr. Bob: Can a patient or family request a consult? Dr. Corbin: It depends on the hospital. For example, at one of my hospitals, where I started the palliative care team, we made it so anybody could request a palliative care consult, family, the patient. It doesn't have to be from a physician. In that setting, we sent a nurse in to really evaluate the situation, to see what was happening, and then to talk to the attending physician and say, "Can palliative care ...?" But it was a real challenge, in the beginning, getting in the door. Dr. Bob: I would imagine. Dr. Corbin: In many ways, we're seen as a threat, or we do another layer of care that then can be seen as getting more complicated, but the reality is is that we're working through all these issues that really are not discussed. So, that's in the hospital. Most hospitals have palliative care, so if there's a desire to have palliative care if you ask. Often you can look online or read about the hospital, and they advertise their palliative program. The big gap is outpatient palliative care, so what happens to the patient when they go home? If they go to a skilled nursing facility, most likely they don't have palliative care. If you go home, most likely you're not going to have home palliative care, although there are some programs that exist now. There are different levels of what that means. So, if you've seen one home palliative program, you've probably seen one home palliative home program in terms of structure. Some are just nurse-driven. Some are just physician-driven. Dr. Bob: Or physician assistant, but none of them have figured out the model so that they can really deliver. Dr. Corbin: And the barrier's really been about reimbursement, who can pay for that. Unfortunately, that hasn't been figured out. There are trends now with private insurances, as well as possibly even Medicare, starting to pay for kind of more home palliative kind of bundle payments towards that, which will hopefully gain more access. Dr. Bob: Apparently Medi-Cal, which is the California Medicaid program, as of January 1st, is now paying for some version, some form of palliative care. Dr. Corbin: I know Blue Shield of California is paying for home palliative services for some of their patients they identify that need that. So, the other is outpatient palliative care in clinics. Now that's the third tier, so it's been kind of hospital-based, an attempt to do more home-based palliative care, and now actually doing even farther upstream where patients in a clinic setting can get palliative care has been pretty rare. I started an outpatient palliative care clinic at Scripps, which we ran in a radiation oncology center, which is a great setting, and I saw patients in the clinic just to kind of see patients kind of farther upstream. The powerful thing of that is that we were having these conversations not in the hospital when you're in the crisis mode. Because what happens? You can have all of this great plan and this great conversation in the hospital and know what you want to do, but as soon as the patient leaves the hospital, it all falls apart, because there's not the infrastructure or process to support it. You go back into the same process of delivering medical care that we do, which is going to your primary office, going to your specialist, and after hours, if you don't have availability, you go back to the hospital. How do you break that cycle? Dr. Bob: Your family was trying to figure out how to find the right resources for you. Dr. Corbin: So, seeing patients in a clinic upstream is extremely powerful. I would encourage patients with any non-curable illness, whether that's heart failure, or early dementia, or Parkinson's Disease, or an advanced stage cancer,–even if you're getting full treatment, you expect to get treatment, your illness will hopefully be well controlled for years to come–still you should have a palliative care type conversation with a physician or a team that understands the longterm vision. One, you start to have conversations that you don't want to have in crisis mode, or you don't want to have way down a couple of years from now when you're being admitted to the hospital. That's not the right time to have these conversations, to really, truly know what you want. It also relieves this burden. It's always the elephant in the room, you know, what do I truly want, and having these conversations. Frankly, having conversations about death, and what it may look like, and what your preferences are if you do that, it's not threatening when you do. If you do it when death is a real possibility– Dr. Bob: Death is looming. Right? Dr. Corbin: ... it's incredibly frightening and overwhelming. Dr. Bob: For everybody, including the physicians. Dr. Corbin: Including the physicians, so by fault, we don't have that conversation. So, the patients that can have these conversations, and they want ... Studies suggest that patients want to have these conversations. Dr. Bob: And experience would confirm that. Dr. Corbin: We just don't do a good job, as physicians or clinicians, having those conversations. We just don't want to have the conversation. Palliative care in the hospital, there is some in the outpatient clinic. For myself now, I have two days a week where I do outpatient palliative care, where I can see patients in a clinic setting. I'm working within an oncology group, but I'm open to more than just oncology, so if patients know about me, they can come and see me. The purpose is to say, "Hey. What's going on medically? What's going on in your life? Where are your stressors?" You know, I ask patients, "How do you feel your quality of life is? What is your distress? How are you sleeping? How are you eating? What are you eating? How is your nutrition? All of these are things that we generally don't talk about with patients. But it's all about how can we identify things that are important to you? I had a younger patient, with advanced cancer who, after a long conversation, two things in her life were missing. One, the ability to still do yoga, and two, she had some experience with acupuncture, and she was interested in trying that again, but she was kind of bummed that she tired and couldn't do yoga anymore. Through connections, and friends, and again, palliative care by chance, I called a couple of friends, and one goes once a week now to help her do restorative yoga, and another goes once a week to do acupuncture. She's just thrilled. She's thriving. Her tumor markers are decreasing. She's responding to her chemotherapy. Her sense of wellness is much better than what it was before. She has hope. She's confident. She's living with her cancer better. I guarantee you in a normal healthcare environment, that would never come up. If she didn't seek palliative care, no one would ever have the conversation about setting her up with home yoga or acupuncture. It just doesn't happen. Dr. Bob: It sounds like a great concept. I kind of wish I had thought of that. Dr. Corbin: And you did. You know, what you do, the services that you can provide through integrated MD care, for example, the music therapy or aromatherapy, or massage therapy, or acupuncture, many patients don't think about that being important, but it's incredible how that can help you tolerate treatment better, reduce stress, take away some of the fears that you have. Ultimately we're deciding what are you afraid of. Is it what's coming tomorrow? Do you make up a story in your mind of what your future's going to look like, or you make decisions based on that fear, or you have conversations about that? Do you understand the facts medically, from a physician and have someone who can tell you, "This is most likely what will happen, and there's evidence to support that,"? And you get rid of this stuff we make up that scares us, and then you start to trust yourself. You start to trust life to give you what you need, and patients start to respond to treatment and can tolerate things at a whole other level. Dr. Bob: If those things that would enhance your life, and those people, and those therapies are presented to you and through trusted sources, and you open yourself up to them, I've seen, as you are expressing, I've seen tremendous, tremendous transformations in people. I've seen people, who had a prognosis of a month, and they were being told that they've got a month or six weeks to live, open themselves to receiving these therapies and ultimately live for a year and a half with an incredible quality of life. The reason for that, it's multifactorial. Part of it is the actual therapeutic benefit. A lot of it is just this connection that happens with life through other people, who are there to reach into your spiritual being, to help bring out the joy. So, that's a powerful, powerful thing that there's really no way to really put any kind of value on. Dr. Corbin: It's really taking your life back from whatever disease you're dealing with. You think about it, you know, you're whole day. I saw a patient yesterday who wanted to come to my clinic, but he said, "You know, but every single day I have a doctor's appointment for the next two weeks. I don't know if I want to come see ..." I mean, your life revolves around testing, and diagnosis, and treatment, and you lose the things that were important to you, like yoga and massage therapy that you used to do. Dr. Bob: Or time with your grandchildren, or time at the beach. Dr. Corbin: Or time to read or whatever. So, if we can challenge patients to make space for that and to remain who they are as a person through their treatment, it's invaluable. You know, unfortunately, I was never taught that in medical school. We're not taught how to take care of that aspect of patients. It's been, you know, over 20 years since I've done that. I think the medical education system has responded to that in many ways, and it's getting better, but the reality is is that we don't ... We talked about this earlier. I'm taught how to do a history and physical, and the things that I ask in my social history, like, "Do you smoke? Do you drink?" You know, those sorts of things, but I'm not taught, "What is most important to you? How is your stress level now? How is your nutrition?" We just don't ask those questions. Dr. Bob: Yeah. Certainly not, "Where do you want to be when you die? Who do you want to be around you?" Because for me, and for you as well, the idea is starting with the end in mind. If you can get people to share what that experience, how they would like that experience to be, it tells you a lot about who they are, and then you can help to guide all the care that happens. Dr. Corbin: That conversation intertwines a lot of spiritual, religious, philosophy, all of these things, right? But it's not about that conversation. I mean, I can have a very religious person or a very spiritual person who still hasn't truly thought about the way they want their end of life to look like. Sometimes who I think might be the most religious or spiritual person struggles the most with that decision, because they haven't thought about it in the context of that. No matter what your belief system is, no matter what your support system is, if you're challenged to think about it, it's an exercise we should all do. Dr. Bob: And people will often spend a lot of time thinking about how it should be for others and what they're comfortable with, and what they believe. But it's very difficult for many people to actually go down that path and take it to the point of imagining and trying to identify what's most important for them at the time of their death. Dr. Corbin: So, we've covered a lot. Dr. Bob: Yup. Always. Dr. Corbin: We've touched on a lot of issues. I think, hopefully, this is really valuable for people to get some real, heartfelt discussion from