A Life & Death Conversation with Dr. Bob Uslander

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 tha

Debbie Ziegler's daughter, Brittany Maynard at the age of 29 was diagnosed with a terminal brain tumor she chose to end her life. Her story was controversial and painful. Debbie shares her daughter's journey in life and how she ended hers. Photo credit: Simon & Schuster Contact Debbie Ziegler website – Get a copy of her book, Wild and Precious Life 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: Well, Debbie, thank you. I can't tell you how much I appreciate you coming and spending time. We've had a number of conversations over, since we met, which was probably a year or two ago. Debbie Ziegler: Yes. Dr. Bob: I think each time we talk, we get a little bit deeper into the conversations, and I think we both are very aligned in what we're trying to do with our time here. Debbie Ziegler: Absolutely. Dr. Bob: Yeah. I would love to use this time for you to share a bit about Brittany so people can really know who Brittany was. I think a lot of people know the name, Brittany Maynard. It's become, in many areas, a household name, and I think certainly in California, and a lot of people think of her as groundbreaking, but they don't really know Brittany. Hopefully, after this, after people hear this, they'll get your book, and they'll learn a lot about Brittany and about her journey, but I'm hoping that you can share a bit about that, because I think it would be really valuable for people to understand who Brittany was, what she did, and then what you've been doing to carry on her legacy and honor her, so ... Debbie Ziegler: Well, thank you for asking me to speak with you today. Brittany is remembered for the last act of her life, and those last minutes of her life are relived over and over again and spoken of over and over again. She knew they would be, and before she died, she asked me ... She said, "Mama, make sure people remember me for how I lived as much as they remember me for how I died." That is something that I try to honor her by doing, and one of the ways that I honored her was by writing a book about the way she lived, and I titled it Wild and Precious Life because Brittany did live a wild and precious life. She was very much in love with this world, and when she was terminally ill, she would say to me, "The world is so beautiful, Mom. It's just so beautiful, and I'm going to miss it so much." She did not want to leave this earth. Nothing inside of her desired that, but the fact was that she was terminally ill, and she had a terrible and gigantic brain tumor that had been growing for over a decade. When I look back at Brittany's life, I try to focus on the brain and how marvelous and plastic it was to tolerate the growth of a tumor for 10 years and to, as that tumor slowly grew, her plastic, resilient brain transferred function. I try to remember that. Even when I first find out she was sick, she had already lived a miracle, and it's important to focus that. The miracle I wanted to happen, which, of course, was that she wouldn't die, didn't happen, but a miracle had already happened in that she had lived 10 years with the brain tumor growing. Dr. Bob: What a beautiful awareness and a gift. It's so interesting because many people don't have that. Many people have a, are diagnosed relatively quickly after something that starts developing because it's created issues that can't be ignored or- Debbie Ziegler: Yes. Dr. Bob: ... their plasticity won't happen, and so everything changes from that moment on. Right? They're thrown into the health care system and start having procedures and treatments, and so ... You know that this is a fatal illness, even when it's caught early. Debbie Ziegler: Yes. I think that one thing that Brittany and I talked about quite frequently is that every person's disease is different, and it annoyed Brittany that people felt that just because their uncle, cousin, niece, had had a brain tumor, that they somehow knew her journey. The same thing happens to, I think, cancer patients with any kind of cancer. We have to remember, as we interface and speak with and try to love these people through their illness, that every body's illness is different. Just as our bodies are different, our cancer is different. It can be very, very frustrating for a patient to be told, "Oh, well, my aunt did this," or, "My uncle did that." Let's just try to take each patient alone and single and look at their disease and look at their illness separately and try not to bring in all these other judgments based on other stories. Brittany's illness, she had been living with, and the tumor had been growing very slowly, and so that allowed for that plasticity. If a tumor grows in your brain in a quick fashion, a much, much smaller tumor could kill you. Dr. Bob: Yeah, or in a different position, a different location in the brain. Debbie Ziegler: This would be the same for other cancers. It would be the same for people with any kind of cancer. Depending on how that cancer, how that tumor's growing, it takes its own cruel path, and so one of my big hot buttons is that we stop and remember that everybody's journey is different, and everybody faces their illness in a different way. The way my daughter faced it was by getting all the information she could get. She was almost an encyclopedia about brain tumors, about the types of cells that make brain tumors, about how those tumors progress in people of certain age groups. She read white papers. She had a good education, so she was lucky enough to be able to read that kind of paper that might put some of us to sleep. She was able to read it and really extract information for it, so when she entered a doctor's office, she was speaking their terminology, and she was very well read, so that is a different kind of patient. Dr. Bob: Yeah. I would imagine that for certain doctors, that would be a little bit ... I'm not sure if "intimidating" would be the right word, but they're not used to that. They're used to having, to doing the education and kind of doing it on their own terms. Debbie Ziegler: Yes. There is, and there is this paternal mold of medicine that's been in the United States for a long time where, for many years, we looked at our doctors as sort of an extra father in the family that what he said was how it went. We had this paternal model where we never even asked the doctor, "Well, what are my options," and we didn't have the internet, and we didn't have this quick way to get information. In the case of my daughter, she was actually checking out medical documents online and reading medical documents. We're in a different place, and we're in a different time. We're struggling with this old, paternal medical model, which isn't working for us well anymore. Then you add on top of that that if a doctor got a scan of Brittany's brain, one doctor said, "I expected her to be wheeled in on a gurney and unable to speak," because the tumor was in that portion of her brain that allows you to speak and vocalize, and it looked like that must, those skill sets must be gone, but because it had grown so slowly, those skillsets had moved, and she was able not only to speak but to speak very articulately. I do think it was a shock, and a little bit more difficult to deal with, with a patient who's very well read and very outspoken. My daughter was, even from a young child, a very purpose-filled person. I remember they observed her playing when they were analyzing whether she was ready for kindergarten, and they wrote in the report that her playing was purpose-filled. That came back to me as I watched her negotiate her illness, and I thought, "Okay, well, those things that made it difficult to mother her, that purpose-filled, stubborn, willful sort of way, was a wonderful asset to her when she was ill and needed to navigate her illness." People ask me all the time about how Brittany could make a decision like this so confidently, and my answer is that she had the innate personality to question and to, and she also had the educational background that she could absorb the scientific information and accept it on a factual level. The emotional part, matching her ability to be emotionally strong, matching her background to be able to understand the information that is terribly frightening, and which, honestly, I mean, I taught science. I couldn't read it in the beginning. It took me about a month to be able to read about brain tumors. I just couldn't do it. [inaudible 00:11:20]. Dr. Bob: You mean you couldn't do it because it was too difficult emotionally or because it was too, the information was too- Debbie Ziegler: It was emotionally. Dr. Bob: Okay. Debbie Ziegler: I also have a science background, and I taught science, so I could read it, and I could interpret it, but as her mother, having just heard that she had a terminal diagnosis with a brain tumor, emotionally I was unable to read about brain tumors for well over a month. This is a part of what happens to the family of the terminally ill person. Sometimes, they're knocked back into a period of denial where they're unable to look at the truths; they're unable to look at the facts. I think that makes it more difficult in some ways, and yet I'm told by psychologists that denial is something that helps us deal with crisis and eventually move on, as long as we move through it and don't stay in that place. I can testify to the strength of denial, and I can certainly say, from my experience, that it is very important to overco

