Plan Of Care Nursing

male speaker: good morning,and welcome to talks at google in cambridge, massachusetts. today, it's my great pleasure tointroduce dr. angelo volandes. he joins us today to discuss hisnew book, "the conversation-- a revolutionary planfor end-of-life care." dr. volandes believesthat a life well lived deserves a good ending. through the stories of sevenpatients with very different end-of-life experiences,he demonstrates

that what seriouslyill people who are approaching theend of their lives need most is notnew technologies, but one simple thing,"the conversation." he argues for aradical re-envisioning of the patient-doctorrelationship, and offers ways forpatients and their families to talk about thisdifficult issue to ensure that patientswill be in charge

of their medical care. dr. volandes is aphysician and researcher at harvard medical schooland mass general hospital. he's the co-founder of advancedcare planning decisions, a nonprofit organization devotedto encouraging the conversation through the use of videos. please join me inwelcoming dr. volandes. angelo volandes:so good morning. thanks a lot for coming.

i really appreciate it. it's a real privilege to presentsome of the work that i do, and especially here atgoogle, because you all tackle some of the mostdifficult problems facing our society. and what i'm goingto talk about today is what i feel is the mosturgent problem in health care today. so maybe you can helpme think about it.

when we asked most peoplewhere do they want to die, where do they tell us? audience: home. angelo volandes: home. most americans wantto die at home. in fact, in the latestsurvey, 86% of americans want to die at home,surrounded by their loved ones, and in comfort. but what are the facts?

where do most people diein our country today? audience: hospitals. angelo volandes: hospitals. people over the ageof 65, 2/3 of them will die in ahospital or nursing home, often tethered to amachine and in a good deal of pain and suffering. this misalignment between thetype of medical care people want and the type ofmedical care they end up

getting in our healthcare system today is what i feel is the mosturgent problem in health care. now, you've all beenreading about it. on the front page of"the new york times" there's been a storyabout the problem. and we usually talk aboutit in terms of cost. yes, end-of-life careis, indeed, costly. but by the end ofour time together, i hope to throw in two otherphrases, two other lenses

from which tounderstand this problem. when americans getcare in hospitals that if they were moreinformed they would not want, let's call it for what itis-- it's unwanted care. and when people get unwantedcare in our health care system today, it's trulya medical error. it's no different thana surgeon operating on the wrong side of the body,or an icu doctor not following a checklist for a patienton a breathing machine.

but we don't want tojust talk about problems. what are somepotential solutions? for me, i feel thatthe primary reason why people get unwanted carein our health care system today is because doctors are notslowing down, sitting down, and having the conversation--an honest and frank discussion with patients and family membersabout what's important to them. but, you know, today we livein a visually-literate society. we're a youtube generation,and that's true of all ages.

and sometimes wordsare not enough. sometimes we need images tohelp people better understand their options. so i'm also goingto talk about how to enhance thoseconversations with videos. but before i getstarted, i thought i'd begin with a story-- thisis, after all, a book reading. meet professor helen thompson. helen thompson was one ofthe foremost literary critics

on the poetry of walt whitman. how many of you arefamiliar with the poetry of walt whitman? great. so there's definitely agenerational gap there. i was born and bred inbrooklyn, new york-- you'll hear my accent occasionally--where walt whitman spent the first half of his life. so every other street cornerhad a whitman elementary school,

and all the pupilswere forced to memorize the opening lines ofwhitman's magnum opus, "the leaves of grass." so professor thompsonand i hit it off because we could bothrecite those lines. "i celebrate myselfand sing myself. and what i assumeyou shall assume, for every atom belonging tome as good, belongs to you." now, you may beasking yourself why

i'm telling you about helenthompson or the poetry of walt whitman. well, what i haven't toldyou is that helen thompson was my patient a few years ago. what i haven't told youis that helen thompson was a 56-year-old female withbrain cancer being admitted to my hospital service. what i haven't told you isthat helen thompson was dying. and so i conducted a history.

i did my physical exam. and then i got tothat point where doctors get a littlebit uncomfortable with, where the words of whitmanmetamorphosed into other words. words like cpr, ventilators,the icu, goals of care, hospice. in other words,the vocabulary of shared decision-makingat the end of life. and i looked at the professorand i said, "professor, you've seen scoresof doctors since you

were diagnosed, and by thetime that you're seeing me. have you ever had theconversation with them?" and she gave methat blank stare. and so i proceeded toask her those questions. what's important to you? what's a good day for you? where did you want to spendwhatever remaining time you have? where are you on thisjourney with your illness?

and then she looked at meand give me that blank stare that i think a lot ofpatients give doctors when they have this conversation. and so i naively askedher, i said, "professor, would you take a walk withme to the intensive care unit so i can actually showyou some of these things?" of course she obliged. we didn't walk to the icu. i put her in a wheelchairand rolled her down

to the intensive care unit. i got to show her a ventilator. i got to show her a patienton a breathing machine. there were a coupleof residents there. one was performinga lumbar puncture, another one wasinserting a central line. and what the professorwas able to do was to get a sense of theplace-- hear the beeps and buzzes, see thecolorful monitors,

to feel the rhythm ofthe intensive care unit. now, as fate would have it-- iobviously did not plan on this, but there was a code blue inthe icu while we were there, and i immediately brought herout of the intensive care unit, but not before she caughta few glimpses of cpr. when we went back to herroom, she looked at me and said, "words, words, words. angelo, i understoodevery single word that you said before.