physicians who have been right in the fray. Right? I feel like we have a kinship here. We both love medicine. We both love medical people. We have a lot of respect for the passion, and the heart, and the compassion of healthcare providers. We're sensitive to the fact that they are often working in environments that don't allow them to practice optimally, and it gets very frustrating and discouraging. We see how wonderful the medical technology is and what it can do for people, and at the same time, we see how that has created this propensity to use that technology, and wield it un-responsibly, and neglect sometimes what's really and truly most important to people which can be to encourage them to take a different path. Dr. Bob: We have a lot of experience. Hopefully, we've shared some things for people to think about, and I think we're going to have lots of opportunities to continue exploring, discussing the pros, the cons, the good, the bad, but I'm excited, because we, in our practice, get to fill the gaps. Dr. Corbin: Absolutely. Dr. Bob: That's why we started Integrated MD Care. That's why we're doing this podcast. That's why we're doing a lot of the things is we're responding, we're taking a risk, right? Dr. Corbin: Absolutely. Dr. Bob: We're stepping outside the norm, and we're facing some folks who don't quite understand what we're doing, how we're doing it, or why we're doing it, but I think we're both committed to the process and to serving people at the highest level. Dr. Corbin: Absolutely. I agree. At the end of the day, we need to listen to the patient, keep the patient in the middle, provide patients with the best quality and beneficial care, and that really comes from talking to the patient and understanding what gives them the most value. That's what it's all about. Then we need to help continue to push our healthcare system to give the infrastructure to support patients with that. It's really exciting to see the work that you've been doing, and the outcomes that you've had with patients and families and really helping patients be able to transcend those gaps to get the perfect alignment of care that they deserve. You know? And making it not about palliative care by chance or this type of care by chance, because someone happens to know you, but really hoping things like this podcast will start to trickle out there, so patients are aware of what is available. Hopefully, we'll push the expectations higher, and our healthcare system will start responding to that. Dr. Bob: Yeah. That's our goal. Dr. Corbin: Look forward to it. Dr. Bob: In the meantime, we're doing it, and we're letting people pay for it, to recognize the value that they receive. The non-profit foundation that's just been created, Integrated Life Care Foundation, will help to provide funding for people to receive this level of care when they don't have the resources to do it. I'd like to now officially welcome you to the Integrated MD Care team, as one of the providing physicians and one of the leaders of this movement. Dr. Corbin: I look forward to it. A lot of work to be done. Dr. Bob: Absolutely. Thanks for coming on the show, and we'll be connecting again soon.

Derek Humpry is an author and principal founder of the Hemlock Society (now Compassion & Choices). Derek shares his poignant story about helping his wife, who was terminally ill, end her life and how he founded the Hemlock Society.     Derek's website: FinalExit.org Transcript Dr. Bob: Welcome to A Life and Death Conversation with Dr. Bob Uslander. I'm very excited to introduce you to today's guest, who is a gentleman who I recently had the pleasure of meeting and listening to during a presentation at a conference. And I just knew when I met and heard him speak that he is somebody who you needed to hear from. I could go on for quite a long time listing his achievements and his accolades in this introduction, but I don't want to take too much of our valuable time away from the conversation, so I will just give a little glimpse of the instruction to Mr. Derek Humphry, who is the founder of the Hemlock Society of the USA, past president of the World Federation of Right to Die Societies, and Derek has been an incredibly strong proponent of people having the ability to determine how and when they their lives will end when they are struggling. He's been very active through his entire life in this regard and is in large part responsible for the movement through in this country that is certainly effective here on the West Coast, in California, in Oregon, in Washington that has allowed people to have a peaceful end of life. And I owe him gratitude because he has allowed me to delve into a part of my career that has really been incredibly gratifying, and he's brought great relief to many, many people around the world. So, Derek, I just want to introduce you and thank you from the bottom of my heart for all that you've done. So welcome. Derek Humphry: Well, hello. Thank you very much for inviting me. It's been a worthwhile journey. I founded the Hemlock Society in 1980 when I lived in Santa Monica and developed it from there. And it was, I didn't do it in any obviously pioneering way thought, but it proved to be the start of the right-to-choose-to-die movement in America as we grew and grew and fought off our critics and published little books and held conferences, the right-to-choose-to-die movement swelled and improved across America ever since 1980. Dr. Bob: So let me ask, how did this all start? I know, and I heard the story, but I'd like people to hear where this movement originated and how it started for you. Derek Humphry: Yes. I was living in London. I was a reporter on the London Sunday Times. And I had a good marriage, a wife, and three sons, and we were getting along fine. And it's great fun bringing up three sons. But suddenly in 1973 my wife, Jean, said that she had a lump in her breast. We rushed her to the hospital, and various testing and so forth. And they had to perform a radical mastectomy, much to her shock and all of our shock. She recovered from that as best she could, but we have further testing of her lymph nodes and blood count and all the rest of it. And it showed that she had cancer deep in her system. It was too late. But we fought, and she fought, took all medical help available, kept her spirits up looking after the family and so forth. She kept it only in a close circle of friends or family did she say that she had cancer. But in about a year it turned to bone cancer, very painful, very difficult to be moving at all except with heavy pain medications. And then after nearly two years, it was really serious, and she nearly died. She was in the hospital in Oxford, England, getting the best treatment that was available back in 1975, and she recovered from one bout, and the doctor thought she wouldn't come out of that. But she did, and she had a fighting spirit. Then came my epiphany. She sat up in bed feeling pretty well in the hospital bed, and I was visiting her. And she said, "Derek, I want you to do something for me." I said, "What's that?" She said, "I've had enough of this pain and unconsciousness. It's getting near the end. I want to die at home. I don't want ..." She took hospitals pretty well, but she was in the cancer ward, and she'd seen too many people die with the families rushing in in the middle of the night to say their goodbyes and a lot of pain and tears. She said, "I want to die at home. I also want to end my life at the point when I feel the quality of my life is gone and that there's no more hope and no more chance of living. And I want you to help me." There wasn't a right-to-die movement in America or Britain to speak of. There were little token meetings, but it was not a subject of public discussion or knowledge. I think I would have had to go to a dictionary to look up the word euthanasia or so forth. I said, "What do you want me to do?" She said, "I want you to go ..." In a way, she prefigured the laws. She didn't know she was doing this, prefigured the laws that are coming into place in six states in America. And she said, "I want you to go to a doctor, explain what the situation is, and ask him for lethal drugs in which at the time of my choosing, I'm not ready yet, but it won't be far off, time of my choosing, I want to be able to take my life immediately in my bed at home with family nearby and so forth." I said instinctively, I know I didn't philosophize about it or ... "Okay. I'll help you." And- Dr. Bob: Do you recall what your initial reaction was to that? Of course, you wanted to be supportive, but did you have ... Do you remember how you felt about doing that at the time, conflicted? Derek Humphry: I remember saying to her, "If I was in your position, I would be asking you the same," so that I comforted her by saying, "We're on the same wavelength." I didn't want her to die at all, but having seen her pain and suffering for the last two years, well, understood why she would ask. She was a very strong, independent woman and knew her own mind. She'd seen her mother die about 10 years earlier of lung cancer, and she had to be with her father at her mother's bedside. I wasn't there. I was looking after the children somewhere else. The mother died an awful death apparently. She didn't realize she was dying, and the pain control was terrible. If I'd known about it at the time, I would have lodged a complaint against the doctor. But I wasn't on the scene. But this obviously triggered in Jean that when her time was closing, that she was going to do it differently than her poor mother had dealt with it. So I went to ... I puzzled over what I should do, how to get the drugs, and I thought, "I don't want to involve her own GP or lead cancer specialist in Oxford." I didn't feel it was right to involve them. They were good people, good men, and women, very helpful, but I've been a journalist in London. I knew a certain doctor who we'd worked on stories about medicine before, and I thought, "That's the fellow." So I went to see him, took him to dinner, and I said to him, told him what the situation was, and he questioned me closely about Jean's illness, the state it was, what we'd been through, roughly what sort of medications and so forth, and where she was. He turned to me and said, "She has no quality of life left. I will help." And he gave me the lethal drugs with which to; she could end her life. We shook hands on the bargain that I would never reveal his name, that that would be secret, and it's been secret to this day, although people have asked me who he was. I took the drugs home. I said to Jean, "I have the drugs. They're locked away in the medicine cabinet out of the way." And we got on with life, and she got on with life as best she could. She took another chemotherapy, which gave some momentary relief. And we had a happy Christmas in the end of 1974; I think that was. And then but by February, March, she was very, very ill and taking a great deal of what in England they call hospice mix. No, in America they call it hospice mix. In England, it's called Brompton cocktail. It's a mixture of drugs that suit one's particular illness. It's a sort of trial and error until the doctors can work out what this particular patient handles best. So we had that. And we continued, and things got worse. Then her ribs broke in a sort of accident, and that seemed to be her benchmark. She couldn't get to the bathroom anymore. She could hardly move. She couldn't get up in bed without a massive amount of painkillers. She couldn't sit up in bed. And I knew the end was coming, and I knew this question was going to come, so I was thinking about it but saying nothing. Then one day I got her to sit, managed to get her to sit up after taking the pain medications, and she calmly turned to me, and