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 inform

In this podcast, we talk about life, death and everything in between. We'll explore how to age more gracefully, have meaningful conversations, and what you can do now to ensure the best possible end-of-life experience for yourself and your loved ones. Let's become friendlier with death.     Transcript Dr.Bob Uslander: Just me. I will be having guests and bring a number of fascinating, interested, and dedicated people onto this show to share their wisdom and expertise. I thought I would take this first show as an opportunity to introduce myself and give you a bit more of an understanding of why I feel this topic and this conversation is so vitally important. Every day in the course of my work, I have life and death conversations. I talk with people about how to make their life better, more comfortable, more supported and, frankly, more enjoyable. I also talk with people about how to make their death better. When people are no longer able to find comfort, or joy, or meaning in their lives because they're old or they're sick, the only thing that they really look forward to at that point is their death and it's amazing to me when somebody is willing to sit with them and talk about that in a comfortable way, in a way that doesn't make them feel judged or make them feel afraid. They open up. They are so grateful to have that kind of honest conversation and connection. I've been a physician now for close to 30 years and I've had so many conversations. Initially, I was very uncomfortable with the whole concept of death.  When I first finished medical school and began my training and then my work as an ER physician,  I had a lot of encounters with death. But, for the beginning of the early part of my career, death was always the enemy. When somebody died, it was a failure and we tried to avoid that at all costs. As I've gotten older, hopefully, a little wiser, and I've had more experiences, personal experiences, as well as experiences in my career, I've come to understand the concept of death and how death fits in a much deeper way. I no longer feel that it's the enemy. I actually feel a close kinship, a friendship with death. That's what I want this conversation to do for others, to help you and everybody learn how to feel like death is not your enemy but your friend. This is delicate stuff. I get that. It's very important stuff. I believe that as a society we need to become more comfortable with the concept of death. We need to understand how our idea of death influences our life day-to-day because death is as much a part of life as birth. They're two sides of the same coin. We have no trouble talking about birth. Will it be a natural birth or will it happen in the hospital? Will it be quick? Will it go on for hours or days? Who will be in the delivery room? It's a very natural thing for people to excitedly discuss all the details of the birth of a child. We even have parties to celebrate the upcoming birth and that's great. I think that's the way it should be, but only a small number of people seem comfortable talking about death whether we're discussing our own death or the death of someone else. Most people do anything they can to avoid that conversation or they quickly change the subject when in a conversation. This avoidance of talking about death leads to an amazing, incredible amount of unnecessary struggle. It leads to anxiety. It leads to regret. It leads to guilt that can last a lifetime for a person who experiences the death of a loved one or a friend. I want to repeat that because really that's the reason I'm having this conversation. Refusing to talk about death leads to an enormous amount of anxiety, struggle, regret, and guilt. Most of that is completely avoidable. I believe the reason that I've been so successful in my new medical practice, which is in large part helping people to have a more dignified and peaceful end of life, is because I'm willing to talk about this. I'm willing to talk about death in a way that most physicians aren't. Unfortunately, most doctors are as uncomfortable and maybe even more uncomfortable talking about death than their patients. This really compounds the problem. One of my goals is to help you help everyone feel more comfortable talking about death because I'm convinced that's how we can achieve a better life. I want you to be more comfortable so that you can figure out how to make sure that you or someone that you care about has the most comfortable and struggle-free death whenever that happens. I want you to have the tools you need so if you're supporting a loved one through the end of their life or you're approaching the end of your life, you don't end up having regret. If you are supporting a loved one, I don't want you to have regret and guilt about what you did or didn't do during that time. When you're right in the middle of that storm, that's not the time to be preparing. The time to do that is now while you have the opportunity. Here's what we need to agree on. It's going to happen. You're going to die. I'm going to die. The people you love are going to die. Our pets are going to die. Try as we might, there is nothing that can change that. Every living creature that comes into existence will die someday, from the insect that lives less than 24 hours to the tallest and mightiest redwood tree that lives for centuries. Everything has its time and then it dies and you're no different. I'm no different. Your parents are no different. Even your children are no different. The goal should not be to try and ignore or defy that principle, that fact of life. The goal should be to recognize and even to embrace the magnificence of this master plan or the random nature of things, whichever way you believe. But the goal is to live a life of meaning and joy and to feel gratitude for whatever time we have to share in this adventure that we call life. There are two choices. You have two choices. You can refuse to think about death, refuse to plan for it, even live in fear of it or you can find a way to become friends with death, to embrace it, to prepare for it and to allow the awareness and acceptance of death to inspire you to live with more inspiration and even to comfort you. Again, death isn't the enemy. What I believe is the enemy is a life without joy, without a sense of control and without hope that things will get better. I'd like to share how I view or feel about death. I don't know exactly how I came to this awareness but it's been helpful for me and comforting for me and perhaps it can be that for you as well. I see death like the same way that I feel about an old friend, a friend who I knew when I was very, very young, maybe four, five years old. I have these friendships from my earliest years that were very dear and I look back at those relationships with a lot of fondness. I feel there was a deep connection that was based on sharing joy. There was very little else. I know that I haven't seen this person, this friend, for many, many years and I may not see that friend for many, many more years. But, I believe that someday in the future I will again. We will reunite. When we do, we'll have this immediate sense of connection, recognition, love, and comfort, and the time that has gone by, the decades that have gone by will be meaningless. We know each other in a way that transcends the knowledge of what happened day-to-day in your life. Those things don't matter. They're just the details. I have this sense that death is like this old friend who's not thinking about me all the time, not necessarily looking forward to anything in particular. But one day we will meet again and we will know each other deeply. That's how I feel about death because before I was born, I was in a void and I was in the same space where I will be again after I die. There's a familiarity. We've been there already. We have nothing to fear. Interestingly, my first exposure to death was pretty traumatic. I look back now and I think about that first real experience with the death of another person and that happened in my third year of medical school. I'll share that story because I think it's fairly poignant. Up until that time, the only person I had known who had died was my grandfather and an old aunt. I wasn't there when they died, and as a child, it impacted me, but I was somewhat removed from it. On the very first day of my third year of medical school, that's when we start doing our clinical rotations and I was on the internal medicine rotation in that very first day. The first two years we spend mostly in classrooms and auditoriums doing lectures and going into labs and dissecting cadavers and learning about germs and medications. We'd have a little bit of contact with patients just by practicing, taking histories and doing physicals but we really didn't take care of anybody. That very first day after a long day of working on the medical ward, I was on call and it was my very first night being in the hospital and I was very excited, a little anxious. I didn't know what to expect. I was very excited. After dinner, I went to my call room and I cracked open my textbook. Then I got called to do a few things, draw some blood, go and manage a couple of minor things. About midnight, I was ready to turn in and try to get some rest. All of a sudden, I've heard the alarm, the code blue alarm goes off. I heard that there was a code blue in the ICU. My call room was immediately across the hall from the ICU so I jumped up and I ran across the hall and I ran into the ICU and I saw a whole bunch of activity in this one bay. I walked into it and I saw a group of nurses scurrying around frantically and on a gurney on the middle of the room was a man who looked like he was in his 40s. He was a young man. He wasn't an old man. He was young and they were trying to administer medications and trying to figure out what do. I realized there were no doctors in the room. There was nobody actually giving orders or dir

Dr. Ken Druck's work in personal transformation, male psychology, parenting, and grief literacy has awakened readers to their absolute best selves for almost four decades. In this episode, Dr. Druck and Dr. Bob talk about healing after a loss.     Contact Dr. Ken Druck website Transcript Dr. Bob: I'm here with a good friend of mine who I'm excited to have this conversation with. Ken Druck and I have had many conversations over the years, most of which end up being fairly deep and a lot of insights come out of them. I think we're just both in this space of really contemplating life as well as death just because of who we are and our experiences. I'm excited to have Ken share some of his insights. He'll do that in just a moment, but I'd like to introduce him to you. Ken's work in personal transformation, parenting, psychology, and the literacy of grief has really helped people become, I think, their best selves for almost 40 years now. When you look at Ken, you can't believe he's been doing this work for that long. He's the recipient of numerous awards including a Distinguished Contribution to Psychology, Visionary Leadership Award. He has really a lifetime of service to the community. He's recognized really as a lifeline to people all over the world, to individuals, families, and communities through his work, which includes the founding of the Jenna Druck Center to honor the life and spirit of his daughter, Jenna; and we'll talk a bit about Jenna and the foundation that he created. Ken really has kind of set a new standard of care and healing out of tragedies like 9/11, Columbine, Katrina, and Sandy Hook, and I look forward to having him talk a little bit about how those experiences have shaped his life and his perspective. Ken has recently come out with a new book called Courageous Aging: Your Best Years Ever Reimagined. In this book, Dr. Ken explores the fears, some of the myths and biases in our culture about aging, so it's a perfect setup here for this conversation. In the book, he also kind of debunks a lot of the myths and offers a path to help people immerse themselves in the wisdom that we've cultivated over the course of our lives. With that introduction, I would like to introduce and ask Ken to say hello. Dr. Ken Druck: Greetings, Bob. So good to be with you and in a conversation, in a life and death conversation. My goodness. What a wonderful forum you've created to be able to talk openly and safely about all these important issues that so directly improve the quality of our lives and the quality of our deaths. Dr. Bob: Yeah. Well, I appreciate that. The inspiration for this really comes from life, from just being in this space. You're the same way. You're having conversations with people, both personal and in your professional life. I think, like me, there are many times when you think, wow, if somebody else had been able to listen in on this conversation, how much value would they have received, how much insight into their own issues and their own struggles and their own sort of triumphs. The conversations I have with my patients, with their families, with people like you, I think are so valuable, and I don't want to keep it to ourselves, right? I feel compelled and pulled to really allow people in on these conversations, so thank you for being willing to join in. Dr. Ken Druck: Thank you for having me. Dr. Bob: Yeah, absolutely. In your introduction, I abbreviated it. There's so much more, and I think we're going to have a conversation that will last about 30 minutes. I know that the wealth of information that you have and the experiences and insights could go on for 30 hours or potentially 30 days. It's going to be a challenge, but we're going to try to keep this concise enough, and then probably have follow- up conversations as time goes on. I posed some questions to you in advance of our conversation, and I want to jump right in. I don't mince words, and I don't pull back. I just want to get this out there because I want this to be part of our conversation, and I want it to inform and infuse our conversation. What are your thoughts about death? Are you afraid of dying? Do you have fear about dying? When you think about death, what comes up for you? Dr. Ken Druck: Well, it's a great question that does go right to the core. For me, the fear or the feelings about death are a moving target. It's not as though you run a marathon and you cross the 26-mile line and it's done. I think things that happen over the seasons and the course of our lives ask us or challenge us or force us to confront how we feel about death, and I'm no different. The death of my daughter 21 years ago was an opportunity as well as a tragedy—  the opportunity to face down my biggest fears of death. My daughter had died. I had to come face-to-face with that reality, starting with holding her body in my hands, in my arms, facing the idea that her life as we knew it had ended. I thought going all the way back to last year where my 92-year-old mother passed, and I had a chance to help her die. I think the things that happen that we react to or the losses we suffer effect and change and create opportunities for us to face down our biggest fears of death, to comes to terms with our life as it really is, life on its terms as it is, and to settle some of those fears. Now, are they going to be settled forever? Are we going to find peace or make peace and have peace forever and it's a done deal? No. Those concerns, those feelings, the sorrow, the love, the complex of emotions that come with dealing with death are going to bubble up and resurface. We want to make sure not just to wait for death to arrive or somebody we love to pass.  We want to be proactive and take steps to get ahead of the pain curve, to get ahead of the fear curve. Dr. Bob: That's awesome. How do you do that? I know it might be hard just to distill it down into a sentence or two, but how do you get ahead of that? If there's somebody who maybe has fear because of an experience because maybe somebody in your family had a tragic death or a difficult death and, like many people, you live with this underlying anxiety or fear about this mystery and when is it going to happen and how painful is it going to be. How do you think people can get ahead of that? Dr. Ken Druck: Well, I boiled it down to what I call the five ideals of courageous living and how we face down the fear of death. I've got basically five things that I recommend. Number one, stay humble, find peace in your unknowingness because there’re  sometimes in life where we just don't know, and we have to hold that unknowingness in gentle hands rather than trying to force and will it into knowingness. We're basically part of something so big that at times it's unfathomable. The true nature of the universe—where life comes from, where it goes when we die—is an unfolding mystery. All we have to do is look up at the stars to understand that. The second thing is to cultivate a calm mind that allows naturally arising fears and doubts to come and go and learn to breathe and release even those primordial fears. It's kind of a form of surrender, and we can learn how to make peace with life as it really is by summoning courage, by facing in. Third is to take the elephant out of the room by opening the lines of conversation, just as you and I are doing today by talking about death and discussing our thoughts and feelings with people we trust. Fourth, keeping the faith of whatever we believe in our heart to be true or what we wish to be true. It's okay to abide by a hoped-for narrative without knowing that it's 100% accurate or not. We don't have to know with complete certainty that oh, here's what it is, here's the program for death, I read it somewhere or somebody told me this is what it is, or this is my sense of it. It's okay to keep the faith, to have it be a gesture of faith, to believe whatever we believe in our heart is true. Lastly, it's also just fine to have faith in a divine truth without apology or justification. We can do that while respecting and honoring the rights of other people who have different views or different religion or different spiritual path that they're on and a different view of things. Those are the things that I believe we can do to cultivate a courageous attitude towards living and to face down the fear of death. Dr. Bob: That's beautiful, so really this is universal. I mean, it's regarding any fear or anything that might be challenging us or limiting us in our life, not specifically around a fear of death, but that seems to be a big one for a lot of people, right? Dr. Ken Druck: Yeah. You know, Bob. We've got these brilliant emotional systems. They're as sophisticated if not more so in some ways than all the other systems that sustain life. We have this emotional system, which gives us internal signals, radar signals, from inside of ourselves, right inside of our hearts, showing up as our emotions. When these feelings turn up, it's our job to learn how to manage them, to decipher them, to decode them, to understand them, and to utilize them as part of our radar, as part of our self management, and to use them to our advantage rather than oh, that's a negative feeling, I better shoot it. That's negative. We've been brainwashed into believing that there are negative feelings rather than understanding that some feelings that bubble up and surface are going to be sorrow, fear, anxiety, worry, frustration, that we need to read these feelings, not become prisoners to them, but to read them and to have them inform us about what action to take, to inform us that it's time to vent those feelings. We're not built to hold them in steel compartments inside of our bodies, but to vent them in a healthy and constructive way and to turn those feelings into something good. Dr. Bob: Yeah. I think that's powerful. I think people need to be given permission to feel, right? My sense is that so many people when th