cpr, breathingmachines, comfort care. i am, after all, aprofessor of english. but i had no idea that'swhat you were talking about. it doesn't look likethat on television." and that's whenit occurred to me, so often health care, we'rehaving these conversations with our patientsand family members, but they're thinking aboutwhat's on the television and that cpr works all thetime, and that everybody

looks like george clooneyon a breathing machine. the clinical realityis very different. so what i decided to do was totake my next six patients, all with a serious illness,and their families on their own personaltour of our hospital. some patients i brought toour intensive care unit. other patients and families ibrought to our dialysis unit. and what everyperson told me was that this was the most powerfuland empowering experience

that they had ever had. that they couldn'timagine making a decision about end-of-lifecare without this tour. now, although thenurses loved what i was doing-- they could seethe educational value in it-- they quickly put an endto my tour business. because they knew i was breakingpatient confidentiality. so here's the conundrumthat i was left with. how could i recreate thispowerful and empowering

experience for bothpatients and families, and yet not breakpatient confidentiality? and that's when i cameup with the idea-- why not create short filmsto help people better understand their options. so it's not just me. it's a group ofaround 100 of us. we are 100 doctors,nurses, patients, families, and video artists from 10academic medical centers

who create these short videos. but we don't justcreate them, we actually study them in rigorous,randomized control trials. and there's threethings that we find. first, for patients whohave a serious illness and watch a video, they're moreinformed about their options. they have much more knowledgewith which to understand their medical options. the second thingis that for people

who have a serious illnesswho have a conversation and use a video,they actually tend to want morecomfort-oriented care. they make decisionsthat lead them to end-of-life careoutside of the hospital, not tethered tomachines, and not in our intensive care units. and the third thing iswhen we asked people, are you comfortable watchinga video about goals of care

at the end-of-life, people areoverwhelmingly comfortable. we truly are a youtubegeneration where people expect these images. if a picture speaksthousand words, videos speak hundredsof thousands of words. so what i thought i'd do isshow you one of our studies. and it was actually ourfirst study done right here at massachusetts generalhospital with patients who had advanced cancer.

so what we did is wetook 50 patients, all with advanced cancer, andwe randomized the group into two groups. the first group hada verbal discussion about what sort of medicalcare they wanted now that they had advanced cancer. we asked them, whatwould you want now that you have advanced cancer,and we gave them three options. the other half of the grouphad the same verbal discussion,

but then they saw a shortvideo that actually showed them what each of theirgoals of care entailed. now, i know most of youare not clinicians, but let me just give you the generalflavor of the goals of care. this is availableanywhere in america today. you generally havethree options. life-prolonging care, limitedcare, and comfort care. and i'll brieflyreview each one. with life-prolonging care,the goal is to prolong life.

it includes anything availablein a modern day hospital-- cpr, breathing machines,the intensive care unit. the middle category,limited care, is essentially hospitalizationwithout the icu, without cpr. and the thirdcategory, comfort care, is essentially symptom relief,really hospice level care. so those are the optionsthat all 50 patients had. but for the patients thatwere randomized to the video, they got to seevisual images of each

of those categories of care. now, the particular video thatwe created for these patients was a seven minute video, andit was filmed and developed with an expert panelof over 50 oncologists, intensivists, palliativecare doctors, nurses, social workers, chaplains,patients with advanced cancer, and the families of patientswith advanced cancer. we wanted to makesure that we offered a fair and impartialportrayal of what

the options were for patients. now, dealing with 50 people,we bent over backwards to make sure that weaddressed everybody's concern. but you know the joke aboutgetting a bunch of oncologists together and asking theman opinion on a patient, you'll get 50different opinions. this video took ustwo years to make. steven spielberg makes probablyfive films in two years. but we wanted to make sure thatpatients and providers felt

that this was a fairand impartial portrayal. [video playback] -i'm angelo volandes, aphysician at harvard medical school. thank you for taking the timeto read "the conversation." it's been a privilegecaring for patients. thank you for hearing theirstories and bearing witness. in this video i'll becovering some of the topics that i touch on inthe book, so make

sure to refer to the book formore details and information. talking about medicalcare at the end of life can sometimes bedifficult, but it doesn't have to be a sad conversation. there's a common three-stepapproach to do it well. the three steps arestart the process and have the conversation. talk to your lovedones about your values and what's important to you.

and then talk toyour health care team about your medical choices. let's review eachone of these steps so you can make sure you getthe right care at the right time and on your own terms. don't wait for your doctorto start the conversation. start the discussion on yourown with family and friends. here are four questions thatcan help start the process. what kinds of things aremost important to you?