she said, "Is this the day?" That's a pretty rough question to answer when you're the ... We'd been married for 22 years and three children and had a happy life together. And I sort of gulped and said, "Well, if the pain is getting worse, you'll probably have ..." I was sort of stalling for the moment. I didn't want to rush an answer. "You'll probably have to go back into the hospital at the end of the week for more pain relief." And she said, "I'll die at one o'clock today." And so that was ... She was a very outspoken north country English woman and- Dr. Bob: Knew her mind. Derek Humphry: ... we talked all morning, and we shared our memories. The marriage had been very solid, but we'd had two quarrels, one over which house to buy and one over my moving to London from Manchester. We'd settled them, but she brought them up, and she said, "Well, I was right about the house, and you were right about moving to London." So we settled the two quarrels that we had. And she told me to go tell her father what had happened so that it wasn't like her mother's death, that hers was much more straightforward. At one o'clock, if she hadn't said, "Get it," I would have just continued talking. I left it, the initial movement, I left up to her. At one o'clock she said, "Go and get it." So I went and got the doctor's drugs, mixed them in a cup of coffee, put a lot of sugar in, and brought it back to her. I told the boys were lying around in the house. The previous evening Jean had sent me on a fool's errand to get something from the supermarket, and during that, my absence, she called in the boys and told them that she was going to die tomorrow. I was not part of that. She wanted me out of it for that communication with her sons. Dr. Bob : How old were the boys at that point, Derek? Do you recall? Derek Humphry: Sort of 17, 18, 19. I can't remember exactly. Dr. Bob: So young men. They were- Derek Humphry: But late teens. Yes, young men. And they'd seen her suffering. They'd helped me nurse her, helped. When I was absent, they would provide her drugs and things like that. They knew the situation, and they knew their mother was a determined woman. If she said something was going to happen and she was going to do, then she was going to do it. So I took the drugs in to her. As I passed through the living room, I said to the boys, "She's preparing to die," so that they were up to mark on it. I put the drugs down beside her, and she said, "Is that it?" I said, "Yes. If you drink that cup of coffee, you will die." She accepted that. I got on the bed and gave her a last hug and a kiss. We said our goodbyes. I got back on my chair so that she could lift the coffee straight up without ... And she picked up the mug of coffee and gulped it down, drink it down. And I sat there watching in awe. And before she passed out, she said, "Goodbye, my love." And that was it. She lingered for a while. Then she vomited a little, which frightened me. I thought, "Oh, dear." I didn't know at the time that right to die was not a subject of ... I never investigated closely or not ... She should've taken some antiemetics. Dr. Bob: As we do now. Derek Humphry: ... to prepare the stomach for that extremely toxic drug that was going to kill her. Anyway, she didn't vomit all that much. And she just quietly died. Dr. Bob: Were the boys with you at the time? Were they in the room or were they? Derek Humphry: No. They were in the next room. But when I went out of the room, I know they went into the room when she was dead and apparently said goodbye to their mother, and after my presence. And I called the local GP who looked after her for about two years and told him that Jean was dead. And he came out. He said, "I'll be around in an hour or so and sign the death certificate." When he came in and looked at her, and I kept out of the room deliberately. I didn't want to muddy the waters in any way or whatnot. And I was out in the garden, but he wrote down death from carcinomatosis, massive cancer. If he'd wanted to speak to me, I was there in the garden, and he could've called and said, "I want to talk to you, Derek," but he didn't. And he thought it was a natural death from her powerful cancer. Dr. Bob: Which it would've been before too long had she not taken this step. Derek Humphry: Yes. Dr. Bob: But it would've come after quite a bit, potentially quite a bit more struggle and suffering, right? Derek Humphry: Yes. Well, certainly she would've been dead within a month. That was definitely on the cards. Her doctors had told me that they would look ... They'd say, "She can come in to Oxford Hospital, and we'll look after her, or she can die at home." And I said, "She wants to die at home." And they said, "Fine. We'll provide as much comfort as we can." So that was how it ended. Dr. Bob: And that was 40 ... How old was she? Derek Humphry: She as 42. Dr. Bob: And that was 43 years ago, 1974. Derek Humphry: Yes. Dr. Bob: So 43 years ago. It sounds like you can ... I know that you've told this story not just a few times over the years, but it sounds like you can almost, it's almost like it was yesterday. You seem so clear that you can recollect the details so clearly. Derek Humphry: Yes. And she was so clear. She wasn't one who would aggravate over things. She wouldn't ... She'd talk things over, "What is this? What is that?" We'd had a pact that when she first asked me to help her that it would be a joint decision. She said, "I could be made woozy by all these drugs." And she said to me, "Back at the first opening of this, she said, "If I'm asking to die at the wrong time because there's been a cure for cancer or if there's more to do, don't help me. It's a joint decision." And so I went along with that. You have to stand by your partners at the worst of times. Dr. Bob: Well, she certainly sounded like she was very clear and wasn't hesitating at the time. And her strength, and her fortitude, and her clarity have had such a significant impact on many lives from that. Had she not made that decision, had she not asked you to support her in this way, it's hard to know what would have transpired and how the right-to-die movement might or might not have developed over time. So can you share how things developed from that point and how her gentle and peaceful death ended up leading to the next steps for you? Derek Humphry: Well, I had written. I was, what, 45 at the time, and I had published three non-fiction books, had modest effect with them. So I was a published author. So I decided to write a little book about this. I was rather ... I studied the subject after Jean died--no, before and after. And I went into the library of the Times of London, and I read up all the assisted suicide cases for the last 50 years. And what struck me was that here were spouses, male and female, dragged into court. Assisted suicide was and is a crime in Britain. And I was shocked by what I read in modern history about this. And what really struck me was that these people that I could see were never sent to prison although they were vulnerable to 12 years in prison, the maximum sentence. But the judge would always say, "You've done wrong, but it was done in a spirit of compassion." Then he would suspend the sentence or put them on probation and things like that. I thought, "Well, this is a wrong law." If it's a crime, well then it should be punished as a crime. But this is not a crime, and it should be modified." So that got my dander up. And so I wrote a little book called Jean's Way in which I told the truth, the harsh truth of what had happened, the good things, the good times, and the bad times, and how Jean had handled it and so forth, and about the doctor, whose name I did not release. And when I took the book 'round to several publishers in London, nobody would publish it. Even though I was already a published author and staff writer at the London Sunday Times, they said, "Oh, no. It's too harrowing. Oh, no, it'll make people cry." And my own editor, Harry Evans, the great editor, he looked at it, considered it, and he said, "No, I don't want my readers crying on Sunday morning." And I said, "What's wrong with a good cry for genuine reason? This is part of human life." But he wouldn't. He wouldn't publish it. Anyway, I found a little publisher who was willing to take the chance, and they published it. And the entire book was sold out in a week. In five days it was gone. The public snapped it up, and I sold the paperback rights, and the Norwegian rights, and the Japanese rights, and Spanish rights. So the publishers and my editor were wrong. People do want to read genuine cases about this, sincere cases. And a huge amount of the public is interested in peaceful and careful dying. So that was that. Then I moved to America to work for the Los Angeles Times. I wanted to change, and the book became very controversial, and I was invited onto lots of television shows, the Donahue Show. All of the big afternoon television shows, all of them invited me on to talk. And it began to stir interest, and I began to get huge mail from people, and they could reach me at the Los Angeles Times. They would just write, "Derek Humphry, Los Angeles Times, Los Angeles," and that would get me. And people said to me, what are you going to do about this? And I said, "Well, I'm thinking," and this question kept coming up. And so I began to feel, "Well, I'll set up an organization to help people as best we can and long term to change the law so that this could be done thoughtfully, legally by willing doctors according to law and guidelines. And so I set up the Hemlock Society in August of 1980, announced it at the L.A> press conference. I remember one reporter said to me, "Are you going to be in the yellow pages?" I said, "Of course. This is not going to be a covert organization. This is going to be straightforward. But we're not going to break any laws if we can help it. We're not that way. We're in the business of changing laws." But meantime I wrote a little book called Let Me Die Before I wake, which a guide to how to do it yourself. This first book was on the right today, well, second if you call Jean's Way as one. It was true cases of people dying, taking their lives, and what drugs they used, and how they handled it. I went around America interviewing people who were willing to talk to me about the death of a spouse or a child. And I gathered these stories together, published it in a little book, which sold continuously for the next 10 years to mostly members. It wasn't a bookstore book; it was people heard of the Hemlock Society, and I did a number of radio and television programs. Gradually the membership at Hemlock Society grew from nothing to 47, and I had a- Dr. Bob: 47? Derek Humphry: Yeah. I had a- Dr. Bob: It's interesting. I meet people in my practice, and many of these older residents of these community are card-carrying long-term members, and they're so proud of it. These are people who are very successful, intelligent, and they're the folks who have always been able to kind of be self-determining and not just accept what is being handed to them but want to really determine the course of their lives. I don't see as many younger people, and you can share your thoughts on this and what's happened since, but not as many younger people seem to be connecting and kind of opening themselves up to this sort of connection because the people who are the older people who are these long-term members of the Hemlock Society, they had to find out it and join when they were about my age in their 40s and 50s. I don't hear a lot of 50- and 40-year olds these days engaging in this conversation, which is interesting. It's mostly the older folks who are looking more- Derek Humphry: I don't agree with you there. Dr. Bob: That hasn't been your experience? Okay. Derek