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

A long-time nurse shares her personal story about her father's end-of-life experience. Hear what the aid-in-dying process was like for her and her family.       Transcript Dr. Bob: The person I'm going to introduce you to today and have a conversation with is a woman who I haven't known very long but in the short time that we have known each other we've become very close friends and co-creators on this journey around exploring how to make the best out of life and helping to support people through complex illnesses and approaching the end of life. Her name is Jillian Alexander and I'm just going to tell you a little bit about Jillian and then I'm going to turn it over and let Jillian tell you more about herself. I think it'll be a fascinating discussion. Jillian has an amount of experience both from a professional standpoint and from a personal standpoint. We've had many conversations and I'm excited to introduce her to you. Before I go on and talk a little bit more about you, Jillian, why don't you just say hello? Jillian: Hello Dr. Bob, nice to talk to you. Dr. Bob: It's wonderful. Thank you so much for taking time to be with me. Jillian is a nurse, she's a registered nurse and has been for 35 years though if you look at her you would think that she actually finished nursing school when she was eight, so it's hard to believe that. She's been a registered nurse and has worked in both pediatric intensive care units and neonatal intensive care units, so a lot of her clinical work has been in the pediatric setting. In 2012, she completed a Master's of Science in nursing and she specialized in education. Now, she's doing a lot of educating of other nurses in obstetrics and pediatrics. Her personal experience with supporting people has been like many of us in the healthcare profession, we take care of anybody who asks us to and especially family members. Eight years ago Jillian's sister, Lauren, her younger sister was diagnosed with ovarian cancer and at that point Jillian took a leave from her job and spent three months with her sister when she underwent surgery with a port placed in her abdominal cavity so that they could administer chemotherapy directly into the area where the cancer was. She went to all of her sister's treatments and after that, her sister actually did really well, Lauren did well and had five years during which time she was in remission.  But in 2014 the ovarian cancer returned and they started together as a family looking at treatment options, doing a lot of research, looking into clinical trials, traveling. Lauren was blessed to have fairly extensive resources available to her so she was really able to find the best care that was available at the time. Despite that, the cancer continued to spread and in 2016 it became apparent that the treatments were not effective, she was getting extremely weak, and having issues with bowel obstructions. That’s about the time that I was brought into the picture, so this was late in 2016. Jillian continued to live in the San Diego area, taking an extensive leave from her career, from the family that she had out there, and was an amazing advocate for her sister, to try to give her the best possible quality of life and support during what she knew to be the final phase of Lauren's life. Lauren passed away, I believe it was in January 2017, is that correct? Jillian: Correct. Dr. Bob: It was truly an incredible experience to be a) working that closely with Lauren and support her, but I was completely blown away and amazed by the level of commitment that Jillian showed by her sensitivity.  We created something almost like a little hospital/hospice setting and we were able to give Lauren a very beautiful and very supportive environment for the final weeks, months of her life. Since that time Jillian’s her life has taken a completely different turn and I'm going to turn it over now and I'm going to allow Jillian to talk a little bit about what that experience was like and what's happened in her life since then. Jillian, a) thank you for being my friend, b) thank you for what you bring to people, and c) let's hear what's been happening for you. Jillian: Thank you, Dr. Bob. That was really sweet. The first thing I really want to say is that, even though I had been a nurse for 35 years, I really didn't know what to do to help my sister. She was so ill, she had a couple of extensive stays in the hospital where they would do another CAT scan and ended up putting a port into her lungs because they had to drain fluid from her lungs every day so she could breathe.  I was really struggling to find her palliative care. I didn't really know exactly what it was and my sister was a real fighter. She didn't want to hear and she would say, "I hope they don't give me my hospice card this time." The “H” word was a bad word and so I didn't know what to do because outside of hospice how do I find someone to help me? I started searching and I had a friend, who happens to be a palliative care physician, who said, "They have to have palliative care, ask them." I started asking her oncologist to get me palliative care and they set me up for an appointment.  But it was three weeks away and my sister was so sick, and I didn't know what to do to help her because she couldn't be at home in her condition without, like Bob said, a hospital type room in her home. I wanted her to be at home and she wanted to be at home. When they gave me Dr. Bob's phone number and I had the first conversation with him, I knew right away I had found the right person. I can't explain how desperate I was and how many dead ends I was facing when I tried to advocate for my sister even something as simple as helping control her pain.  Because she had a bowel obstruction, she couldn't take medicine by mouth, and I knew that a fentanyl patch would help her, but the oncologist said she had to be in hospice to get a fentanyl patch. I said, "Well, why?" I couldn't get her the help. When I finally met Dr. Bob, within 24 hours we had her at home, on a fentanyl patch, with IV medication to control her pain when that didn't work, and everything we needed to keep her comfortable. Every medication and it changed everything from this aura of suffering and fear to there's somebody here that's going to help us go through the next phase of our journey. Finally, someone ... Honestly, Dr. Bob, you were the first one who said to my sister, "You're too sick to have treatment. Maybe if you get stronger,…” because she just wanted treatment, treatment, treatment, and nobody said that to her. Nobody said you can't have treatment;  it was a relief to stop trying to find treatment somewhere. She was ready to go to Mexico and try anything she could because, like you said, she had the resources and the fight in her to try to stay alive.  But you can't always win. Sometimes you're going to cause more suffering than you need to and that's where you helped us to make a bridge, so to speak, for that next experience, and made it palatable, and made her understand and accept what was going to happen. Dr. Bob:    Jillian: It really was beautiful. Dr. Bob: From my perspective, I didn't know her that well, and we just met, and it was a really challenging.  It was challenging on many levels but, knowing what a fighter she was and hearing from everybody and her husband who would not hear anything other than full charge, whatever it takes we're going to do it and we were not going to quit. I don't think we mentioned how old she was at the time. She was very young, she was 53, is that- Jillian: Mm-hmm (affirmative). Dr. Bob: I knew that she wasn't ready to just throw in the towel, but I think as we discussed the best approach we had to keep hope alive for her that there was a possibility that she could resume treatment at some time so we never ... I wouldn't say no treatment is going to help you. It was really no treatment is going to help you right now and it's likely to harm you. Now, the focus is on finding a way to be comfortable, to build yourself back up if that is possible,  and we'll do everything we can to keep that possibility open. She was incredible. She had a naturopath coming in, she was getting infusions of amino acids and other types of supplements that would be beneficial. She had a masseuse coming in and helping to keep her muscles relaxed and she had a team. You were a major part of building this team, but I think what you are lacking and what I was able to come in and provide was a leader of the team, a captain of the ship, to help  coordinate all  the things that needed to be put in place and keep you and the family from being so incredibly overwhelmed. It was a gift for me and you stepped up like nobody I've ever seen. An incredible champion for her in an incredibly complicated environment. You were my teacher as well and I think. Jillian: I think what I would say about that is sometimes you have to meet patients where they are. It's not about you; it's about the patient and, even though I would've dealt with it differently because I know so much and I knew what was happening, we really tried to meet her where she was. She knew she was dying; she would say little things like, "I don't want a funeral,”—just blurt it out all of a sudden—or other things that she would want to happen if she died. She told me her dying wishes for her siblings and family members, but she didn't want to accept it and actually was taking a medication up until two days before she died that was maybe going to help her. I supported her in that too because I felt it was her journey and her decision to try as hard as she felt she wanted to try. Dr. Bob: Yeah, and she wasn't doing it for herself. She was doing it for her family because she had children, the youngest of which was 12, and leaving him was the main thing that was causing her so much angst. We weighed that when we looked at the pros and cons of that medication.  We all came together and we felt like, w