what concerns do you haveabout getting sick or needing medical care? if you were very sick, are thereany specific medical treatments that might be too much for you? and finally, whatare your spiritual, philosophical, religious,or cultural beliefs that would influenceyour medical decisions? considering these questionsis only the beginning. these reflections are not aone-time event, but a process

that you shouldreturn to over time. after you've thought aboutyour values and wishes, it's important to share yourinformation with your loved ones. holidays are a good time tostart having these discussions with the people youwould want to be around if you became very sick. pick a calm andquiet place to talk. the talk doesn't have tohave a certain structure,

let it just happen. and you don't need toestablish everything with one conversation. after the conversationi often tell my patients to use their cell phone ortablet to film themselves telling their loved ones whatis most important in their lives regarding medical care. they can then sendthe video to them. and if you are ready,complete the appropriate legal

paperwork. now you're ready to completethe last step, talking with your health care team. talking with yourdoctor is vital, since he or she will knowyour medical condition best and will be ableto help translate your preferences into anactionable medical plan. there are threegeneral approaches to medical care forpeople who are very sick.

they are life-prolongingcare, limited medical care and comfort care. the first approach islife-prolonging care. with this option thefocus is to lengthen life. this includes all medicalcare that is available in the hospital likecpr, breathing machines, and treatments in the icu. for healthy people, cpr hasa good chance of success and has improved over time.

however, for people withan advanced illness, cpr's overalleffectiveness is not high. it's important toask your doctor what the chances are that cprwill work in someone like you. sometimes people decide to trylife-prolonging interventions for a short period of time. and if the interventionsare not successful they move to the nextoption, limited medical care. with limited medicalcare, the focus

is to take care oftreatable problems. people who choose thisapproach want medical care that will help restore their health. my father receivedlimited medical care. he had iv medicationswith careful monitoring. but he did not want anylife-prolonging interventions like cpr and breathing machines. he chose to avoidthese procedures, even though he mighthave died without them.

the third approachis comfort care. with comfort care, the maingoal is to be comfortable. treatments are only used if theyhelp make people feel better and improve theirquality of life. people who choose thisapproach are usually treated at home, in hospice,or sometimes in a nursing home. talk to your doctorand your loved ones. if you let themknow your choices, they can help makesure that you are

at the center of and incontrol of your care. thank you for takingthis journey with me and hearing the lives ofsome extraordinary people. their stories are our stories. take care. [end video playback] angelo volandes: what didthose 50 patients, what were their decisions? so let's take a lookat the group that

only had a verbal discussion. in yellow we havelife-prolonging care. in blue we have limited care. and in green wehave comfort care. so why don't you take a guessof what you think people wanted. charles, what do you thinkpeople in the verbal arm felt? audience: [inaudible]. angelo volandes: what percentagewanted life-prolonging care? audience: about 65%.

angelo volandes: 65% wantedlife-prolonging care. this is what we found. 26% in yellow wantedlife-prolonging care. 52% in blue wanted limited care. and 22% wantedcomfort-oriented care. i'll be honest. i admit these patients tothe hospital all the time. i wasn't surprised by this. the patients that i admit to thehospital with advanced cancer,

i'd say a quarter wantlife-prolonging care, a quarter wantcomfort-oriented care. half the people aresomewhere in between. well, what happened to the groupthat actually saw the video? the gentleman with the greent-shirt, what do you think? audience: a sharpdecline in life prolonging care and shiftingdown to comfort care, so call it 10, 40 and 50. angelo volandes: a sharpdecline in life prolonging care,

an increase in comfort care,10% life prolonging care, 40% limited care, andthe rest comfort care. well, let's take a look atwhat our patients chose. a dramatic difference. the interesting thing was thatthe people who saw the video also had more knowledge. we actually quizzed themand they answered many more questions correctly afterwatching the video compared to patients who didnot watch the video.

so what this told us wasif you saw the video, you had moreknowledge and you were more likely to choosecomfort oriented care. now to be clear, when we haveverbal discussions today, what happens? most people still end updying in our hospitals. 2/3 of folks are dyingin our hospitals. that's what's going on today. but can we imagine a time whenpeople are more informed, where

they had theconversation, they have a video that explainstheir options and standardizes the process. what happens then? most people die outsideof the health care system, surrounded by their lovedones and in comfort. this is the medical emergency ofour lifetime in the health care system today. we are delivering unwantedcare every single day

in our hospitals and nursinghomes across the country. it's a medical error. so this study was done closeto the seven, eight years ago. since then we'vedone many studies and the interesting thing iswe're seeing the same things. so i'm just going to giveyou a quick glimpse of what some of our other work shows. we asked 200 elderlypeople what sort of medical care they would want if they hadadvanced alzheimer's disease.

and we did the same study. randomized control trial. half of them had averbal description. the other half had a verbaldescription plus saw a video. here's what the group thatonly had a verbal description, this is what they told us. 19% wanted life prolonging care. 17% wanted limited care. and 64% in greenwanted comfort care.

what happened to the group thathad the same verbal description and then saw a video? a very differentpicture emerges. 86% of people wantedcomfort oriented care. we even went to aprimary care clinic and did the samestudy asking people, if you had a serious illness,what sort of medical care would you want? in the group that onlyhad a verbal discussion,