Humphry: My experience is different. I have two websites. I have a blog, and I have a Listserv, and I find that the ratings of people, it varies a great deal. I get an uncomfortable amount of students approaching me, wanting to interview me and to know background, and so forth because they're writing projects on it all over America. And I get some end of term or so forth, I get swamped with these. So I think there is fairly across the ages group of support, true most support from people over 50, and that's very often because they've seen their parents or grandparents die in circumstances that they would not want for themselves. Dr. Bob: That makes complete sense. Derek Humphry: Whereas young people have probably not. Thank goodness they've not seen loved ones die. But we older people, of course, have, so and- Dr. Bob: I appreciate that perspective. I appreciate ... Obviously, you've been in this world for longer and are very tapped in to it. So I appreciate knowing that from in your experience, that there are people across the age ranges who are paying attention and supporting. So what happened with the Hemlock Society? I know that there were changes that occurred. Derek Humphry: Yes. Well, because the movement grew bigger, and other organizations formed. Ten years after I formed the Hemlock, Dr. Kevorkian came on the scene with his very controversial tactics and actions. And of course, the media were fascinating with Kevorkian. I mean, they'd never heard of a doctor with a suicide machine that killed patients on request. So he got an enormous amount of ... far more publicity than I got. I washed with interest. In terms of informing, because a lot of people only watch television, and they don't tend to read books and papers, and that's their choice. So suddenly Kevorkian offers so many television appearances. We're telling people about the right to choose to die, and he helped directly with drugs 130 people to die and could have going on doing that. He was twice charged with assisted suicide, and the juries wouldn't convict him. He was acquitted. But then he wanted to make it a bigger impact. He believed that all this publicity would make the medical profession change its mind about assisted dying. He was wrong, but he persisted, very persistent, tough man. And he performed active voluntary euthanasia, a man ,very sick man came to him and asked to be helped to die. The family was behind him, and he was a very, very ill man And when Kevorkian ended his life, this man's life by injection, and he filmed it, and he got 60 Minutes to put it on film, and on the 60 Minutes program, Kevorkian looked down at the camera and pointed his finger, and then said to the district attorney of his area up at Michigan, "Either you prosecute me, or I've won." Very [defact 00:36:24], strong ... He threw down the gauntlet to the legal people, who were not going to prosecute him again. They've got fed up with him. But this time they had to take him to court because he was such a defiant act. And they were willing to look past assisted suicide, but death by injection, they were not. That was ... They charged him with manslaughter and second-degree murder. And he was convicted. He'd overstepped the mark because of assisted suicide before the courts, you can plead ... It was something you had to do, something that was by choice and by agreement. Although it's strictly it's against the law, juries accepted that when they heard the cry is from the family and what the dead patient had said and so forth. Now, with second-degree murder, you cannot bring evidence of compassion and sympathy. That's not allowed in Britain and America under a murder charge. You either did it, or you didn't do it. You can't say, "He asked me to kill me." You can't say, "I did it for a good reason." That argument, the judge will immediately stamp on any argument, and he has to. That's the law that's in the practice. Bob Uslander: I imagine it may have an impact on the sentencing and on how the punishment is meted out? But it sounds like not on the actual determination of guilt or innocence. Derek Humphry: Yes. Dr. Bob: Is that correct? Derek Humphry: Yes, and he repeated his thing, "This action of mine, helping this man to die was merciful, and the law should be changed," and all the rest of it. He said to the jury, "Do I look like a murderer?" Of course, he didn't. Dr. Bob: Of course not. Derek Humphry: But the judge was pretty strong on him. He'd appeared before her before, and he signed a bond that he would not help any people to die, and of course, he obviously broke that bond. And so the jury found him guilty, and the judge said that "This is the end of your actions on this." And he was sent to 10 years to life; I think it was. It was a certain period to life, and he went to prison. He appealed, but he had no grounds for appeal. He kept on appealing, but they didn't have good grounds for appeal. That's the way the homicide laws are: You either did it, or you didn't do it. He had a film with himself doing it. So his work ... He did eight years in prison, served it very bravely, and nobly, and was let out after eight years instead of life on a promise that he wouldn't do it anymore. And he stuck to that promise. A few years later he died of kidney disease. He certainly had his impact. But where I, and I'm not medical profession, I'm not a doctor, of course, only a journalist, and people would write to him and say, "Will you help me?" He would write them back or call them back, and he would say after he'd saw the circumstances, "Yes. Fly up here." So people that he accepted would fly to Detroit, check into a motel. And he would help them to die next day. Now, that upset the medical profession. They said, "Look, that's not the way you practice medicine." Even if the end result was a Kevorkian-type result, you would evaluate a patient. You get to know a patient. You make sure it's a genuine, compassionate request. So he didn't move the medical profession at all. I'm afraid, and- Dr. Bob: Right. And that's really what's developed of course in the states that do have loss that allow physician-aided dying. Those issues are addressed. And as somebody who's practicing in that realm, I can assure you and everyone listening that the relationships are very important, and this is not a quick transaction, right? Derek Humphry: Yes, not a casual thing at all. There has to be understanding and friendship and signed documents saying that that's proving that this was the patient' own decision, the witnessed documents and whatever. It must be done carefully. And Kevorkian, one, in the start of his antics, he came to me, and he said that "Will the Hemlock Society send me patients?" And I said, "No. I don't believe in ..." Oh, he said he was going to start a suicide clinic. And I replied to him straight off in my office, he came to my office, asked for help, and I said, "No, I don't believe in people being helped assisted dying in clinics. This is something that must be done in home with knowledgeable doctors and agreeing families. This is not acceptable at all." He got very angry and stamped out of the office because I wouldn't help him. And I said, "Alright." Even before he got out, I said, "Alright. We have to change the law, not break it." Dr. Bob: Right, not circumvent it. Derek Humphry: Anyway, so he never spoke to me again. Dr. Bob: First of all, thank you for that history lesson. It's fascinating, and I now a lot of people will benefit from having a greater understanding of how the right-to-die movement really began and where Dr. Kevorkian fits into it. Share with me a bit, if you would, about what you're doing now. What is life like for Derek Humphry these days? Derek Humphry: Well, I'm 87 years old, in pretty good heath instead of some of the things like nerve-ending damage, or losing my hearing, and so forth that old people suffer from, but I don't have any major illnesses or terminal illnesses. I resigned from the Hemlock Society seven years ago. It was getting too big. I'm a writer, not a CEO, and so I handed it over. A few years later it merged into Compassion and Choices, into another ... It was merged, and the Hemlock Society doesn't exist anymore, except Hemlock Society of San Diego: They've kept their name and a very strong chapter down there. Dr. Bob: Yes, good friend sort of mine, and I will be introducing the listeners to some of the folks from the Hemlock Society of San Diego in future podcasts. Derek Humphry: Yes. I run a little organization that supplies quality literature about the right to choose to die, about assisted dying. And my book Final Exit, which is the guidebook as to how you can practice your own self-deliverance, what you must beware of, the dos and don'ts, the law. It's all described in journalistic terms. I'm a very straightforward writer. The book Final Exit has been selling since 1991, selling today. I sell about four or five a day. It's in the bookstores. It's on Amazon, and so forth. And it's sold all over the world. Most languages have taken, and even China and Japan have taken it. And then I've just published a memoir of my life, Good Life, Good Death, which is the story of my life before 50. I was 50 when I started the Hemlock Society, but it describes my life there, and then the second half about Jean's death and how the right-to-die movement numeric grew and grew. I moved to live in Oregon from Los Angeles, and I discovered that Oregon had a system of you could change the law by citizens initiative, that citizens could vote in their own law. It's quite complicated to do it. So in 1993, we set about, I gathered people around me and Hemlock Society of Oregon. I met other good people, doctors, and the lawyers, and nurses, and laypeople, and we got a citizens initiative going in Oregon in 1994, and we learned from other failures that we'd had previously in California and Washington. And to everybody's surprise, we won. We won by 2%, and the right-to-life movement sprung into action, got an injunction against us, stopped it. Then we fought that injunction off. Then they brought another one in, and they delayed the law for three years, and they called another vote, a state-wide vote in Oregon. They called another vote. And it was the biggest mistake they ever meant. We won by 4% the next time. We doubled our gain. So the vote, it was twice voted on in Oregon. And the law went into effect in 1998, and has worked- Dr. Bob: Yes, it has, and then- Derek Humphry: ... very satisfactorily ever since, and I think- Dr. Bob: Yeah, and then laws, the law in Washington became essentially modeled after that, and California and now Colorado, and I understand that there are initiatives and bills in many other states. So we are I think the progress continues. Derek Humphry: Yes. It's slow progress, and people would like to see more, but in a democracy and a free country like America, you've got to go step by step. Dr. Bob: Yes, you've got to go through [crosstalk 00:49:14]. Derek Humphry: Interesting. In Britain, it's still a crime to assist a suicide, but the Chief Prosecutions Department in London has issued guidelines. This is two years ago. They issued guidelines as to when they would prosecute a person and when they would not, what their markers were, what their standard was. And I agreed with it. I thought, "That's ..." I could see that I was ... Oh, there was a ... After the cheese, we came out, he police came to me and said, "Did you do this?" And I said, "Yes, I did. Oh, yeah." I said, "If you take me to court, I'll throw myself on the mercy of the court." I did help her. But the public prosecutor decided not to prosecute me. He used a clause in the law that if he felt one way about it, he could decline prosecution. And in Britain, they have this new law. They still haven't