Diane Forster is an Intentional Living Expert and author of "I Have Today". Diane talks about her attempted suicide, how she changed her life and is now helping others. Hear what helped turn her life around.     Contact Diane Forster website Transcript Dr. Bob: I'm here with my guest, Diane Forster, and I'm really excited about having this conversation with Diane. She's an incredibly dynamic woman. I was only recently introduced to Diane through a mutual friend, and this friend somehow knew that Diane and I were kind of kindred spirits and would hit it off and have a lot in common, and I'm excited about where this friendship is going, and I just immediately felt that Diane would be somebody who our listeners would really like to hear from. She has a very interesting story. She's made quite a dramatic shift in her life that was inspired by things that she'll be willing and happy to share with you. Diane, she calls herself an intentional living expert, and she's a coach, mentor, and facilitates masterminds. She is very well educated and trained in NLP and human interaction technology. She works with clients privately in their professional and personal goals, has really helped transform many lives, and it really comes from having hard her own transformation in her life. She's an author, a best-selling author of a book called I Have Today, Find Your Passion, Purpose and Smile Finally, and is the founder of I Have Today, which really focuses on helping women living more empowered, fulfilling lives. Interestingly, Diane's also an inventor, and I will let her share more about how that has happened and what being an inventor has brought to her life and means to her. So Diane, thank you so much for being here. I'm really looking forward to this conversation. Diane Forster: Thank you so much, Bob. Thank you for having me. I'm honored to be here, and I feel the same way, kindred spirits immediately. Dr. Bob: So, we're talking about life and death. As you know, my focus is on ... I mean, I think we have a lot of alignment. My focus is on helping people live a more peaceful and meaningful life in the face of challenges. I didn't necessarily come to this calling, or I didn't find it, it didn't find me for a while, but once it did, it's been driving me, inspiring me, pretty much every moment of my life, and it's about having a meaningful life, and it's about having a peaceful and self-determined end of life. So, you ... In our initial meeting, you really kind of blew me away with where you came from and what you were experiencing and where you are now. So, would you be willing to share a little bit about that? Diane Forster: Of course. I'm happy to. You know when I was in my late 20's, I got married, and I married a man that, we weren't really in love with each other, but we loved each other, and it just seemed like the timing to ... It was the time of life to do that, and I grew up with a mom and a dad who really, didn't really love each other ... Weren't in love with each other, but did love each other. Let me say that better. And so I never really witnessed any real romantic, intimate connection between the two of them, so I grew up thinking that's what marriage looked like.  So, of course, I attracted a man into my life who was similar, and while we had a deep love for each other in some ways, we didn't have that connection, and I struggled in that marriage for many, many years, trying to make it work. And what was happening to me is I just didn't want to walk away. I didn't want to be a failure. I didn't want to give up on it. I thought I could make it work, and it just was not working, and my soul and spirit were chipping away, day after day, month after month, year after year until many years into it, almost 20 years into it, I just couldn't take it anymore, and one night, in June of 2011, I attempted to take my life. I just thought I can't feel this pain and loneliness anymore. And so what happened to me in the bathroom that night, was I had two full bottles of pills in my hand, and I was ready to end it all, and they got knocked out of my hand, and the voice that I heard told me, "You are not ending your life this way, Diane. You need to go get help. You need to tell your story because you need to help others." And being a very intuitive person, I just threw my hands up and said, "Well, you need to show me the way." And so, that was a pivotal moment in my life, and that lowest, lowest point for me was the thing that needed to happen for me to catapult me out of that state and out of that place in my life and really reach out for help. And so I did the next day and reached out to a therapist, and I said, "I need your help. I need to change my life." And so it took about six more months to get out of that relationship, but when I did, after a brief grief period, I went into a deep introspection and personal development and spiritual awakening and ownership of my part of that relationship not working and where I was in my life at that moment, the condition of my life, and I decided in that moment, I want an extraordinary life. I don't want to live this way, and so I really delved deep into everything that I could get my hands on to read and to watch and to attend and listen to, and what was happening to me, Bob, was I really starting to heal in a very profound way and live in a very different way than I had been living before. I was alive. I was awake. My spirit was nurtured and felt loved and what it was that I came to was I had no self love. I had such low self-esteem and low self love for myself, and I developed it in this process.   I started writing a lot. Getting all these downloads, and so I would get this hits of inspiration in the middle of the night, and I would write poetry stories, and one night, in August of 2013, I woke up with a poem I Have Today in my head, and so I got up. I wrote it down right away, and it was I have today to love and be loved. I have today to start fresh anew, and it went on and on and on, and when I finished the poem, I looked at it, and I said, "This is way more than a poem. This is a movement. This is what God was talking to me about that night in the bathroom in June of 2011."  And that's the moment that the idea of I Have Today was birthed where I really wanted to help and support mostly women because I knew so many women were feeling the same way I was, and I see this every day, so that was really where I started back in June of 2011 and where I am fast-forward to today.  I'm now living a life that I've completely manifested, and I've completely reinvented myself, and am living the life of my dreams really intentional and purposeful every single day, and now I help others to do the same thing. Dr. Bob: Wow. I don't know that there's really another word that would actually be appropriate right now, but wow. I mean, you shared this with me the first time we met, and I remember having this feeling, the same feeling, but I'd forgotten part of that story, and it just kind of came back to me powerfully. So number one. Good for you. Phenomenal how beautiful that you went from this place of despair where you were really on the brink of death to where you are now, and not just having sort of reinvented yourself and found your own bliss, but taking that experience and taking that incredible pain that you were going through and using that to fuel the career that has now, I'm sure, been able to inspire and support many, many other people in finding their path out of that. Diane Forster: Yes. Dr. Bob: And not just taking people who are in despair and considering suicide, but taking people who are living an average life or what they feel is a mediocre life and being able to decide that they're going to have an extraordinary life too. Diane Forster: You said the magic word. It's a decision, and it is a choice, and it takes a lot of help. It takes a lot of support, but yes, it is something that you really have to decide for yourself, how do you want to live every day? How do you want to feel every day? And so along my path with it, I've developed a lot of different processes, a lot of three-step processes that I've made it easy for me to catch myself when I'm not living in the present moment and to help and support me on this journey to keep that positive momentum going every single day, moving it forward, feeling alive, feeling fulfilled, feeling the expansion and the growth and all of that. For me, I could've never imaged that my life would've taken the turn that it's taken, but I feel such fulfillment and joy every day helping and serving others to help them create the life of their dreams. Dr. Bob: Yeah. Well, so we were so aligned there, and what's interesting as well is that our journeys have been parallel. I don't remember ever being at that place of despair. I've been married for going on 30 years, and I love my wife more today than I did when we first got married, and I feel very incredibly blessed. It hasn't always been easy. I would be lying if I said that there haven't been challenges and struggles along the way, so I haven't had to deal with that, but I've had career burnout and stress and of course, my own struggles, and in 2011, is when I decided that I'd had enough of the life that I was living and settling for and decided that I needed more, and that's when I got inspired and started doing a lot of soul searching and a lot of reading and a lot of self development and became more spiritual and started on this journey, which has led me to the place where I am now. And then you mentioned August of 2013 as a ... What happened on August 13, remind me? Diane Forster: That was the birth of "I Have Today" when I wrote the poem. Dr. Bob: Okay. That's when you woke up with that poem. So, in April of 2013, just a couple months before that, I had my epiphany where I became very clear that I'm here to help people die, and from that moment on, providence has opened up incredible opportunit

