earth was kind enough to talk about the book how we die that changed my life in the early ninety's from being a busy surgeon a busy university community to suddenly being proclaimed an oracle on the subject of death which i didn't realize i had spent my life thinking about and actually planning to write this book until after i had written it and let me let me tell you what i mean i was born in an immigrant family and the legend of the family was about my grandfather and two uncles who came from a small village in what is now below us and who developed tuberculosis in the early twentieth century as so many immigrants did on the lower east side and died before my grandmother and the girls in the family could come over to one of those girls died in childbirth another those girls died in her thirties bright's disease i had a brother who was stillborn i had another brother who died at the age of three death without my really acknowledging it was in the legend and lore of my family and my mother died of colon cancer when i was eleven after a very prolonged course and i realized looking back on it obviously that this is what drove me to medicine it wasn't the fear of death it was having control over disease if all i were to become a doctor i could stop the disease that had decimated my family over the course of three actually three generations and so there i was light went into a surgical residency developed the usual busy surgical practice i'd been at it for about thirty five years and one day my secretary not one of the nurses my secretary walked into the examining room where i was just finishing up a physical examination of a new patient and she whispered in my ear secretary they never walk into examining rooms i'm not supposed to do that she whispered in my ear this is a phone call i think you'll want to take this and i said sidhu should from she said the magic words she said it's a literary agent i don't feel well i had written a book on the history of medicine and so i had a little bit of a taste of the writing life and how much fun it can be and i finished the examination i was actually near the very end i mean i was literally near the end i was at the end i was doing the fifth rectal exam so i slipped out and i slipped out of the room and i went to speak to this fellow on the phone who introduced himself to me and he said that he had an idea for a book an original idea and he had been speaking to some editors new york knew about some of the previous writing i'd done and then my name kept coming up and he said i thought i'd try what is the book to be about he said you know that there is no book lots of such books that was our first conversation he said will try me just over the next couple of days visit some libraries and i did i went to the el medical library nothing for students nothing for house officers or faculty and of course in the new haven public libraries it was the same thing so lo and behold there was we have nothing available and here we were near the beginning of the hospice movement near the beginning of the growth of bio ethics the beginning only the beginning of the awareness of how badly we treat people at the end of life and yet if you want to know what actually happens to someone with a longstanding malignancy there was no way to find out what that person feels what his or her doctors feel what they go through physically but also emotionally primarily physically though there wasn't any such thing so i took him up on it and i wrote this book took me exactly a year took me three i took three years leave of absence and it took me three hundred sixty five days i never spoke to him for the whole he had no idea what i was going to do with this book and neither did i but i found to my astonishment that the book wrote itself it came off the end of my eberhard faber two point five pencil i write on double line stationery i shouldn't say double on i write on every other line double line stationery is what they give you and hebrew school which is how i first learned to do that but i have one of these things you see it's close and now because i was working on the plane and i wrote it out that way and when it was published it was barely edited something in my unconscious mind had told me what i should write and when i came to the chapter on old age and this is a story i've told a number of times and i don't want ever to forget it i realized and remembered that for the first seventeen years of my life i had been living with a woman who was dying of old age she died at ninety seven my grandmother who we called bubba in the in the eastern european way and i watched that slow deterioration and i remember distinctly my wife was at home at that time i walked into the kitchen and i said you know i'm writing about old age and i want to write about my baba but who will care about oh four foot ten inch woman who couldn't speak word of english who had no idea what this culture was all about who can identify with such a person and she said three words to me she said don't censor yourself just write what you think needs to be written well i didn't think it was all again out of the unconscious and i wrote that chapter in the stylish ing thing happen after the book came out you know you get a lot of letters about a book and one of the letters came from man named jim barnes who described himself as a pig farmer in iowa and he wrote this in longhand he wrote this four page letter and at the end of it he said and l but most important thank you for your baba i knew her at a different time by a different name in a different place and suddenly i understood something what i understood was that the more personal one becomes in one's writing the more universal one is my own deepest an acknowledged thoughts that just poured out on the paper turned out to be so universal without my realizing it that this book has been translated into twenty nine languages now i keep the arabic and the hebrew edition next to each other on the shelf hoping i can bring about some kind of peace in that area hasn't worked very well thus far and and as many of you know that this book was was an extraordinary sensation because it really was true that here we were at the beginnings of our discussions of death and dying in the way we care for people and their spiritual needs and their physical needs and nobody knew how it happened doctors had to learn it by being at bedsides over and over and over again because nobody taught it in the classroom so after that of course i became absorbed with the topic and became active in a number of organisations and when i would visit a foreign country would you do when you when you write a book you know study the ways in which death was handled in those countries so differently in  every country in every culture and i had always been well not always but for about ten years involved in matters medical in china and i had an opportunity study it there now with this new focus and so i've spent all of these sixteen years since the publication of the book watching to see what effect all of the talking was having not just my talking picos you know there were many many many books after this point about death and dying about the compassionate care of the dying about emotional needs spiritual needs physical needs the needs of the family and when the book been out fifteen years my publisher alfred a knopf company contacted me and said you know it's been fifteen years  why don't you write a followup one of your i not a new book but a coda a new ending a new summary of what's going on now have things changed so i spent close to a  year visiting places that i had visited before talking to people i had met along the way physicians nurses hospice workers members of the clergy aids who i had run into and primarily though i was talking to people very much like myself younger than myself because almost