72% of people wantedcomfort oriented care. add the video andall of a sudden, that jumps up to 91% of people. not a single personwanted aggressive life prolonging care. we even went to nursing homes. and this is something reallynear and dear to my heart because i'm notonly a doctor, i'm also a son who's dealingwith this with his parents

as we speak. so let's take a lookat a nursing home. same study. half of people wereasked, how do you want, what are your goals of care? how do you want to spendthe end of your life? in a skilled nursingfacility, right here-- these were two facilitiesright here in boston-- 57% wanted comfort oriented care.

what happens whenpeople actually watch a video that explains tothem what their options are? that number increases to 80%. but even that wasn't enough. we went to our medical icu righthere at massachusetts general hospital and we asked,not the patients because they weretoo sick, in fact, all the patients were intubated. they were on abreathing machine.

so we asked their familiesto make a decision about cpr. and these were allcritically ill patients who had a terminal diagnosis. and this is whatthe families told us about cpr when we describedto them the procedure. 78% of people in red wanted cprattempted on their loved ones. what happens when you actuallyshow people what cpr involves? that number drops to 41%. we live in thehealth care system

that does not do a goodjob of communicating with patients and families. and we've now done trialsin over 2,000 people all across the country. but it's not enoughto show that people are more informedwith videos or to show that they make decisionsabout comfort oriented care. you have to show that peopleactually like the videos. so we asked all2,000 subjects, what

did you think about the video? this is what people told us. 90% of people who viewedthe video found it helpful. but were they comfortablewatching the video? 93% of people were verycomfortable watching the video. and then i think thegold standard question as a doctor is asking mypatient who has seen the video, would you recommendthis to your mom or dad or to a sibling who has tomake a similar decision?

97% of people said they would. when did 97% of patientsever agree on anything? these are really highnumbers, as you can imagine. i think it justspeaks to the fact that we are a visuallyliterate society. our patients and familiesare now expecting this. so i could have stoppedand done my research. i would've gotten on myway to getting tenured at harvard medical school.

wonderful. sit on my derriere atmassachusetts general hospital. but our group didn't wantto just make publications. we didn't want to have thiswork really just in libraries and read by a bunch of doctors. we are interested intransforming health care. so three years ago,i co-founded along with another colleague who'sboth a doctor and a lawyer, we co-founded anonprofit foundation

whose mission is to transformhealth care across the country by using videos. and as of today, there are200 hospitals, clinics, nursing homes, hospices,and health care systems across the countryin nearly 25 states who use our videos totransform the medical culture in their health care system. think khan academybut for medicine. and it's probably themost exciting work

that i do because fortoo long we've just been talking about the problem. we haven't been posingsolutions to what to do about this unwantedcare in our health care system now our library ofvideos has exploded. we have over 60 videosbecause we not only make videos for the leadingcauses of death, cancer, heart failure, dementia,but also in all the languages that represent ourdiverse community.

so we have videos and spanish,cantonese, mandarin, japanese, korean, vietnamese, tagalog,ilokano, marshallese, even samoan becausewhat we're trying to do is to meet peoplewhere they're at. our latest series of videosare actually in persian because we found a greatneed in the persian community to actually make sure peopleunderstand their options. but i know we're at googleand it's all about data. so we are alsointerested in big data.

and what we wanted to askis do these videos actually make a large difference? sure, you could try to attack200 hospitals and clinics across the country,but what about an entire geographic area. so our nonprofit isnow involved in one of the largestprojects in america when it comes toend of life care. and what we've decided isto blanket an entire state,

the wonderful alohastate of hawaii, where all 1.4 millionresidents have access to all of our videos. over the course of threeyears-- we're about halfway through-- every singleresident of hawaii has access to the videos. 15 hospitals, 50 skillednursing facilities, 10 hospices, over 600 providers,regardless of your insurance, regardless of where you'reseen in the entire state,

you have access to avideo, in your language, that will allow you tounderstand your options. and what we're doing isusing very large databases to see, over the courseof three years, what happens to hospitalizations. what happens to the numberof deaths in the hospital? what happens to number of daysin the icu before people die? and we're going to use thosemetrics to see, can a video and prioritizing theconversation at an entire state

wide level, can you reallytransform health care? we've already startedgetting the data and i'm pleased tosay that indeed, we're seeing transformation already. in fact, four othervery large states are interested in replicatingwhat we're doing in hawaii. because that's whatthis is all about. it's making surethat patients get the right care at the righttime, but on their terms.

today, although we say we livein a patient centered health care system, i thinkmany of you know we don't live in a patientcentered health care system. we live in a cliniciancentric health care system, where peopleend up getting "care," that if they were moreinformed, they wouldn't want. now before i end, ithought i would tell you about my own journeyto this work. and so i thought i justtake a 10 minute book

reading, since we areat a book reading, of telling you aboutmy very first patient. taras skripchenko was a livingpart of american history. as i later found out, taraswas an ethnic ukrainian who had emigrated to the unitedstates from the soviet union as an adolescent. he was one of thelucky few who escaped the chaos that took over duringthe months before world war ii. taras wanted to start over,to rewrite the opening

chapters of his life. at 18, he found a new homein a ukrainian enclave in one of the miningtowns of appalachia and quickly found laborin the coal mines. for years he led a life ofunremitting physical toil, working 12 hour shifts,six days a week. unfortunately for taras,a lot of the detritus from smashing coaldug its way deep into the lining of hislungs, plugging the airways.