Dr. Rob Jonquière is the Executive Director of the International Federation for Right to Die Societies. He shares how euthanasia is helping people who want to die in the Netherlands. Now, assisted suicide is also legal. Hear how this is impacting the country.       Contact World Federation of Right To Die Societies website  San Diego Hemlock Society website 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 to another episode of Life and Death Conversation. I'm Dr. Bob Uslander, and I'm here today with a guest who I'm anxious to hear from. He's got a rich experience in caring for people at the end of life, and he's really on the forefront of the movement to assist people in having a more peaceful and dignified end of life worldwide. So, welcome Dr. Rob. Jonquière. Thank you for joining me today. Dr. Rob Jonquière: Good evening, yes. Dr. Bob: Yes. It is evening. For me, it's morning, for you it's evening. Dr. Rob Jonquiere: Sorry. Dr. Bob: Can you tell us where you're calling, where we're talking from? DrRob Jonquière: Amsterdam, in the Netherlands. It's evening here at this moment. Dr. Bob: Very nice, and you were just mentioning to me that you're in the midst of winter, but you're having some- Dr. Rob Jonquière: It's not a real winter, unfortunately. It's too hot. They are expecting a little bit colder next week, of course, in my youth, I used to go skating outside, and it is a long time since we have been able to do that, so probably the climate change, I'm afraid. Dr. Bob: Well, as you know, I'm in sunny San Diego right now, having grown up in the Midwest in Chicago, I had my fair share of snowy, cold winters, so I'm feeling fairly blessed knowing what's happening in the Midwest and the East Coast right now. Well, again, thanks for taking time. We met not long ago, a month or two ago, when you were here in San Diego at a conference, and I got to a chance to hear a bit about your background and what you're involved with, and I think we are kind of birds of a feather. We seem to share a belief system and philosophy about how people should be cared for and supported at the end of life. You live in a very progressive country, with respect to this, and you've been a pioneer for many years, so I'd love for you to share a bit about what you're doing and kind of give us a sense of how you came to be in this position. What was the path that brought you here? Dr. Rob Jonquière: Yeah. Well, actually, at this moment, I'm involved in the international movement as it is called, the Federation for Right to Die Societies, which is an international federation of 52 societies, like the Hemlock Society of San Diego is one of the members, and I am the executive director of that federation, which implies actually looking after the website of the federation and assisting the committee or the board of the Board of Directors of the federation, and I came there after I was retired. I had been retired from my work at the Dutch Right to Die Society, NVVE as the name is, and in my retirement, I'm not used to sitting still, doing nothing, and I'm very interested in the whole movement, not only in the Netherlands but also worldwide. When I was working at the NVVE, I was started work there about five days after the health minister brought her bill, an euthanasia bill in the Parliament, so I have been involved in all the debates actually right from the beginning in the parliamentary debates, and as Chief Executive Officer of the NVVE, I've been for eight, nine years involved in the practical situation after the bill was approved in the Parliament, and now we have our official euthanasia law since 2002, and having a law is not the end of ... Well, it is the end of a process, but it's the beginning of a new process, to get people to accustomed to the fact that we have a law where it is legal for a doctor to assist in euthanasia, and aid in dying as it is called today, and we have to see the patients get what they want and that the law is used as it should be. And, of course, it's interesting how I became to be the executive officer because my original profession is a family medicine, so I have been working as a family doctor in the eastern part of the country, and I know from the beginning, I always have been very interested in ... Well, let's say, not the patient with colds, or a little complaints or things like that, but especially the situations in which patients needed guidance, whatever they need guidance in, so I have been delivering babies on the one side of the life, and I also became involved in the end of life guidance, where automatically, in that period, first careful questions came from patients especially patients working in the healthcare field, about my position regarding euthanasia as it was known, but as it was illegal at that moment. And, of course, I had never got training on what euthanasia was, how you do it, or what kind of medication you use, so it's using your experience and trying to sort of help people die in a peaceful and dignified way, and of course having been given this kind of help, I have never reported it, because if I had reported it, I would have been persecuted and probably get before the courts, and I didn't want to do that- Dr. Bob: Of course not. Dr. Rob Jonquière: No, and my patients didn't want to have me in front of courts. They asked me to help. They said not if you're getting trouble, and of course, in the situations I'm talking about, it has been patients with terminal cancer situations, who actually were really at the end of their lives, suffering from their cancer situations, although we have been treating with all kinds of care and medication and help we could. Dr. Bob: So, I want to touch on that, I want to clarify a bit for anybody who would like that, this was occurring when you were a practicing family doctor. Dr. Rob Jonquière: Yes, the '70s, '80s. Dr. Bob: Okay, and you were doing the whole full spectrum of caring for people from birth to death, and you recognized that there were people who were suffering, and you obviously philosophically felt comfortable with providing that support, even though it was not legal. So, first of all, the statute of limitations, I'm assuming the statute of limitations, for that type of activity, is past so that you can speak freely about it- Dr. Rob Jonquière: Yes. Dr. Bob: About your experiences back then. Dr. Rob Jonquière: Well, I can, and I mean, even you can say that is kind of a Dutch culture. I mean, at that moment, I could not go to the authorities and say, listen, I've terminated a life of a patient because she was suffering terribly, so I just said, in my records, that she died because of her cancer, which was actually the case. I only speed up the dying process a little bit. Dr. Bob: Which is the same as the aid of dying laws here in the United States, where the patients are dying. Anyone who is eligible for physician aid in dying is dying. Dr. Rob Jonquière: Certainly. That is now, and of course, in the Netherlands, it is now absolutely normal practice in terminal cancer situations. People are in such a situation, and don't want to go to the real end of the suffering can ask for it, and will get euthanasia without any problem. Dr. Bob: Okay, so let's go back. So you ended your clinical practice. What drove you at that point to stop practicing in the way that you were in that practice? Dr. Rob Jonquière: Well, you know, the main reason is I have always been interested to not only do my work as a family doctor, but I always liked to work in organization, to support, to develop things, to do on education, or research, or whatever, so I did many things besides my practice, and actually that became a little bit too much for a work situation, and then I got the opportunity to become the head of the vocational training program for family doctors, which actually meant that I could go to work on a university. I had the opportunity to be involved in research, in education, in organization, and it was still inside the field of the job and the kind of work I liked, which is family medicine. So, not specifically my work in the field of end of life, just a change of work from being a, let's say a medical practitioner into a person on university working on a higher level. Dr. Bob: Got it, and through that period, were you still working in the end of life arena, helping patients at end of life? Dr. Rob Jonquière: Not intentionally. Not as a kind of idea. There were other things that I was focusing on. You can say that I developed, in that period, the vocational training scheme for nursing home physicians, which is a little bit that way, and whenever in the curriculum of the vocational training, the topic was end of life or palliative care, although they didn't give it that name at that moment, but end of life care, guiding dying people, yes, of course, I was interested in that because it touched a part of my practical work. Dr. Bob: Wonderful. And, then additional sort of responsibilities and opportunities, and then eventually found yourself really diving fully into the Right to Die organization, is that right? Dr. Rob Jonquière: That was also, actually, accidentally. I was looking for ... I don't know whether you know the issue of middle management. Working at a university, I was all the time in a middle management position, and I wanted to take one step further at being, having the end responsibility of something, and then I was invited,

Cathy Spatuzzi is a yoga and fitness instructor who works with Integrated MD Care. She shares how she helps patients and her views on why she doesn't fear death and, instead, makes sure she is living in every moment.   Books on End of Life Being Mortal, Atul Gawande Knocking on Heaven's Door, Katy Butler Find more in this blog post, here. 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: Hello and welcome to A Life and Death Conversation. I'm here today with a good friend and a really valued member of my Integrated MD Care team Cathy Spatuzzi. I'm very excited to introduce you to Cathy and to hear some of her insights. Cathy and I have known each other for a bit, and we've shared some incredible experiences with our patients. We're going to touch on some of those, let you know what Cathy does and how she does it because I think she's really quite an expert in her field and I know that she loves what she does. So, Cathy, thank you for being here and joining us. Cathy Spatuzzi: Hello, Dr. Bob. Thank you for having me. Dr. Bob: Yeah, my pleasure. It's great to see you. I'll share that trying something new, our podcasts, the ones that I've done previously have all been recorded on the phone. Today Cathy is in the office, and we're doing it together. It's really nice to be able to look at her in the eyes as we do this. Cathy Spatuzzi: Yeah, I agree, face-to-face is very nice. Dr. Bob: Yeah. So Cathy is … her title is yoga and fitness instructor. I know that there's probably a lot of yoga and fitness instructors out there who work in various capacities but that doesn't really begin to explain quite what Cathy does because I've seen her in action and I've seen the results of her work. It's nothing short of magical; I have to say. Cathy goes in and works with some of our sickest and most frail patients. She works with people who have dementia. She works with people of all ages and abilities. They don't even know they're exercising. They actually just think they're playing games and meeting a really cool, fun, person. So Cathy, can you just share a little bit about how that happens, what you do, how you approach your patients and just share a little bit about how that magic happens? Cathy Spatuzzi: Sure. So I got my yoga instructor certificate, and I started teaching seniors. I took an extra class in teaching seniors, and I really loved it. Then I met Dr. Bob, and I've always been a physical exercising person myself, and so I've made up my own little program where I go into a person's home, and we have a whole hour of exercise. So we do physical weights, and whatever that person needs at the time, that's how I meet their needs. So we do dancing, we do marching. I bring some music sometimes. I have little balls that we do exercise with. They're bright and colorful. We play games with the balls. I also have just blown up regular balloons, and we hit the balloon back and forth and play a game that way. A lot of people that used to do tennis or volleyball, they remember that, and their muscles and cells remember that and they really get a lot of fun exercise just hitting the balloon back and forth. They tell me lovely stories. Most of my people are 80 to 90, some are a 100 years old, and they tell me fabulous stories. They all have a very positive attitude in life. Dr. Bob: I've met with people, I've been there after you've been with them and it really is pretty dramatic. A lot of our patients, because a lot of times they don't feel well, they don't have a lot of energy, they're dealing with pain, they're dealing with other challenges, and exercise is not something that they necessarily prioritize or look forward to, but that's not the case with you. They obviously don't feel like they're doing exercise. They don't feel like they're working. There's something else. There's another piece that obviously you're bringing to it, which, to me, it feels like you're just really connecting with them very deeply and appreciating them as human beings, and the exercise just happens as on the side. Cathy Spatuzzi: Yes, I agree. I don't think of it as exercise myself. I go in, and I have fun, yes, and I connect with that person one-on-one, find out what they like, what else do they like, then I bring that in with them. Dr. Bob: We've shared a couple of patients that had had some pretty remarkable experiences, people who were not expected to live more than a month or two who through combined efforts have gone on to live for a couple years, people who were not walking who are now walking half a mile to a mile without difficulty. Can you share maybe a little bit about what that's like for you to be part of that? Cathy Spatuzzi: It's a gift. I love all my clients, but to work one-on-one and to see a person that was maybe almost on their deathbed to come back and is living and they want to have a life. One of my sayings is motion lotion. If you don't move your body, you're going to get stiff, and you're not going to feel like moving so let's just keep moving. Some of my other seniors that are more fit, that's what they say, you have to keep moving, you have to keep moving, you have to keep moving. So I keep them moving. Dr. Bob: You keep on moving, and you keep it fun. Cathy Spatuzzi: Yeah. Well, you have to have fun in life, so why not bring it to your work? Dr. Bob: Yup, I agree 100%. So this is A Life and Death Conversation, and part of what we're trying to do is give people just a look into how we can have an easier time talking about topics that can be difficult: death, illness, debility. So as an example, we are doing that there. We're talking about things that might not come up in normal conversation. I, as you know, go right to the point. I don't mince words. I don't hold back a whole lot. I just want to ask you and get some of your personal perspectives on some of these things, if that's okay. Cathy Spatuzzi: Sure. Dr. Bob: All right. Tell me, do you have … and this is a question I ask all my guests. Are you afraid of dying? Cathy Spatuzzi: No, I'm not afraid of dying. Dr. Bob: You're not afraid of dying. Cathy Spatuzzi: No. Dr. Bob: Well, why? Can you share why you're not afraid of dying? Cathy Spatuzzi: My maternal grandmother always talked to me about death. Dr. Bob: Really? Cathy Spatuzzi: It wasn't morbid. It wasn't like, "Oh, I …" I don't know, she just always talked about it. It wasn't something under the covers. Dr. Bob: Just kept in awareness of it in the home? Cathy Spatuzzi: Yeah, like when somebody died, we'd talk about it, or when- Dr. Bob: Okay, how healthy. Cathy Spatuzzi: Yes, uh-huh (affirmative), and so I think I've just adopted her attitude and calmness about it. For me, thinking about dying, I think about living. So I'm alive. I can walk and talk, and do all these beautiful things, but let's be present doing it. If you're just walking through life in a fog, then you're not living, but when you think about you're going to die, maybe that's a point where you're going to wake up and start being present in your life. Dr. Bob: Do you feel like thinking about dying, talking about dying is responsible for you having a greater awareness of and maybe gratitude for life? Cathy Spatuzzi: Yes. I think I have gratitude every night before I go to bed. Dr. Bob: I guess, not being dead is a part of that, right? Cathy Spatuzzi: Right. Driving around and you see the beautiful clouds. You might see an airplane. Let's take each moment for today because maybe you will die tomorrow. Let's be grateful for what we have today, not think about what if, what if, what if it's going to happen. I pray that I have a beautiful day and then I have a beautiful meal and then I go to sleep and die. Not tomorrow. Dr. Bob: Not tonight, yeah. Cathy Spatuzzi: Not tomorrow. I got- Dr. Bob: Because I know you have some things to do this weekend. I know you have some plans. Cathy Spatuzzi: I know, yeah. I have plenty more years ahead of me, but that's what I've always thought about, nice and peaceful. Dr. Bob: Beautiful. Interesting. We both are spending time now with people who believe that they may not have a lot of time left, some of them because they're elderly and some of them because they have a terminal illness, and in some of those conversations, I hear people talking about how their time is so limited. Occasionally, they get into this pattern of feeling bad about it, and I wouldn't say necessarily feeling sorry for themselves, but focusing on how their life is going to be shortened and they're aware of that. I always accept that. I never try to convince them to think differently. That's their thought, and I would never judge that, but what I'm aware of is that there's no guarantee for any of us. I may have a patient who has a prognosis, a life expectancy of three or four weeks. There's a lot of people who are going to die unexpectedly before that person dies. We may be one of them. We have no guarantees, and so focusing on what we have today like you're talking about like you're suggesting being grateful for the fact that we are alive and that most of what's going on in our life is good, may not be perfect. Jon Kabat-Zinn, the creator of the mindfulness-based stress reduction program, had a phrase that I love and I repeated often. It's, "As long as you're breathing, there's more right with you than wrong with you." Cathy Spatuzzi: Yes, I agree. Dr. Bob: Yeah. Cathy Spatuzzi: That's beautiful. Dr. Bob: Sometimes if somebody is lame