changed the law in Britain, and though they've tried the Oregon law two or three times, it never gets through Parliament. But they do have these guidelines which you can read there on the Internet and everywhere, which says if you assist a loved one, it can't be strangers, if you assist a loved one under these circumstances, I can't spread them all out now, but intelligent circumstances, then we are not likely to prosecute. If you do it for monetary reasons, or selfishness, or any criminality, then you will be prosecuted to the full extent of the law. Dr. Bob: As it should be. Derek Humphry: So go ahead. Dr. Bob: No. I said, "As it should be," right? I know that sometimes there can be nuances, but we do need to be protecting ... We need those protections in place. Derek Humphry: Oh, yes, undoubtedly. We're moving towards doing it. And I think that the whole change in America society is swinging, going to swing in our favor. I mean, who would've thought 10 years ago that there would be gay rights as clear as they are now, that there would be same-sex marriages? Who would've thought that a few years ago? But it's gone through, and the Supreme Court approved it. So there is a change in attitudes. Dr. Bob Bob: There is. Derek Humphry: And younger people are more open to intelligent decisions instead of old-fashioned and religious decisions. Bob Uslander: Well, you were ahead of your time, my friend, and you were it sounds like an accidental pioneer. I personally and professionally am grateful. We will be kind of carrying the torch and continuing in the efforts that you and many of your peers have put forth. And there are many, many people who owe you gratitude for going out and being willing to put yourself out there because it wasn't the easy path. It wasn't the path of least resistance by any stretch. I know that. Dr. Bob: So, Derek- Derek Humphry: ... had some ups and downs. Dr. Bob: yeah. Well, no doubt. And there is more work to be done. Derek Humphry: Oh, yes. Dr. Bob: There is quite a bit, but we also want to, like you were indicating, we want to recognize and appreciate the strides that have been made. And we are, I feel like we're moving clearly in the right direction. Derek Humphry: Yeah. I hope so. Dr. Bob: If people want to connect with you, and certainly you discussed a few of your books, I know there's others, but Let Me Die Before I Wake was one; Final Exit; Good Life, Good Death, which I have a copy of, and I can't wait to crack it open and dive into it. What is the best way for someone to learn more about you, be able to access your blog or give access to your books? Derek Humphry: My main website, which is the name's easily remembered, and then that leads you on to my other websites and blogs. It's www.finalexit.org. I'm not a nonprofit organization. If you go to finalexit.org, you could then see how you could move on to our bookstore very clearly or join a blog or the Listserv. So that's the easiest way to get in contact with us, finalexit.org. And my latest book is my memoir of all these years before '50 and the turbulent years since 50, and I call it Good Life, Good Death, so not all about death. There's quite a lot of humor and irony in other parts of it. And it's available through me or Amazon or so forth, but prefer you bought it from me. And you can find it through finalexit.org and get it at the discounted rate. Dr. Bob: Wonderful. Well, Derek, I just want to thank you for taking time and sharing so openly, and, again, for everything you've done to move, I think to move humanity forward. Derek Humphry: In a small way, and it's been very rewarding. I've built up a huge friendship and wonderful friendships, and people to work with on these calls, and particularly down in San Diego there seems a real hotbed of thoughts and action about this subject. Bob Uslander: Yeah, well, I know you've got some very good friends and admirers down here, and I'm one of them. So I'll look forward to continuing this friendship, and I know that we'll be back in touch soon. So I'll be signing off. Thank you so much, and we all appreciate you. Derek Humphry: It's been good talking to you. Dr. Bob: Okay, Derek. You take care of yourself. Derek Humphry: Okay. Thanks very much.  

In a very candid and poignant conversation, Bill Andrews' sons share what their dad's end-of-life experience was like for them. Hear how they worked as a team to help their dad have the best death.     Note, if you haven't already listened to their father's episode, please click here to listen to Bill Andrews share why he chose to end his life after battling ALS. Transcript Dr. Bob: This episode is a follow-up to a previous podcast with Bill Andrews, a patient of mine who ended his life on October 23rd, 2017, using The End of Life Option Act, also known as Physician Aid in Dying, or Death With Dignity. The law, which became effective in California in June of 2016, allows a competent adult resident of California with a terminal illness to request from their attending physician a prescription for medication that will end their life in a peaceful and dignified manner. Bill Andrews had ALS, also known as Lou Gehrig's Disease. He was a surfer, a thrill-seeker, and an adventurer prior to the onset of this illness. He also was a devoted son, father, and grandfather. I recorded a podcast with him four days before he ended his life. Two of his sons were present for that interview, as well, and all three were with him when he died a few days later.  I invited Bill's sons, Chris, Eric, and Brian, to join me and share what they had learned from this experience, and to help carry on their father's legacy by helping others understand more about what it's like to help a loved one through the Aid in Dying process. Bill was a pioneer, and he was also a humanitarian. He wanted his death to have value for others, which I'm hopeful that these podcasts can help accomplish. This discussion is fairly graphic and detailed. Some people may find some of the content uncomfortable. Others will find it gripping and refreshing. I found it incredibly inspiring, to hear the words of these intelligent, thoughtful and grieving young men as they share what they went through as a family and honor their father, Bill Andrews. Please share this with others who may benefit and feel free to head to my website, integratedmdcare.com/newsite1, for additional information and support and other topics related to life and death. Welcome to another life and death conversation. This is Dr. Bob Uslander, your host and the founder of Integrated MD Care. Today is gonna be a bit of a different format, we're doing a group podcast, and I have a few gentlemen here with me who I shared a pretty special experience with just a couple months ago. I did a podcast interview with Bill Andrews; you may have listened to that one. Bill was quite a character, well loved and well respected, a gentleman who made the brave decision to end his own life after struggling with ALS for several years. I did an interview with Bill just a few days before he did end his life and he did it in the company and the presence of his family, and his sons, Brian, Chris and Eric, have decided that they wanted to speak and share their perspective and help others who may be trying to figure out how to navigate this terrain and how to support each other and their loved ones through this process. So I'm grateful and very please to introduce you to Brian, Eric, and Chris Andrews. Thanks for being here guys. Patient Son: Thanks, doctor. Patient Son: Thank you. Dr. Bob: Okay. There's a lot of things that we can talk about. There's a lot of different components to this, but one of the things I want you to share ... And you were on that podcast when we talked to your dad, and we got a little bit of your perspective on that, but he was the star of the show. You guys were in the background, but it was nice to have that. Now I'd like you to, in memory of him, in honor of him, we know that he was very, it was really important to him that people understood that this was an option and they understood why he took this option. Why he made the choice. From your perspective, can you share a little bit about why you felt it was so important for him to share his story? Patient Son: This is Brian. Dad loved being a pioneer in life. He liked being out in the forefront doing things in business that were new and innovative, and in his action sports lifestyle, surfing big waves, motor crossing areas that people had never been. I think he really felt good about being a pioneer and doing something here that was newly available. Dr. Bob: Okay. Patient Son: He really wants people to hear his story, and he was really happy to have done that, the podcast with you, and he really wants to get this information out for people considering this. Dr. Bob: That's cool. It's interesting to think about that, the pioneering spirit. I relate to that. I'm kind of, as a physician, a bit of a pioneer in this realm. Of course, had he not been dealing with a terminal illness that was challenging him every day and getting worse, he probably would have found other ways to pioneer, right? Patient Son: Yeah. Dr. Bob: But this was an opportunity for him to take his own experience and what he had to deal with and go through and hopefully allow others to benefit from it. So, not just being a pioneer, but being a humanitarian, I think. Patient Son: He's always loved helping people and helping to share wisdom and teach and coach. That's just the kind of guy he was, so yeah, this is good. Dr. Bob: Yeah. How long before he actually, his life ended, did he start talking about this being an option for him? Patient Son: I don't he knew it was an option to be honest with you 100%. But I think it was something that we discovered along the way, and it might have been Brian who brought it to his attention as an option to look into. Dr. Bob: Okay. Patient Son: We were reading all about ALS and how it was gonna end. But the question was when and how right? So we were just learning so much about it and reading about it and meeting people, going to support groups. You know at some point it's gonna end. The average time was supposed to be two to three years, and so we didn't know how long. It turned out to only be, from diagnosis, it turned out to only be a year for dad. Through that journey of reading about that we read about this option and talked about it. Dr. Bob: And so you discussed it with him. Did you guys discuss it with each other first? Patient Son: We did. We shared it with each other and just, you know, it was earlier on. I think that was maybe in the first month or so after his diagnosis. It was around the holidays a year ago. We had read about that and said, "Well, this is something we should keep our eye on." We knew we were going to go through a journey together. We just wanted to have that as something to learn about and so we did. I think dad was also reading on his own and I'm sure he read about it as well. It's something we ended up talking about together. Patient Son: ALS was not something that I think any of us knew anything about prior to his diagnosis. It's the type of thing we all had to be learning about as we were going through it. We were also trying to form opinions about it as we were going through it. I think that when Brian came across the Death with Dignity website, and there were some other materials that kind of lead us to that path to look at that. It wasn't like, "Hey, what do you guys think?" It was just like, "Let's just read this and try and understand this a bit." The whole process was a lot of like learning, talking, digesting everything. Like facts, emotions, decisions, kind of all doing it simultaneously. But yeah, we really, it was something that we brought to his, for him. Dr. Bob: Which is