it would also plant the creepingcancer that would devastate him decades later. this once hulkingmine worker had dwindled to a mere whisperof his former muscular self. this frail,bed-bound 78-year-old with inoperable lung cancer wasadmitted to my medical service during my first yearof residency training. slowly suffocating todeath, he experienced both transient momentsof hallucinatory

joy and unconscious,yet peaceful somnolence on the oncology ward. taras was too confused tohave a lucid conversation and lacked family members toguide his decision making, so his medical plan wasthe default approach for all patients. do everything. despite my efforts to comeup with a plan for taras, i knew that his cancersurely had a plan of its own.

doctors can foolthemselves into thinking that they are in charge, evenwhen disease and pathology are in the driver's seat. frequently, we are onlyalong for the ride. taras was dying. i knew it and thenurses knew it. but as far as the medicalteam was concerned, taras was a full code. if his heart or lungsstopped working,

we would attempt cpr and placehim on a breathing machine. exhausted from a long day, ipaged the overnight resident to meet me in the cafeteriato review my patients before i signed out. the overnight doctor was asenior resident named edward and i was glad anexperienced resident was on call that night. i told the residentto keep a close watch on taras skripchenko.

he's a ukrainian gentleman. he worked in the coalmines of appalachia. about eight months ago,he started having a cough. he saw as primary care doctorwho ordered a chest x-ray. stop right there, edward said. start again. start with initialsand then in one line, give me the pertinent info. less is more.

i have 30 other patientsto cover tonight. when a resident is responsiblefor 30 patients at night, too many personal detailscan muddle one's thinking. ts is a 78-year-old male patientwith metastatic lung cancer who presented with shortnessof breath and delirium, i said, he's really sick. modern medicinecan be dehumanizing and the first stepin that process is to remove all theindividualized details.

to obliterate personhoodand replace it with patienthood, wheretwo letters are a patient's diagnosis, treatment,and prognosis. code blue. edward and i sprintedtowards the oncology ward, racing through theobstacle course of stretchers and patients. we finally arrived, out ofbreath, at taras's room. i was always taughtto hope for the best

but prepare for the worst beforeentering a patient's room. but it's not always clearhow to define the worst. the gathered nurses whohad ordered the code blue had already started cpr. i clumsily jammed my handsinto a pair of rubber gloves and joined theritual, relieving one of the nurses doingchest compressions, which is far more physicallydemanding and brutal than what is portrayed on television.

my clasped hands pressed hardagainst taras's frail chest and all i could here and feelwere the cracking of his ribs with practically eachchest compression. the rhythmic pumping on hischest eerily emitted a coarse. velcro like sound. edward stood atthe foot of the bed and took charge,directing what was likely to be taras'spassage from life. i searched for apulse on taras's neck.

any fat had meltedaway long ago and all i could feel wascartilage and wind pipe. it's an eerie feeling,sliding bloody gloved fingers along the skin, searchingfor signs of life. shockingly, i foundonly a thready pulse, one that lacked vigor. taras was stabilized. he was connected toa breathing machine and had a pulse witha normal rhythm.

the team had savedthe patient and now it was time to transferhim to the icu. edward and i bundled tarasand his machines onto a gurney and navigated the labyrinthof hallways to the elevator. we squeezed intothe narrow elevator. as the doors closed, i kept myhand on taras's carotid artery, making sure to feelfor a pulse until i realized he no longer had one. there was no spacealongside the gurney,

so i jumped on, straddledhim, and started performing chest compressions. in all likelihood, the cancerhad spread to the thin sack around his heart, allowingblood and fluid to seep in and surround the vigorouslypumping heart muscle. to get the heartbeating again, a doctor must emergently stick a largeneedle into the patient's chest and draw out the fluid. we needed to move fast.

do you feelcomfortable doing this? edward asked. i told him that i hadperformed the procedure on a cadaver in anatomyclass, but i'd only seen one on a patient. see one, do one, teach one. here's your chanceon a warm body, he rejoined, asthe elevator doors opened to a crowd ofnurses ready to wheel

the patient towards the icu. i descended from the gurney. edward handed me a largesyringe, attached to a needle the length of my ring finger. i stared at the needle. my hands were shaking,not surprising since i was about to poke arounda man's heart with a needle. you don't know how deep toslide the needle into the body in order to draw out thefluid from the sac surrounding

the heart. every body is different. some are fatterthan others and some are more muscular than fat. i pierced taras's skinjust below the sternum and carefully pushed theneedle through the skin, simultaneously pullingback on the syringe, hoping to see fluid. no luck.

the tremulousness in my handsworsened and beads of sweat trickled down my forehead,falling onto the syringe. i advanced the needle alittle more, but no luck. i pulled needle out and triedagain and again and again. by the fourth time, i gave up. residents are usuallyallowed three strikes before being asked to stop. edward gave me a fourthsince this was my patient. i probably should havestopped after the third.