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 any

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

Hear beautiful stories about end of life. Dr. Bob and Veterinarian, Liz Fernandez, discuss how there are similarities in their end-of-life work that helps people, pets, and families who are dealing with end-of-life issues. 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 Liz Fernandez website Dr. Bob: Liz Fernandez is a doctor who makes house calls. She gets to know her patients and families intimately, and she frequently provides counsel and guidance as her patients head toward the natural end of their lives. In many circumstances, she lovingly administers medication through an IV that allows her patients to fall asleep and die peacefully usually in the arms of their loved ones. What Dr. Fernandez does is legal and acceptable because she's a doctor of veterinarian medicine and her patients are mostly dogs and cats. Although I don't perform euthanasia which is illegal in this country, I am with many patients as they die peacefully after self-ingesting medication that allows them to have a quick and peaceful death. In many respects, Dr. Fernandez's practice is very similar to mine. We both drive all over the place to make house calls, we both develop very intimate relationships with our patients and families, and we both help to guide and counsel as our patients approach the natural end of their lives. In this episode, we share some of the beautiful and some of the challenging experiences that we've had, and we discuss how it affects us to be in these emotionally complex circumstances so often. I hope you find it interesting, informative, and meaningful in some way. Liz, thanks for coming on the show, and I'm looking forward to having you share some of your insights from your really fascinating career. Can you just share with me a little bit what is it like? You have a unique model of practice for a vet, and what's a typical day or typical few days for you? Liz Fernandez: I practice in Ventura County. I work with small animals, and I do house calls, and most of what I do is Chinese medicine acupuncture, so most of my clients, my patients are older. I may see anywhere between three to six patients a day, and I drive all over the county. Sometimes I keep it localized in a smaller area, but my radius is about 60 miles from my house so it could be anywhere in that to give you an idea. Yes, I drive about 30,000 miles a year- Dr. Bob: Which is kind of similar to me. It sounds like your work is in many ways similar to mine; going out and meeting with older patients and addressing the concerns that they and their families have and supporting them. Liz Fernandez: Right, and so I have ... Since I see them ... I see them. I'll spend an hour or so. Each appointment is about an hour unless it's an initial appointment and it's usually about two hours. I may be seeing them once a week, or once every other week, or once a month, so I get to know the clients quite well and as their animals, either dogs or cats, for the most part, start to age and get near to that point when they're going to have to make some decision, we've already had probably at least a few discussions if not more; just some in general and some more specific. It's nice because I do have that connection already with most of the clients that I work with, and that makes it a lot easier to move into that idea of now we may not be trying to get them better, we're just trying to keep them comfortable. Dr. Bob: Got it. So you have the conversations ideally upstream about what will happen when things change, and you're looking now at a comfort-focused end of life scenario. It's interesting because you have an option to help create a very peaceful end of life for your patients that we don't necessarily have. Not necessarily have, we don't have. We don't have euthanasia. It's not legal; it's not available. Fortunately in California now we do have the medical aid in dying through the end of life option app, so there is another conversation that can happen when people are open to it, but everybody is aware that euthanasia is a viable and acceptable option at the end of an animal's life. Liz Fernandez: Yeah, and I find it fascinating because with the animals, we almost more often than not, people demand it for a multitude of reasons; the most common being, "I don't want my pet to suffer." That I totally understand and I agree with, and I support them in those decisions. It's just fascinating that ... And part of it I guess is with people we have more options in terms of supportive care to keep people comfortable and just have somebody there 24/7. That's pretty very challenging for most people. I have had clients that have the ability to have somebody with their pet 24/7 offer doing whatever it is that they need to have done in a home situation. It's not like they're putting him in the hospital or something and not being with them, it's just that they can manage all of those little things like if they can't get up from by themselves that somebody can take them and help them to get up and go outside and if they're not continent then they can take care of that in terms of changing the bedding and that sort of thing in helping them. But that's not the norm. For most people, it's just not an option. What do you do if you can't be there or if don't know someone who can be there or afford to pay someone to be there, what do you do? This other option is available especially when there's no hope of improvement. And so that's what happens. Dr. Bob: It's interesting to think about those scenarios because it's just natural to make the comparisons, right? This is between people and animals, and if you have a person who needs care to manage their ADLs because they can't get up by themselves, they can't clean themselves. That's not enough to justify having their life end. For some people, it may be that the complexities of creating care- Liz Fernandez: The other part of that is that a lot of times, it's emotional least distressful for the clients because they realize their own limitations whether that be physical, emotional, financial. All of those things factor in, and so they wind up making a decision because not that they think it's what is necessary that the animal is that near to death that that's what is appropriate, but because the entire situation is such that they can't handle it. If you have an 85-year-old woman who's got 100-pound dog and she doesn't have anybody else to help or take care of it, she may be healthy within herself, but to be able to meet all the needs of a big dog- Dr. Bob: That's dangerous. Liz Fernandez: Yeah, it's dangerous. Or even somebody who's 50, but they have a bad back. Dr. Bob: That part like knowing that the dog is not or the animal is not necessarily imminent, that close to death, or maybe it's not even suffering that much, right? It may not be in pain, it may just have these limitations, and if the family was able to meet those needs even though the dog is not living its ideal life like a human being who's 90- Liz Fernandez: Right. A lot of people feel like if they can't get up if they can't do those things, that they are suffering, that it is not a life that they would want, so there is that. I would say that with most of my clients they do a really good job of trying to make things work, but on the other hand, most of them have co-morbidities that are ... Like if their back legs aren't working anymore, there's a good chance that they probably have some other issues going on whether that be kidney disease or sometimes some underlying, whether it's cancer or heart disease or other things that make it even more challenging. I honestly can say that I don't find myself in situations where I feel that it's inappropriate. Dr. Bob: Well, imagine if you did then you would find other solution. Liz Fernandez: Exactly. I mean, we each have to do what we feel in our heart is right or for us, but I also try and tell people that there's not necessarily an objective right or wrong. There's a right or wrong for you in this moment, but not necessarily a right or wrong that is somewhere posted in a book somewhere that says that this is the way you have to proceed. Because we have to be honest and compassionate with ourselves as well as in the whole situation. Dr. Bob: Well, I read your book Sacred Gifts of a Short Life: Uncovering the Wisdom of Our Pets End of Life Journeys, and it's really touching, it's really well done and smart. Liz Fernandez: Thank you. Dr. Bob: It was great stories and as I'm reading it, I so often I'm finding corollaries to my life and my practice and my thought processes. One of the things that was really poignant for me is your ... One of the stories, I think it comes up a number of times when people ask how they'll know when it's the right time. For me being a physician who assists some patients through medical aid in dying, there are times when people get a prescription for a life-ending medication, and one of the big questions that they have and that their families have is when will I know it's time? When will I know that it's the time to take this? What their experience or if they're struggling to go through is what your families are dealing with. The difference, I guess the difference in my situation with human beings is that they're the ones making these decisions for themselves, no one can make it for them. And they recognize that when they do take this medication, they may be robbing themselves or ... They're clearly shortening