unusual. You don't have much other exposure to this, but it's unusual that families bring it to a person. In my experience, most of the time, the individual is the one who has been either, for years has been kind of secretly knowing that if things got to a certain point if they develop these challenges, that they would want to look for that out. But most of the time, the family members bring ... the patient, the one who's dying, brings it to the family members and they have to try to convince the family members that it's the right thing for them. That's what I see more often. I think it speaks a lot to your relationship with him and your level of love and trust, that you felt that you could bring something like that onto the table and talk about it as a family looking at all the different options that were out there. This is never the first option. This is never what anyone is hoping for. It's always after exhausting all the other possibilities. But as it turns out in many cases, it's the best of the various options that are out there. So you guys, at what point did you speak of this to a physician? At what point did, and I know, but for the listeners there, what was the path that was taken once it was discussed as a family? Patient Son: We had seen one of dad's primary physicians, and they had a good relationship with one another. End of life, quality of life was a big conversation between those two, especially within the last year. We weren't a part of those conversations until recently when we started going to the appointments with dad, you know, having to take him there and so forth. So being there gave us exposure to some of those conversations, and it was no surprise to his physician, approximately two months before dad left us, that we went to him with that formal request. He was ready for that call. Dr. Bob: Okay. And even though he wasn't necessarily familiar with the specifics or how to put things in place, he was receptive and willing to support your dad through that? Patient Son: Very much so. Dr. Bob: Great. I know that that's ... How long was it between that conversation and when he reached out to me? Do you have any idea? Was there much time lapse in there? Patient Son: Yeah. He doesn't know the exact time. Patient Son: I think it was about four to six weeks. We had the conversation saying, "We're ready to move forward." We had some learning to do on our side that took some days and some weeks. Our physician wasn't familiar with the process whatsoever, so he needed to do his own research as well. Two, three weeks went by, we realized together, with the physician, that we were at a stalemate. It was at that point that we decided to explore other options and getting some additional help, and that's how we met you. Dr. Bob: Great, yeah. I had met him. I had a prior relationship with this physician. He, I guess put the word out that he was looking for someone who knew more about it. Patient Son: He did. Dr. Bob: And then we connected, and I think it worked out well. He got to be involved, as everybody wanted because he had that relationship and you got the benefit of working with someone who knew how to get you down that path. Patient Son: Yeah, you ended taking over as the primary and then he took over as the supporting physician. Dr. Bob: Right, it worked out really well. Patient Son: It worked out great. Everything was smooth once we got rolling on that program. Dr. Bob: And he deserved that, he deserved smooth sailing because there's a lot of folks who start down this path and they just hit one roadblock after another, one obstacle after another. And either they struggle for longer, or they often get passed the point where they can even take advantage of this, which is really unfortunate. Patient Son: We actually had that as a time constraint, because dad has the ability to walk and his arms were getting really weak, and his hands, gripping was getting weak. We had to start hand feeding him in his final week. So it wasn't too much time left because he could life a cup with a few ounces of weight and drink when he needed to do, even do any other way to self-administer. Self-administering was a requirement, so we had a time horizon that was limited. So we were getting a little bit, a little nervous about that as time marched on, which is another reason we contacted you to help get things moving. Because he really wanted that, he had talked about having three options. He could just let the disease take his course and he'd starve to death and wouldn't be able to breathe. He didn't want to go through that, but that would have been his second choice. The other option was to be kept alive through any medical means possible, feeding tube and ventilator. He did not want to do that. So that's what knew right from the beginning, he did not want to be kept alive, didn't want to be bed-ridden, didn't want to be having this, any medical means to keep him going. Because he lived a great life, and he was ready to go, so that was the last of the options, and this became his leading options hands down, was to take this California End of Life, with a graceful ending on his terms, not having the disease run its course all the way to the end. He was getting very close. We were only I think a few weeks away at the most.  Dr. Bob: As things were changing? Patient Son: Yeah, things were changing pretty fast for him. Dr. Bob: Yeah. I know that it's hard to even imagine how frightening that would be. Even though he knew that he had plan B, but he knew that that was going to be difficult for everybody. It was going to be challenging for him, and it would have been difficult for the family to watch somebody going through that. So I know that he was very, very determined to be in control. We know that he set a date, and setting a date is probably a bit challenging because you have children who live in different parts of the country, and he wanted to be accommodating.  He wanted to make sure that everybody could be there and participate, but he didn't want to push it off too far because he was worried about the possibility that he would lose the ability. He also didn't want to cut offany more of his life than he had to because he loved the people who were around him. He still loved life; he just hated the circumstances. So when I talked with him, he was four days out from the date that he had set. We knew at that time that he was not going to change his mind, he was determined. Can you talk a little bit about what it was like from your perspective to be setting a date for your father to be ending his life? Patient Son: That's a terrific question, Chris. Do you want to start Eric? Patient Son: Yeah, I feel like jumping in. I think this is sort of like the piece that was ... I think were saying it was a little morbid, but it was also really amazing. It ended up being fascinating. Typically, when someone dies they die, and then they're gone, and you have to deal with everything all at ones. You have to deal with your emotions and the planning and logistics. You have to deal with everything all at once. But what this afforded us was an opportunity to chip away at all these things. We knew his day was approaching, so we all knew that we could say our goodbyes. It also meant that we could be emotional one day and they be very pragmatic another day, and just say, "What should we take care of today?" Because we had time, we didn't have to deal with it all at once. You could deal with it as you were leading up to the day. It was really comforting. It gave everyone the time and the space to wrap things up in a way that we all needed to individually. I always tell people, it's like a really weird experience, but I got to write his eulogy and then read it to him. There was one part that I didn't say very well, and so I actually rewrote a part of it and then read it again to him. No one gets to do that. I thought that that was a really special opportunity that this afforded us, that I found fascinating. Patient Son: His, dad's terms were reverse engineering. He was an engineer. He liked planning things. His goal was to pick a date that would work well for the family. Once we did that, then all the other pieces fell into place. So picking the actual date was pretty easy for us, because dad was not doing well at all, getting worse day by day, having a harder time day by day, so the sooner, the better.  He wanted to take advantage of the quickest it could happen, you know after the process, which was about a little longer than two weeks, 14, 15 days, something like that. So we worked together, the three sons and dad, to pick a date that would work best for everybody. Then, from there, worked backwards to what he wanted to do and what we wanted to do leading up to that date. Patient Son: Cool. Eric, you should tell him about the day before, like what ... Patient Son: Do you want to get into that or some of the things that happened before then? [crosstalk 00:19:41] Dr. Bob: No, no. I think it would be fascinating, but do you have anything you wanted to add- Patient Son: Yeah, I'll comment on the date. Dr. Bob: ... about setting the date? Patient Son: Yeah, it was a powerful, impactful moment to set the date. We bounced around on phone calls and texts, trying to pick a date. Dad, when he was ready, he was ready. He was, "As soon as possible," but I want to make sure it works out for all of us because we have our families and birthdays and holidays. He was ready to go, time off work. He was really concerned about a date that would work for all of us, but he was ready, so of course, we wanted to accommodate him with as early as we could pull it off. So we bounced around a couple of dates. We had one and then we actually switched. We had to have Chris come out from New York, and thinking about your family when they would come out. I would just say that it was a heavy moment to set the date, but also it was very freeing at the same time because we did have it on the calendar. We circled that date, and then we could reverse engineer it and start to plan all these activities. So it kind of gut us unstuck and it started some real positive moves to happen, to have that. But it was powerful. Dr. Bob: I imagine it amazing freeing for him too. Patient Son: It was. Dr. Bob: I mean it sounds ... I think that I hear families talk more about how knowing the date makes it more real, and sometimes even more uncomfortable. You guys are unusual in that I get the sense that you guys are all, you were so deeply connected with your dad that you were experiencing this as he was experiencing it, not separate. I mean yeah, you have to think about how it's going to impact you and deal with those feelings, but I really felt like you completely put him first, and that was the only thing that really mattered, was making sure that he got what he needed to get, and with as little interference or struggle as possible. Patient Son: Yes, it's very true. I think we're just like every other family; nobody's perfect. We've all had our disagreements throughout the years and certainly some tough times all growing up; things weren't always perfect. But the disease brought us together, and then this decision brought us together even closer, which was fantastic. Dr. Bob: Cool. That's a gift. Patient Son: It was. We all had our own unique relationships with him for sure. When the disease diagnosis was given a year prior, we said, "We're going to really bond as a team." We had a team name, Team Keep Paddling, dad's a big surfer, right? So he always said, "Just keep paddling. If you ever want to give up, just keep reminding yourself to keep paddling. One more wave, paddle, don't give up. Bust through the white water and get out there and catch that last wave." So that's what, we formed our team name, and we were all about being