taras's ribcage had become a pincushion from all my attempts. as soon as we enteredthe icu, edward filled in the medicalteam as they took over, using the ultrasound machine toremove the liquid surrounding his heart. taras's once flailingheart could beat again. he had a pulse. taras's care was now beingmanaged by the icu team, so edward and i headedback to the cafeteria

to grab some coffee. after every code blue,the team is expected to review what transpired. it's a ritualized momentto grapple with the trauma surrounding a full on code. debriefings are alwaysdifficult moments as each of us dials down therapid pace of a code blue to digest the events thathave just transpired. we sat quietlyfor a few minutes.

we reviewed therunning of the code, how each team member hadperformed his or her duties, we replayed each ofthe interventions i had performed anddiscussed how i could improve my technique for the next time. silence settled again oncethe routine items were out of the way. but there was more to be said. we just completedby the book code

but i wonder if wedid them right thing, i said, needing to telledward what was on my mind. perhaps it was becausei was a young doctor and i had not yet been numbed tothe brutal experience of caring for hundreds of patients. i hoped edward, amore seasoned doctor, would have a better perspective. we did exactly whatwe were taught to do. everything was by the book.

look, this is the system. we have a job to do, he said. but i could see a slightunease in his face, a hint of upheaval. we both knew somethingwas not right. i can't believe wejust did all that to a man who has one footin the grave, i pushed, not mincing my words. would he havewanted any of this?

would you havewanted any of this? would you do this to your dad? something is wrongwith a health care system that puts terminalcancer patients through torture. edward put a handon my shoulder. it's going to be all right. you're still new at this. you'll get used to it. get some sleep andpage me tomorrow.

get used to this? is one supposed toget used to this? over the next twodays, edward and i followed taras everyfew hours in the icu. he was no longer ourpatient but we could not let go of him either. by the following morning,he had a tube or catheter in almost everypart of his body. a grand total of eight plasticintrusions, taras was fixed.

doctors like to tackleproblems and fix them. and it is truly amazingwhat modern medicine has achieved in a relativelybrief span of time. the tougher issue,however, is when to recognize that thesmall fixes do not change the larger picture. to recognize that fixingspecific problems may not fix the whole patient. this is medicine'sversion of not seeing

the forest for the trees. doctors always searchfor the next fix. but we need to know when touse or not to use our growing toolkit of fixes. taras's heart hadstopped three more times and miraculously, the icu teamhad brought him back each time. but not surprisingly, apatient in the late stages of terminal cancersuccumbed to his disease. whatever the next newfixes, nature eventually

takes her inexorable course. taras died 48 hours afterthat initial code blue. americans receive some of thebest health care money can buy. they also experience some of theworst deaths in the developed world. the primary reason weexperience such horrible deaths is doctors' failure toopenly discuss medical care with seriously ill patients. taras skripchenkodied 15 years ago.

i have since witnessedhundreds of deaths but his, which i experiencedduring the formative years of my medicalresidency, haunted me for the first decade of mylife as a young physician. so too did thatconversation with edward, as we both struggled tomake sense of the drama that had just unfolded before us. today i am a fullfledged medical doctor, a senior physician,and teacher of others,

yet i still think about taraseach time i meet a new patient. a new beginning, a cleanslate, but also a potential ts. thank you very much. so we have allowedsome time for q&a. and what i wasencouraged to do is to have you come onup to the microphones because this is being recorded. yes. audience: thank you for doingthis very important work.

i could ask a lot ofquestions but let me ask one about data, basically. i am interested inhow you're actually measuring the outcomes ofyour video intervention. in the first series ofstudies you described, you described thoseas randomized trials but the outcome you weremeasuring there was simply, as i understand it, justthat people then told you what they would prefer.

now in your hawaii study,which you mentioned, obviously a muchmore massive study, you clearly are aiming tomeasure actual outcomes in terms of what kind ofcare these people got, but from the wayyou described it, it sounds like you're usingmore of an epidemiological model that there is not arandomization component there. so i'm curious abouthow you're going to extricate the effectsof your intervention

from all the other stuff. are you just going to usestandard statistical techniques to do that or do you have anactual randomized component somewhere where you'reactually looking at what the outcomes were andnot just what people told you at the end of the studies. angelo volandes: whata wonderful question. i wish i had more time to tellyou about all of our studies, but let me tell you about threethat address that exact point.

so just last week astudy was published in the "journal of generalinternal medicine" where we not only looked atwhat people told us, we actually looked atwhat happened over time through the electronicmedical record. and we found three thingswhich were fascinating. again, same thing,randomized control trial. half of people got theusual care at our hospital. the other half of people hadusual care plus the video.

and we actually foundthe following abstracted from the electronicmedical record. people actuallymade real decisions after watchingthe video that was for not having the aggressivelife prolonging interventions. the other thing we found, whatthere was actual documentation of doctors havingthe conversation and stating that theyhad the conversation. written documentation.