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

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 th

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

Chelsea Berler is a successful entrepreneur, and author and an inspiration for many people. Tragically, she is also dying from breast cancer at the age of 34, but you won't hear Chelsea describe what she's going through as a tragedy nor is she a victim. Listen and please share this episode with others who need to hear it.   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 Learn more about Chelsea's nonprofit organization, The Foye Belle Foundation, by watching the video below and visiting her website:  Foyebelle website Transcript Dr. Bob: Chelsea Berler is a friend, a successful entrepreneur, and author and an inspiration for many people. Tragically, she is also dying from breast cancer at the age of 34, but you won't hear Chelsea describe what she's going through as a tragedy and she certainly isn't a victim. Dr. Bob: She has an amazing perspective on life and on death, which she shares with me during this interview. Anyone dealing with life challenges or has a loved one who is will certainly benefit from listening to Chelsea's heartfelt and loving words. As well as from the book that she recently published 'The Yellow House on the Left'. Listen in. Dr. Bob: Looking at your picture, your Skype profile and it looks exactly like you, but I'm assuming that that's ... I wouldn't see all that flowing blonde hair. Chelsea Berler: I look very different right now, I'd probably look like a teenager going through puberty because I am on some massive steroids and I'm getting hair where I haven't had hair before, and of course my hair's starting to grow back from the chemo. So I'm looking mighty, mighty different these days. Dr. Bob: Yeah. Well, I imagine that that's just one of the many lessons, right? Chelsea Berler: Absolutely. Dr. Bob: To learn humility not get too attached to certain appearances. Chelsea Berler: You're right. Dr. Bob: Well Chelsea, thanks for reaching out. I mean we're having this conversation because you had reached out to me recently just to touch base and honestly, I didn't know that you were dealing with any of this. That was a big surprise to learn that you were on this journey and I appreciate it in the thing that stuck out what your phrase that you wrote was, I would love to see you do more with people that are directly in the path of your work. Dr. Bob: Would you be willing to share a little bit about what that means to you? What's your thinking around wanting to connect with people who are directly in the path? What does that look like? Chelsea Berler: You know, it was so interesting how it kind of came to be is, of course, we've been connected for years and had worked together in some capacity or the next, and we play in the same circle of really great people. You were on my mind the other day because I was ... One thing I've been spending a lot of time doing is listening to podcasts and one of the biggest reasons is, is because of my current state, I have this ringing in my ears pretty consistently. Chelsea Berler: What helps is listening to something or listening to music or things of that sort, I was actually on the podcast app and just trying to search for a podcast that was inspirational, podcast about death and dying and all that. And I thought, "Oh, Bob has one." I went and looked up, and I started listening to all men. I really enjoyed them, and then I got to thinking, you know, it'd be so great to listen into other people's stories that are going through death and dying. Chelsea Berler: I'm assuming, in some situations people often aren't in the mood to be sharing any stories or feeling good enough to do that, oh who knows, young or old. But I thought maybe there was, and maybe there was an opportunity for you to be able to add some of those stories, and I thought, oh, I would also love to share mine just because it's rather unique to in hopes that it will also help someone else that may be in that same situation looking for a podcast or trying to find something like that, that kind of helps them with the process as well. So that's kind of how I came to reach out and be like, "Hey, Bob!" Dr. Bob: I'm so glad that you did and I'm so glad that you were open and that you're feeling up to doing it, I know that it's kind of day by day in terms of how that goes and so thank you. I spent a little time over the last couple of days reading some of your posts and the articles that you have on Huffington Post and just kind of getting more familiar with your journey. Dr. Bob: So first of all, you're an amazing writer and I knew that before but I'm seeing a different style, and it's a different theme of course but your ability to express yourself and the pain of it, the wonder of it, all of it, just the full catastrophe in the middle of the night. So I appreciate that you're willing to share and I know that there are people who are benefiting from that, everything that you've put out there. Dr. Bob: A lot of people just kind of shrink into their own world and don't want to contribute it anymore. Thank you for being somebody who's not doing that, who's continuing to shine your light out in the world despite the challenges that you're dealing with daily. Chelsea Berler: Yeah, and something to piggyback off that and I know that we'll get into this story a bit, but I actually decided right when I found out I have been writing and so I have another book with that, it's going to be done this week, I'm having helped from a writer that actually helped me write my last one, and it's basically on death and dying. So in all the right ways and it was mostly because I had these Huffington Post articles that I never in a million years thought I would be dying from this cancer. We all were focusing on a cure, which was very much the what was going to happen. Chelsea Berler: Since that didn't we pulled together these Huffington Post articles and wrote, she's been helping write this next book that will be out soon too, and I think that it'll be a really great contributor. It's going to be called 'The Yellow House on the Left,' so that'll be fun too. So I'll keep you posted on that. Dr. Bob: When do you anticipate that it'll be available? Chelsea Berler: I think that it'll go to print end of next week and then it'll be about two weeks until we can get that in our hands. We've been rocking and rolling on that, and I think it was just one of those things where I thought, it now is time to put all of these things into writing because I do think that there will be people that would be helped by these stories and my story and I wanted to get it out as quickly as I could, but I was like, "Gosh, could I actually make this happen?" Because day-to-day my challenges get worse for sure and so I think we'll make it. Dr. Bob: Awesome. I can't wait in that, and I'm looking forward to seeing it and reading it, and of course trying to spread it, spread it out to those who will benefit from it. Chelsea Berler: Thank you. Dr. Bob: Why don't you tell listeners what's going on, what do you, what are you dealing with day-to-day right now? Chelsea Berler: I turned 33 last year in March and my husband at that time was traveling every week to Europe for work, so he would spend basically Monday through Friday in London and Paris for work and then he comes home every week. That's been our life forever, he travels during the week, and we see each other on the weekends, and it's been lovely, that's the life that we love to live. Chelsea Berler: He was traveling a lot, and so we decided I'd love to take a big trip and go to Europe, and in lieu of him having to come home for a couple of weeks and kind of see his life there, following him around, enjoy some time in Europe because I had never been, and so we were really excited about that. Chelsea Berler: So came May, I flew over there, and I had the best trip of my life, it was truly so much fun. It was great to just see not only how busy, and crazy his life and lifestyle was over there–like the guy is like the energizer bunny–but it was just fun to just immerse yourself in another country for a while, and so we did that. That was a lot of fun. But I noticed while I was there, I was like, I could not keep up with him and to be honest, I can barely keep up with him and how like he does have high energy and I'm probably more chill. Chelsea Berler: I just noticed I was really tired and I thought, it could be jet lag and the time difference. We were between London and Paris, so it's six, seven hours difference and maybe I was trying to kind of get used to it. Then when I got back, there was about a month in between where I was still really tired. But again, I just thought, maybe I wasn't eating well or whatever, and so I started working on a program with a friend [Christie Smear 00:10:26], you probably know her. Dr. Bob: I do know her. Chelsea Berler: Wells Fargo or The Wealthy Thought Leader can. Anyways, I started doing like a cleanse with her and like I was feeling really good, and my energy was a little backup, so I was excited about that. Then in July I noticed a lump in my armpit, and it literally like, just was like in my armpit and I thought, "Well, that's weird," I'm young, you know, at the time of 33 years old and so it didn't even phase me that it could be like something crazy, but I thought, "I'll get it checked out and see what's up." Chelsea Berler: So I had just a regular gynecologist appointment that was already scheduled like my yearly exam because when you're 33, they don't h

Hansa Bergwall is the creator of a new app called "WeCroak". Out of his own personal meditation practice, he determined that death contemplation could be beneficial, not just for him, but for many people.      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 You can download the app from your iPhone or Android device. You can also visit Hansa's website to learn more and download his app. WeCroak website Transcript Dr. Bob: So, Hansa, I'm totally curious about this. What prompted you to put an app out there that is going to notify people several times a day to think about death? What was the impetus for that? It's fascinating to me. How did that all come about? Hansa Bergwall: So I'm a daily meditator and have been for a while now. And regular death contemplation is actually a really millennia old part of most serious meditation practices. So that's how I first got ... I learned about some of these ideas. And some of them are pretty intense, much more intense than what I'm doing, meditating in [inaudible 00:01:19] grounds, where bodies decompose as a way of laying them to rest, to know about your impermanent nature. Stuff that would be hard to do today living in New York City. Hansa Bergwall: And then I came across the Bhutanese formulation of the practice that was, one, recommended for everyone and just really simple. It was just think about it five times a day that you're impermanent, that one day you will die. And you must do that in order to be a happy person. Immediately, it appealed to me as the kind of death contemplation that I wanted to add as a compliment to my meditation practice. So I just tried to do it myself. I thought, oh, this will be easy. I'll just think about it five times a day. And what I found was it was actually really hard. We have this pretty stubborn cognitive bias that we don't want to think about mortality all that often and it's hard to do, so I would get through my day and get to the end of the day and realize I hadn't done it even once. Hansa Bergwall: So that was when the idea of something to remind me came about and the idea of WeCroak, the app, which sort of fell into my head as a fully formed idea that honestly I never thought would go anywhere 'cause I'm not a coder and had no way of making it a reality until Ian Thomas, my cofounder, happened to rent my extra room on AirBnB and we got to talking one night and I basically told him/pitched him my idea for WeCroak and he wanted it on his phone, too. He never thought it would go anywhere. And we made it together for the next couple of months, so it happened really quickly and really fortuitously, organically out of me trying to do something that I thought would help. Dr. Bob: That's crazy. So if Ian hadn't rented your room, there's probably a pretty good chance that this never would've come to fruition, right? Were you going to go out and seek an app developer? Had you gotten to that point? Hansa Bergwall: I had. I made a couple of inquiries, and it was going to cost me $10,000 or something like that if I wanted to develop this on my own. And I didn't have that kind of money sitting around, first of all. And, second of all, sounded like a lot of money to spend on something that I was quite skeptical would be broadly popular. So really we made this kind of as almost ... We were talking about it when we started as it was like an art project or something that we really wanted for ourselves, maybe to share with our friends, and we wanted it in the world. That was how we went about it. Dr. Bob: Great. Without any huge expectations or goals that would potentially disappoint you if you didn't achieve them. That's usually the best way to start something. Hansa Bergwall: Yeah, and what it allowed us to do is we stuck to our guns a little bit, the Bhutanese folk saying is five times a day. So we had a lot of people asking, like, oh, shouldn't you toggle it, so people only want one? We're like, but that's not the recommendation. We're going to do this tradition. We're going to do it right. So because we have our day jobs and other ways of making money, we could really make it be something that we thought would be a real mindfulness tool. Dr. Bob: Great. So when did it actually become available? When did you complete the development process and put it up there for people to download? Hansa Bergwall: So I first had it on my phone in August of 2017, and it started right away reminding me five times a day that I'm going to die with a quote that I had picked out. And it was really fun. It was this creation that we had done. There had never been anything like it before. For the first few months, it was just a few of our friends and us. I think there were 80 people on it tops as of a few months later, kind of working with it and enjoying it. And then I do communication and PR for a living, and so I had reached out to just a couple people about the idea, and the Atlantic magazine covered it in December, and that was when it really started to take off in the world, and it has to a huge degree since then, beyond our wildest expectations. Dr. Bob: That's awesome. So how many downloads? I'm sure you're able to track that. How many people have downloaded it at this point? Hansa Bergwall: Yeah, so as of a couple of weeks ago, we just crossed our 40,000th download. Dr. Bob: Wow! Hansa Bergwall: So that means that 40,000 people around the world have elected to pay 99 cents for an app to remind them that they're going to die five times a day and we estimate we're going to deliver our seven millionth reminder on May 7th. There's been a lot of these little reminders going out, interrupting people's days. They happen at randomized times, and that has been the journey since December. It touched a nerve somehow. [inaudible 00:06:53] not the only people that wanted these reminders, wanted to remember that life is precious and time is limited. Dr. Bob: Have you gotten feedback from people? Have you had people who have shared any of what's come up for them or any interesting stories that have come out? Hansa Bergwall: Yeah, of course. It's a strange thing because we know these reminders are going out, seven million of them, and mostly it's like we have no idea how these are affecting people. Except when you hear back from people every once in a while. A very common response is that it helps pull people back to what's important, gives them a little bit of perspective and they use that for everything from getting off addictive social media or technology, to getting out of anger or having better relationships just by not sweating the small stuff as much, to seize the day kind of moments of, hey, I'm just gonna go do this thing I wanted to do because otherwise I may not do it in my life and I want to. Hansa Bergwall: So that's the most common response is people just using reminders to live a little bit better. And then there's this other category of people using it in much more serious positions and those, to be honest, moved me to tears a few times where I'll hear from people who are using it to help them in the grieving process for this woman said her son had passed away, and somehow it was helping. Another woman reached out to say she was having a hard time dealing with a mother dying of dementia and that it was helping her appreciate the time that they did have at the capability that they did, rather than just get into the poor me and my life kind of story. Hansa Bergwall: Just last week I had a young man reach out of the blue to tell me he'd been using it and mourning the death of 20 friends to the opioid epidemic over the last year. It gets out there in the world, and you realize that this kind of information is pretty powerful in that it's useful whether you're just trying to live a little bit better or if you're really facing some of life's hardest moments. Dr. Bob: Such a simple, simple concept to imagine having that kind of impact. Are you getting a sense that it's the reminders that are making more of an impact or the quotes that people are reading and that are touching them? What are your thoughts on that? Or what are you hearing? Hansa Bergwall: I think it's the whole thing. First, we're doing the Bhutanese formulation of just think about it often. Five times a day. That alone is powerful enough if that was all it did. And then the quote part of it is we live in a society where there's a tremendous amount of noise, distraction, technology, addiction, screens, everywhere that keep us from being really present where we are often. So in order to keep it fresh and keep it interesting, we introduced the quotes as well as the randomization of the timing so that it would interrupt you at times you couldn't predict. Kind of like the idea of how an eight ball, it only has maybe eight answers, and yet it can be interesting for quite a long time just because of the randomness of you don't know which one you're going to get. Hansa Bergwall: So that aspect keeps people engaged, on their toes, where just the many coincidences of life, there are those moments where the randomness of the time and the randomness of the quotes selected feels like it's speaking directly to that moment because we have a database of quotes. They're all worth looking at I think, but people never know what kind of quote they're going to get. We have quotes from people writing from the palliative care community or poets or philosophers or meditation teachers or even comedians. So people really