together. It's actually the best team I've ever been on in my life, in any sports team or work team. This team, this Team Keep Paddling, was the best team I've ever been on. Dr. Bob: That's wonderful. I just had an image that came to me. I'm sure that your dad taught each of you to surf. Whether you kept surfing or not, at some point, I imagine that he'd spent his time pushing you into the waves and getting you up there. I just had this image of you guys, because he couldn't move, he couldn't walk, he couldn't do it, that you guys sort of pushed him into the wave. Patient Son: That's really good. Dr. Bob: [crosstalk 00:23:31] into that final wave. Patient Son: You're right. Dr. Bob: And he rode that wave in. Patient Son: Something I think the three of us did really well together, was that I think when this first started, there was a lot of, "I, I, I, I," type of thing. "I feel this way. I might do it this way," and so forth. Then you, as time goes by and the situation gets worse, you tend to ... well at least for us I think it became more about dad. You know, what he wanted. It was crystal clear towards the end that all the decisions that we should make were in his best interest and making sure that he could go out the way in which he wanted. We're very proud of our team work together to support him. He was so happy at the end. We can live the rest of our lives knowing that we did the right thing for him. Dr. Bob: Yeah, and you created that piece for him in that place, and part of that was that you guys were coming together and working in that way and that you always ... I'm thinking about my own experience with my parents and how that affected me, but now that you know what it feels like to fully support someone, to remove your own needs from that, it affects everything. You can never un-know that. You always recognize that there's a part of you that is able to completely forget about your own needs and put others first. This is potentially the culmination of that, but it changes us, right? When we do that it changes us, and all of our other relationships going forward are influenced by that, which is pretty cool. So that's another gift. His gifts continue to be apparent. Patient Son: Yeah. You're right. Dr. Bob: So you guys, you alluded to this, and I definitely want to talk, you created, the whole couple of day leading to and including the day of his death were pretty incredible. You want to talk a little bit about that? Patient Son: The things towards the end that were very important to him, which they were forever just reinforced a little bit, were some time with his sons, some time with his family, some time with his grandchildren. So the day before he passed we set it up so that the grandkids could spend some time with him in his room as residents. We weren't sure how that would go so we just kept bouncing ideas off each other about what would be comfortable for everybody. We thought just opening the room up and letting the kids run around and play and be themselves was the right thing to do, because that's what they're good at and that's what dad wanted to see them do. We had a couple activities. One of which was we made a t-shirt for dad that we would were the following day. Patient Son: It was his idea. Patient Son: It was dad's idea, right. Why don't you talk about the shirt? Patient Son: [crosstalk 00:26:53] told you. Patient Son: We thought this was really special. He'd said ... We were actually trying to talk ... He wanted to know who should be in the room the day that he was actually going to go through with this. We talk about it, and he said, "Well ... " He's like, "Obviously I don't want the grandkids in the room." He's like, "What would be amazing is if, when you guys bring them over to play, bring a white t-shirt and some paint. I want them all to put their hand prints on the t-shirt, and I'll wear it.  That way the next day I'll feel like they're in the room with me." It was super sweet, and so we did that, as part of the day before. We had the kids come over, and they thought it was a lot of fun.  But maybe they didn't realize at the time they were actually making him a really amazing memento. And then Eric had another amazing idea... He bought a plain white sheet, and he bought a ton of fabric pens and paints. He had all the kids; it was Eric's idea, he had all the kids draw pictures, "Just draw whatever you want." Whether they knew it or not, the age range in the room, how old is Paige? She's 10? Patient Son: 12. Patient Son: 12. The kids ranged from two years old to 12 years old, and they were six of them. We put a big tarp out and the thing, and they all went to town on it. After they were done, they got in a little line and one by one they brought ... We put the sheet over dad and one by one they each pointed to their artwork and explained what they drew and why they drew it for him. What was really special is that we didn't really say, we didn't say, "Draw something intense," but they all I think were feeling the moment, and they did in their own ways. Each one of them got to express through pictures something for him. At the end of the day, he had a t-shirt to wear and this beautiful artwork on a sheet that he go to bring with him the next day. Dr. Bob: When I went over that next day, he was beaming. He was so proud of what he was wearing and just talking about that experience from the day before. That was brilliant. That was brilliant. Patient Son: In addition to seeing the kids and spending some time with them, he also had a couple places that he wanted to visit one last time. Two of which were his favorite beaches, where he wanted to get down there and smell the air one more time, see the waves one more time. We were able to make one of those trips, the other one he just wasn't feeling well physically to go down and make that trip. But we were able to get down to the beach. He wanted to see his grandkids and some sporting events, so he came and watched some flag football, some baseball, some gymnastics. That was important. He had some great meals towards the end; he would eat whatever we want, so we were bringing him things from all over San Diego, some of his favorites. And then also spending some time with his brother, his sister, his mom, close family, as well as some of his dearest friends. He had hundreds and hundreds of friends, so many he knew so well. But there were a handful in particular that he wanted to have some special conversations. So there was a lot that happened. He was able to cross off just about every single thing on that list within that short window of time that we had, or that he had, to be able to follow through this way. Patient Son: I think Eric told you, dad reverse engineered things. So he knew that on the day, it was not a day for goodbyes, it wanted it to be just a business day, where we just took care of things. The day before he wanted to see his grandkids. The days before that, he leaned on us to basically setup times for people to come through. It was very organized. This is exactly the way he wanted it. Patient Son: Went through all the pictures and he explained where places where and who people were. All that was just quality time. Patient Son: One cool think he did that I thought was really special too is he talked about time a lot in the end. When we picked a date it sort of made time more real, but he often said, beyond this, that time is the greatest gift. In the context of running towards the date that he picked, time became more real. But one cool thing he did was he recorded a bunch of things. So he had, I don't know, a checklist of 50 recordings that he wanted to do. He wanted to say something to each grandkids. Patient Son: His own voice recordings. Patient Son: He wanted to something to his friends. He had all these things that he wanted to get out. Obviously, he couldn't write anymore, and so he recorded his voice. But again, having that time, having that date is what enabled him to feel like he could accomplish something. Like, "Alright, I've got to see these people and do these things and make these recordings, and this is what I'm going to do." Patient Son: While he had a completely sound mind and was full of life mentally, just the body was breaking down. But we got to take advantage of that all the way to the end. Completely sound mind and great conversations, all the way to the end. That was a gift. Dr. Bob: Incredible. It's incredible. I didn't know about those recordings. I do know how structured his time was towards the end, because I had to come out and make another visit with him, and I had a short window. I was fit in between a whole bunch of other people there. I was like, "Come on, I'm the important one." Apparently not. Anyway. Talk a little bit about the last day. I think it's important for people to hear what that experience is like from the perspective of those who have helped to allow it and create it if you're comfortable with that. Patient Son: Sure, yeah. I mean, it was surreal, being the last day, for sure. He had hospice care. They were amazing, amazing people. They came by and gave him a shave and a bath. He smelled like a rose. Patient Son: He spoke very complimentary about the people who bathed him and supported him. Patient Son: Yeah. They were phenomenal, really amazing people. So, he got clean, he got dressed in his shirt, and he had the sheet. We had some time together in the morning to have a few more conversations, but he wanted to keep it pretty light that day. He already felt like he had said everything he needed to say, so that last day was just being together. We played some music, some of his favorite songs. We ordered the prescription. That prescription was delivered on that day. It's how that works. Between the order that you put in for that prescription, and they made the delivery to us. That kind of dictated our time window a bit. We didn't have the luxury of having that medication already in hand and waiting for that. So we had to make that happen all that day. But they were great as far as getting that to us pretty rapidly, just a couple hours and we had the medication in hand. Then we had planned to have everybody over. We had his mom and his brother and his sister and our mom and the three of us together all day. We had everybody planned to come over at a certain time once we had time to get the medication. Dr. Bob: You guys want to talk a little bit about that final hour or so? Patient Son: His last day went as good as we could have scripted it, I guess is the most important thing. I agree when you say he wanted to keep it light and so forth. For me personally, it almost ... I hope this doesn't sound cold, but it felt almost as if a formality, because we were able to spend quite a bit of time with him leading up to it, having a chance to say everything that we wanted to say. So that day became just being there for him, as proud, encouraged and strong as he was, he was probably feeling scared, although he'd never admit it. So it was just letting everything go and just being there for him and holding his hand and just telling him a couple more times how much we loved him, and then supporting the other ones in the room who had a tough time with it. Just kind of being there together, and luckily you did a great job for us, where we didn't feel any sort of stress. It just felt calm and the way it was supposed to go, I guess. I'll remember those things, that it was a beautiful day, it worked out perfectly, wouldn't have changed a thing. It all happened pretty quick. Dr. Bob: Were you nervous? Were you nervous about things potentially going badly? Is that a thought that you had? Patient Son: Me personally, no, because I didn't know enough about the medicines or things to understand the true percentage of them not working or