but we went evenone step further. we actually followedpeople for one year and what we found was thatpatients in both arms, the first group that did notwatch the video-- i forgot the number of people, maybe40 or something people-- were readmitted to the hospital. and what we found wasthat 22% of people ended up getting an interventionthat they never wanted, that they actually told us.

what percentage doyou think in the arm that saw the video gotsomething that they didn't want? audience: zero. angelo volandes: 2%. and that person wasactually someone who had a procedure done andit was temporarily reversed. so what we havefor the first time is hard data of real decisionsof people showing exactly what the previous study shows.

but that's not enough. i'm with you. that's a small studyat two hospitals. what we're doing inhawaii is the next step, which is we're doinga natural experiment. we actually know whenwe started in hawaii in terms of the videos. so what we're doing at time 0when the videos were started and we know thepenetration rates.

it's not like all ofa sudden everybody and hawaii iswatching the videos. it's graduated over time. so over the courseof three years-- three years is ourpoint-- at that point, we're actually going to comparehospitalization rates, hospital deaths, icu deaths,chemotherapy in the last life, compared to three yearsbefore we started in hawaii. furthermore, we know what'sgoing on in the state.

so we will account for thosethrough statistical methods. but even that is not enough. our biggest project today,which i didn't mention, is looking at a randomizedcluster trial, which is called a pragmatic trial. this is all fancy words of justsaying, instead of randomizing by the unit of the patient,why not randomize 600 nursing homes all across the country. half of the nursinghomes get usual care.

that data is collected througha large database called mds. and then the otherhalf of nursing homes, the other fewhundred, will actually get to use the videosafter being trained and however they wish. and what we're going todo is to see over time those hard outcomesthat we talked about. that's truly therandomized control trial that you're asking about.

but we've moved beyondthe data that i've shown which is more of what dopeople tell us to hard data. what happens. because we feel that thiswork will truly transform care where using largedatabases now we have the opportunity to do that. and i should mention that thenursing home study is actually funded by the nih, thenational institutes of health. thank you for thatgreat question.

audience: thank you for coming. so when you talkedabout the video showing the comfortlevel, when you talk with people innursing homes about that, how does that-- they're ina nursing home, which is not at home with family and things. do you adjust that? or how is thatpresented to them? angelo volandes:wonderful question.

and in fact, wedeveloped a video for that study with the nursinghomes, just on this point. people don't realize justbecause you live in a nursing home, in a skilled nursingfacility, if you're a resident there, what is theassumption of most people? i get sick, i'm going togo back to the hospital. that's not true. there are manythings that could be done focused on quality oflife and comfort oriented care

right there in the nursing home. and so people actually do havethe option of hospice care at a nursing facility. it's one of thenewer waves of what we're seeing in skillednursing facilities because let me tellyou, as a doctor and what i see here allthe time is the revolving door of the hospital. we get a frailelderly person who's

admitted to the nursing home. no one has had the conversation. no one has startedthe process of talking with the family, what'simportant to them, what do they want to focus on. and as soon as theyget a fever, as soon as they becomedelirious, they're just, and i hate to use the word--shipped to the hospital. call 911 at the nursing home.

the ambulance comes. nobody has asked the patientor the family what they want and they're broughtto the hospital. that fix that we do inthe hospital, antibiotics, get the patient backto where they were, and then they're shipped rightback to the nursing home. it happens thousandsof times a day. and it's because innursing facilities, we're not havingthe conversation.

no one's explaining to peoplewhat their options are. and that's that sortof disruptive nature of the videos. the idea behind the videos isthat today, i'm the doctor, i have all the power. if we're going totalk about this, it's only becausei raise this issue. and most of the time, i'mnot raising this issue. what we're hoping the videosdo is empower patients

and families so they knowwhat their options are. so that they knowwhat are the questions they should beasking themselves. this way we're not relyingon the health care system to bring up these questions. patients and families arebringing up this question. and, in fact, thatstudy that i mentioned, what we found was thatpatients indeed were asking their doctors, hey, ijust saw a video that

mentioned my options for care. i want to talkabout this with you. i have much morefaith in relying on patients and familiesto raise this question by empowering themwith videos than i do on the health care system. it's disruptive becauseit flips the power dynamic and i hope that the video,which is on youtube, it's at theconversationbook.org.

i hope that people useit to empower themselves. audience: thank youalso for your work. four really short questions. angelo volandes: fourreally short questions. let's go one by one. audience: all right. where can we get the videos? can we get them online? two does it make a difference--

angelo volandes: sothe first question, theconversationbook.org. it's a short video. it tells you through all yourquestions and your options. your second question. audience: is the video withoutthe conversation as effective as the video withthe conversation? angelo volandes: great question. what we've done inall of our studies

is not only done thevideo in isolation. this is meant to supplement"the conversation." so it's always beenconversation, conversation plus video. and i truly feel that at the endof the day, videos are a tool. the answer and the solutionis having that conversation with your clinician. it's just that videos helpspark the conversation as we saw in our study.

audience: but you don't have anydata on whether the video alone is as effective or close to. angelo volandes: so we don't dothat intentionally because we don't want people tosay, i could envision, my worst nightmare, whatkeeps me up at night, is a surgeon-- i hate tosay surgeon-- who says, hey, go watch this video. tell me what you want. i don't want that.