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.' Ri

District Attorney Summer Stephan shares what San Diego initiatives are in the works to protect seniors from abuse and fraud. She shares information about her programs and efforts to help keep our most vulnerable citizens safe.   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 San Diego District Attorney website Transcript Dr. Bob: In this episode, I speak with San Diego County District Attorney Summer Stephan, about her passion for protecting elders from abuse and fraud. Summer is leading the way to create a blueprint for a program that brings together many agencies and organizations throughout the county that typically work in silos, including the medical community, in an effort to create programs that protect our most vulnerable members of the population. I for one was inspired by her passion and her commitment, and I will be joining in this effort. I hope you enjoy the conversation. Summer, thank you so much for taking time out of your busy day. I'm sure that you have a pretty packed schedule most days, huh? DA Stephan: Oh, well, it is. As a district attorney for the second largest county in the state of California and the fifth largest in the country, we are hopping at all times, but protecting seniors is really a passion for me, so any chance I can get to talk about it and share information and things we've done, I love to do it. Dr. Bob: Fantastic. Well, I'm excited to hear some of ... I've read up and gotten familiar with some of the initiatives in your areas that you're really committed to and devoted to. I mean it spans of course from children to seniors, the whole gamut, but I understand needing to place emphasis on protecting seniors, because there's so many, and the numbers are growing, and I think that they're becoming more and more vulnerable over time. And you mentioned while we were talking a bit ago about really wanting to engage the medical community in partnership to help with these protections. Can you expand on that a little bit? What are your thoughts about how we as physicians who are working with the senior community, can be of support? DA Stephan: Well, I think that we're finding in a lot of our obstinate crimes or ones where the victims are especially vulnerable, that engaging the medical community is of really big value. And I've come at this through a 28-year journey of public safety and prosecution and working with vulnerable children, domestic violence, sexual abuse, and elder abuse. And we find that whenever you can get a well-educated and trained medical community to spot the warning signs, you can really do a lot better. It's something that I've done consistently in sexual trauma of having doctors really be able to detect that. In human trafficking, we are engaging the medical community on the warning signs of sex trafficking and human trafficking with our victims. And in domestic violence, we've done it for years to look for those telltale signs, document them, and engage police where necessary. But we've kinda left out the elder abuse area. And it is just as important if not more important. Seniors, generally they are so vulnerable to crime because their contacts with the community become less and less as they age. They're not showing up to work necessarily on a daily basis, they're not at school, so the regular places where people may spot those signs are not there. And so the ability ... But they often do still keep a medical appointment, or they have to be seen by a doctor for their eyes, or some issue with their health. And I feel, and my team of experts feel that that is a perfect opportunity to really touch base on the whole well-being of the senior, make sure that they are doing well. Really asking additional questions if there were signs of malnourishment or pain, it's incredible that amount of intersection that medical professionals can find. I mean we are ... Something as simple as even the pain killers or medications for some of our seniors that are suffering from cancer and different pain ailments is getting stolen by caretakers. And our seniors are left to stand for their pain. So that's just one thing. Sometimes they seem like their financial situation has really changed, and they're talking about moving from their home and poverty and things like that, that are also tell-tale signs. So we really believe that the medical engagement is gonna be critical. Dr. Bob: I can see that. I mean it makes so much sense. As you're talking about some of these things, that's actually ... I'm getting chills to think about how vulnerable some of these people are. And they're at a point in life when they become so trusting and dependent. And then if somebody is taking advantage, there is just reluctance to call them out on it, because then they're even more isolated or they're at that person's mercy. So there are so many factors at play that would keep people from getting out from under some sort of abuse of relationship. So, really, we need to look at any advantage that we can find and the physicians and the nurses and the people in those offices or whatever they're going, getting their blood drawn if they're going to get X-rays. I think it makes so much sense to create an army of people who have the same mindset, the same perspective of trying to protect our most vulnerable people who don't have enough protections in place. DA Stephan: I completely agree. I mean you've really hit it on the nose. It is creating that army of eyes and ears and touchpoints that are natural, where our vulnerable populations may have that kinda rare human touch of someone who actually cares and is there for them, and taking full advantage of that. So that was kind of part of the genesis for me bringing together in San Diego, a regionalized coordinated plan, blueprint, to combat elder abuse and to protect our seniors. And we had a blueprint, if you will, for domestic violence, child abuse. But while we were doing a lot of work on seniors and crimes against seniors, we were working in silos. So the prosecution, law enforcement lane, the aging and independence services, the medical community, all kinda working in separate venues. We weren't seeing the whole coordinated vision for how we can do better. And what drove me into prioritizing and recommitting to this, is that San Diego very very fortunate for this, and really a credit to our whole community that just has a beautiful spirit. We are one of the safest urban counties in America. We are at a 49 crime rate low. However, the one outlier is that crimes against seniors went up by 38% in the last five years. And for me, how our civilization treats our most vulnerable, our children, and our seniors, and our disabled, is really gonna be how we'll be judged, how we will be judged as a civilized society. So that just didn't sit well with me at all. And I am in a full combat mode to bring those numbers down. And we brought together small stakeholder groups to iron out where the gaps are, where the needs are. We then went to a larger stakeholder group. We drew out a blueprint of a coordinated plan so that we don't miss these touchpoints. What is really incredible is that we're seeing so much similarity between seniors not reporting and how under-reported the crimes are as we see in areas of sexual assault and human trafficking, strangely enough. It really is that element of shame. Seniors report to us, when we uncover their abuse, that they felt ashamed to tell someone, they felt it made them seem weaker, they felt stupid for falling for different fraudulent schemes and buying, for example in a case we did recently, fake gems that took out all of their retirement money as an investment. They felt silly for falling for those scams, and they didn't report them. So other seniors became victims as well. So it's really that kinda shame element. And then the element that you brought out so astutely, and that's that a lot of the abuse is really by caretakers who are sometimes family members, often in San Diego, and I know across the country, it's an older son, who is taking care of a widowed mother. That's our number one target for abuse. And that older son is ripping off the mom, they often have mental health issues and drug addictions, and the mom is ... This elder mom is just a victim continuously. Dr. Bob: And there's probably some really blurred borders there, right? The boundaries of that, where does helping your child and abuse begin. So that's probably a really difficult one to go after, but if the numbers show that this is one of the big areas, then obviously we need to figure that part out. DA Stephan: We do. And in San Diego, what we're trying to do is we're trying to offer the seniors an understanding that our goal isn't gonna be just to lock up their son. Our goal is to also provide mental health treatment, drug addiction treatment, offer treatment for the son, so that the mom is not alone. But we also are not gonna permit that abuse. It just can't happen. So really we have a very excellent elder abuse unit with trauma-informed people that care, victim advocates that talk to our seniors about look, if you don't come forward, if you don't go through this, this is only gonna get worse. But if you let us help, we will do everything possible to also help your son find treatment, find resources, so that you're not alone in this. So it's a very balanced approach to the issue. Dr. Bob: That's wonderful. Well, so we've been talking for about 13 minutes now,