something. The family, we were all so communicative together that I knew there would be no outburst or something emotional from anybody in the room. You're always a little nervous I guess in any situation, especially one like this, that it might not go well. But I was so confident and feeling so good for him at the time, that it erased any stress I think leading up to it. Patient Son: I would just say thank you to you too. I think having you; there was ... as I understand you don't have to have a- Dr. Bob: No, there's no requirement to have a medical person there. Patient Son: That would have made me nervous of think. Having you there with us was really ... Patient Son: Yes, agree. Patient Son: I don't know, it was calming and assuring. It was really great for you to tell everybody in the room too what to expect, here's what's going to happen, as we get rolling. It calmed a lot of the ... a lot of confidence that there was actually someone here who had done this before and this is going to be okay. I think without you I would have been more nervous. Patient Son: Yeah, me too. Me too. We knew from you that the medications were going to work. That was undoubtable. So then it was a matter of what it would be like for us in the room and how gentle it would be. That's what was an unknown. Dad was totally at peace. He had said even that three to five days prior, that was the most peaceful time of his life. He felt so confident and was looking forward to that day actually, this next adventure that he was going to go on free from his body with ALS. We all felt very positively about the day. We have had zero regrets and have felt good about it all along to this day. But he was at peace. With his mom there, she was 95 at the time; she just celebrated her 96th birthday. Everyone came over; it was about one o'clock in the afternoon.   We were going to give about an hour or so, a little over an hour, to just be with him, as with the larger family who were there earlier. So his mom came by, and his brother and sister and so on. One thing that was a little bit different for us is we have to prepare the medication. You explained this to us and were totally prepared for it. But with the medications, there's an anti-nausea, those are done an hour prior. Then you get into the; in our case, it was Seconal we used. So we had to open up the 100 capsules. We did that together, the three of us. We got, banged through it pretty quick, it seemed like 20, 30 minutes maybe to do that, 20 minutes maybe. But that was a process to go through. We had the family in the room, and we were going through and opening these and getting it ready. That was a little bit- Dr. Bob: Distracting. Patient Son: A little bit. Dr. Bob: Yeah. Patient Son: Yeah. We weren't just sitting with him; we were opening these capsules and so on. But it was part of the process. We understand that there's no other option right now. We knew that was a proven medication that was going to work and so that was the choice all along. It was just a process... Dr. Bob: Chris? Patient Son: Yeah. This is the only kind of negative part for me I think, was I didn't know. I didn't realize, that we were going get 100 of these capsules and have to break them open and empty them out. It was a little unexpected thing that I felt kind of threw off a little bit of the vibe because everything was so peaceful and we had confidence. All of a sudden, I don't want to speak for you guys, but I didn't feel 100% confident that I was doing it right or that, am I allowed to touch this stuff? Do I inhale this? It was a little weird for me in the moment. And then, I didn't really care until our grandma came and his brother and sister, and I felt like we weren't done with that part yet. So I felt like they were seeing the sausage get made or something, and I was like, that part freaked me out a little bit because I would have rather that just been done. It was the one thing I felt like wasn't exactly ... I mean, it sounds really hyper about our schedule. But it schedule and that part was a little frustrating for me. I think emotionally it was a little weird too because I felt like I was really participating with kind of this medieval act of poison or something. That part I didn't love so much, but I think had we been able to do it earlier, not too much earlier but just earlier enough, where I didn't feel stressed about it with other people in the room and ... Dr. Bob: I think ... So, part of the comfort level and knowing what's safe or reducing that stress, that's on me. I could have certainly given you a bit more information. But now that I'm remembering, you couldn't have done it earlier because of the timeframe. The medication was just delivered that day. Patient Son: It was just delivered. Dr. Bob: And he wasn't going to wait. Patient Son: I would have just told them to come later... Dr. Bob: So for anyone who's listening and you're in the process of planning, this is something to keep in mind. And there is another medication. Just to make sure that it's clear, there is another medication besides Seconal, and it's called DDMP2, which is a combination of powders. It's morphine and Valium and a couple of heart medications. But I typically don't recommend that to my patients, because it's not quite as proven, it's not always as smooth and quick. You might have had a very different experience had he taken that because sometimes it takes hours, rather than the minutes that it took your dad to gently stop breathing. So there are other options. I appreciate you sharing that because it's part of the experience. Patient Son: It was. Dr. Bob: This is a conversation. We're not trying to gloss over anything. We're not trying to make it sound simple or anything other than what it is. This was a very; it was a very meaningful difficult, beautiful, challenging time. It was all of that. I will never forget your grandmother doing the hula. Dr. Bob: She was incredibly special. Was that her idea? Patient Son: It was. Patient Son: Completely her idea. 95 years old at the time, and she spent a lot of time in Hawaii, spent 20 years or so out in Hawaii. So she learned hula out there, and she was a swimmer, very active and learned to dance. She had this idea that she was going to do this hula for him, to send him off on his next journey. So she stood at the foot of his bed. They had their eyes locked, and she did this amazing dance, stood up, she kind of leaned against the bed a little bit to steady herself. She did this amazing hula. Their eyes were locked, and dad looked so happy. He was just smiling, beaming. It was a beautiful moment. We all were blown away by that. But the connection they had, it was amazing. Dr. Bob: Yeah, it was beyond description. And she wasn't just dancing and granted this was a 95 year old dancing; it wasn't- Patient Son: Mostly upper body. Dr. Bob: Mostly upper body. Patient Son: Part of the hula, maybe people ... I'm not an expert in this but it's singing and dancing combine into a really beautiful choreographed moment. She choreographed not only the movement but also she wrote and sang her own song. The essence of the song was about passage, safe passage. It had a surf, nautical kind of thing happening. It was about letting him pass through. It was his mom, saying, "It's okay," and giving him that comfort like it's okay. It was through beautiful hand movements and song. It was really pretty. Dr. Bob: Yeah. And I believe it ended with, "And I will see you before long." Patient Son: Yeah. Yeah. Patient Son: That's right. Patient Son: It was her way to say goodbye. It was very beautiful. Yeah, it's crazy. Dr. Bob: Yeah, and then he reiterated how incredibly at peace he was. I truly, as difficult as this is, to be part of these experiences, truly it's incredibly gratifying to see the depth of the connection and to know that you're left with this beautiful memory that you allowed him to have this peaceful end and to be in control at the end of his life. I thank you. I thank you for being here and for sharing this. I know it's not easy to talk about, it's still so fresh. Is there anything else that you feel really strongly that you want to share that's coming up? Don't feel pressured, I don't want to end this with you having something that you think needs to be said. Patient Son: Well, the actual, once he took the medication it was very peaceful. We weren't sure what to expect. It took 19 minutes from start to finish. He was asleep within a minute or so, a minute or two at the most. Very, very peaceful. He started out with just a relaxed breathing, and it slowed and slowed and drifted off. It was very peaceful. We were all gathered around him and holding him. It couldn't have been better from that perspective. We've always felt good about it; I guess that's a true test. Two months later, here we are, and we're feeling like it was absolutely the right decision for him to make. We were happy to be a part of that for him, to support him, what he needed to do given the scenario. Thank you, Dr. Bob, for helping us with that. Dr. Bob: It was my honor. Patient Son: I would add to that, that since this has happened a lot of people have asked about it. Telling people about this is cathartic because it kind of helps to tell. But it also makes me realize how little people know about the Right To Die Act. It's something when you start telling them your story, they get very engaged, and they're very interested. They want to know more about it. I think it's just not a lot of people know about this but everybody I talk to and tell the story to is fascinated with the dignity and the choice and the control, and dying in a way that's very graceful. What you hear from other people is like, "That was not my experience." My grandma or my father, whoever died, they died very bad. It was not good for anybody. So to hear this side, it's almost like they're like, "Wow, I wish we could have had that. I wish we could have gone through that." It's interesting that when you bring it up ... no one would ever bring it up, but when you talk about it, it does open up a really interesting conversation. Dr. Bob: Well, that's why I so appreciate you being here and being willing to have this conversation because this is the kind of thing that people, they need to be able to share these discussions. Imagine what my party conversations are like. My wife hates going to parties with me because invariably people ask what I do, and we start talking about these conversations, about situations. Then they start telling about their experiences. For me, I live and breathe it, but I recognize that not everybody has the same comfort level with it. But people are fascinated when they understand that there is another better option. Patient Son: I'd just say that the whole thing is so sad in terms of the disease and knowing nothing about it until he was diagnosed. To see how he deteriorated physically so fast. The disease doesn't normally have pain associated with it, but he was a different case where he had so many orthopedic issues from surgeries, he was in incredible amounts of pain. It was so sad to see that. For him to be able to make this decision and to escape that pain while being so sharp mentally and so forth. I think it was one of the best things that happened in this journey. Like my brother said, we're so appreciative because we cared about him so much, and so many people in San Diego and the surrounding communities do. He was very well loved, and he deserved, like so many other people in this world, to go out the way that he did, on his own terms. Thank you so much. We'll always be appreciative for that. Dr. Bob: Alright guys. So Chris, Brian, Eric, thanks for being part of the conversation. You're awesome. Thank you all for tuning in to this episode of Life and Death Conversation.