i got into medicine becausei love talking to patients. i hope my colleaguesfeel the same. your other question. audience: ok. the third question isso do you routinely have the conversationat the revolving door now in your practice? angelo volandes: in mypractice, absolutely. and what's remarkable isthat it's not just me.

i'm proud to say that not onlyin our health care system, but all around thecountry, what we see-- and this is thework that the profit does-- is people aremaking this routine. it's changing theculture where part of the responsibilityof being a good doctor, a good clinician, is not onlyasking what medications are you on, what are your allergies,and your past medical history, but let's sit down and talkabout honoring and respecting

your choices if youhave a serious illness. and the last question isdid edward change his mind about following the book? did he question the book ever? angelo volandes: so that'sa wonderful question. edward is a dear friend of mine. edward and i have both grownthrough that experience. in fact, part of our subsequentcode because we had many codes together, edward and i lookedat each other and we said,

you know what, we're bothcommitted to changing health care. and i'm very happyto say that edward is one of our big supportersin our nonprofit work and actually has transformedcare in the city that he's at. thank you. audience: you talkedabout measuring the effects this has onwhat choices people made and figuring out whether thosechoices are followed through

on. did you also measure howthat actually affects length of life,quality of life, how their friends and family feelabout what happened, and so on. angelo volandes: yeah,what a wonderful question. so we are actually now,with our other studies, looking at those veryimportant questions. what was the bereavementexperience for the family? we often focus what's happeningon the patient but remember,

when the patient dies, it'sthe family that experiences that moment over and over. so we are looking at thingslike anxiety and depression on family members, what we callthe bereavement experience. and the other onesthat you wanted? audience: what effectsit has on the patient's both length of lifeand quality of life and how they feelabout what happened. angelo volandes: wonderful.

so we actually arelooking at survival. slowly we're seeing research. in fact, one of thebig papers on this came out in mass generalhospital and my colleagues there, where theylooked at people who chose early hospice care. and what they foundin a randomized trial compared to people who didnot choose hospice care, was they actually lived longer.

that's a new finding. and that's somethingwe are publicizing. and what's happeningis-- this is what we think isgoing on-- people actually live longer whenthey feel that they're in control of what's going on. but going to the hospitalmight be bad for you. medical errors that wehave in our health care system, whether it's infectionrates or procedures that

are performed on people whoare critically ill, actually might lead to earlier deaths. this is a verycontroversial thing that we're tryingto publicize about. and we tell people, do youknow that in numerous studies now, people who choosemore comfort oriented care with a life limitingillness actually live longer. and so we are looking atthat with our studies. what happens to survival rates?

what happens to those600 nursing homes? what happens to folkswho decide i'd rather stay in the nursing home. i'd rather not get cpr or notget aggressive life prolonging interventions. i want aggressive care. but i want aggressivecare focused on my quality of life and comfort. we'll be followingthat and it's really

transforming what's goingon in health care today. audience: you stoppedshort of any discussion of actually assisting patientsin their death process. can you discuss that issue? angelo volandes: why doesthis question always come up? audience: because there'salways someone like me. angelo volandes: there'salways someone like you. ok. so let's be clear.

the book's aboutadvance care planning. it's about what affects everysingle person in our country it's about makingsure we're honoring and respecting people's wishes. the issue of-- i'm going to callit for the variety of things-- today it's aid in dying. euthanasia, passiveassisted suicide, whatever phrase youwant to call it, is somethingincredibly different.

i'm not a policy wonk. i don't understandall the issues. but i will say two thingsbecause this issue, this question always comes up. it's complicated. it's really complicated. and i will say first, inour health care system today, for the vastmajority of americans, we are not meeting theirneeds for suffering and pain

and control of their illness. and so the amountof resources that we have for hospice andpalliative care services across the country isclearly inadequate. and so i'm reallyfocusing on trying to make sure we have thoseresources because the question that i always have is ifwe actually meet people where they're at, if we actuallygave them control to not be in pain and suffering, wherethey feel that they are truly

at the center of care, i feelthat a lot of the issues that come up during the debate aboutaid in dying will disappear. that's my personal opinion. but i think the issue of aidin dying is so complicated. i'm not an expert on that. i don't cover it in the book. i'm sorry. but i try my best to makesure that people understand that we do a horrible jobin health care today on just

meeting people wherethey're at when it comes to end of life care. because it's notjust-- even though i call it end of life care,it's not end of life care. it's about good care. it's not about a good death. it's about good life. we're all going to die. i'm going to die some day.

and every good lifedeserves a good ending. so that's where iwant to meet people at and i know that's anunsatisfactory answer. i'm asked it all the time. and i try not todeflect it too much but i think it's complicated. i honor and respectpeople who debate with me about thisquestion because i think every patient has a story.

and i've been onthis book tour now for a few weeks andthere's a lot of pain and suffering out there. and it's patients butit's also family members and everybody deservesto have their voice. we're just hoping"the conversation" and the videos help everybodyhave a voice at the table. i really appreciate your time.