everybody's younger than myself now a finding out what had happened primarily to medicine with all of the press from the general public all of the demand for compassionate care of the dying all of the need for knowledge what had happened in fifteen years in america and i wrote this code this final chapter this new summary and i want to tell you what my findings were and the findings turned out to be very very different from what i had gradually come to believe there was some things that were quite encouraging and some things that were very shocking after all the time past all of the enlightenment all of the new knowledge all of the seeming progress in medicine itself we seem to remain in this one area the area of how we die in a morass yes there have been dramatic changes yes there have been new ways of looking at the process of death and yes there have been more ways of teaching medical students and residents about it but in fact have we made progress and this is what i'd like to talk to you about this evening what are the improvements that have taken place or one of them i've just alluded to an increasing awareness and increasing sensitivity to our deficiencies and increasing attention in the minds of everyone that matters have to change well what have we done in teaching compassionate care to our medical students who after all all the first line of defense there have been a number of efforts some of which are very well known about and some of which are less well know about deliberate attempts to teach students compassionate care of the dying we have classes in compassionate care of the dying call that as a matter of fact in the first two years in just about every medical school in this country now there is whether it's a short seminar or semester's worth there will be a period of an hour a week set aside for this kind of teaching there are classes in what we call professional responsibility an attempt to bring to the students a feeling of the nobility of medicine the traditions of medicine the obligations of medicine to the community the sense that medicine is indeed not even a profession it is a calling and those of us who are fortunate enough to be called to it have to think of it as though we were called to the ministry and this is a lifelong ab absorption and we must be proud of that calling we've come to realize and our historians have taught us this really medicine is not a science medicine is an art that uses science as best as it can to heal not necessarily to cure but to heal and healing being a total body process the physician herself or himself is part of the healing process hippocrates knew this one of the great sayings in one of his it's not his actually there are a lot of people who wrote the hippocratic books but one of the great sayings is some times this is almost a direct quote sometimes a patient will recover simply because he is convinced of the goodness of the physician actually engaged in the project right now to study this concept of what the physicians actual morality and goodness have to do with how she or he can build be an effective healer so the cultural aspects out of which medicine springs must be taught nowadays if you look at a pre medical students curriculum for self more year or junior year there's almost no time whatsoever on that curriculum for a course in english literature or in history or in philosophy or of any of the background knowledge that used to be perfectly straightforward for liberal arts students in a college fifty years ago because the pre med requirements have become enormous largely because of the splitting of biology of chemistry into various fields and the kids feeling oh i won't get into medical school if i don't do physical chemistry and this kind of specialized organic chemistry and the quantitative analysis and some are rigid requirements and some of the kids take has they feel otherwise they'll be at a disadvantage they spend their summers working in professor x s lab or going off to nigeria to help take care of the sick there with the missions  medical missions that go and they never sit under a tree and read proust like some of the doctors in this room certainly did it is impossible for any person any individual to experience everything our culture has been through and this is why we read fiction because we learn what life is about from reading friction friction that's interesting that oh dr freud actually freud himself said this that his theories had a lot to do with his wide reading fiction this is how you learn about human nature but kids are learning about human nature and now they're learning about micro molecules so there is this intent to teach courses in medical humanities northwestern university in chicago the madison not the medicine it's the more cat campus of university of wisconsin has a program chair a department of medical humanities and these would seem to have been very helpful in rounding out medical students who have very little have had very little contact with humanities we give prizes to the most compassionate physician foundations give prizes to faculty members who are exemplary in caring for the sick caring for the d foundations do the same thing the foundation i belong to the hastings center which is a bioethics think tank it gives awards to a senior physician a junior physician and a house officer large amounts of money twenty five thousand dollars i myself have a feeling that these awards may be exercises in futility you're not going to be compassionate because someone tells you you might win a prize ten years down the pike you know i am one of these people who is convinced that you you learn your morality at your mother's knee and when medical students tell me oh i have two weeks free in the middle what do you suggest i should do because i teach undergraduates right now i don't actually even teach medical students anymore i say go home hang around your mother hang around your minister hang around the people that you learn from to be the person you're wal mart don't go to the bahamas and chase boys or girls or whatever you're chasing and certainly stay away from the professor's laboratory don't volunteer to help him at all and we teach classes in ethics that's another thing that we try to teach they are sometimes taught by card carrying ethicists and sometimes they're taught by doctors who have a particular interest in ethics we have many kids who volunteer in hospice as you know we have within ten miles of new haven america's first hospice t connecticut hospice in the good number of our medical students volunteer there follow after the nurses help out in the care of patients so those are the changes those are the kinds of progress that have occurred in these fifteen years in medical schools and among the doctors who teach medicine to students another great change has been the enormous mushroom ing of the palliative care in general obviously this was going on in one thousand nine hundred four when the book came out but it is much much larger today a great deal more attention is being paid to palliative care and doctors have established and the actual specialty board and and the american i think it's american academy of ford specialists or something supervises the exam now so people are important progress and then of course there's a growth of hospice i don't have to tell members of this audience about the great work of dr cicely saunders who started out as a social worker or allman they call him in england then became a nurse and then went to medical school became a physician and found that the two first hospices and london in one thousand nine hundred sixty seven in one nine hundred seventy four one of our own physicians at the  medical school actually the chairman of the irrelative department spent a year working with her came back and with members of the clergy members the yale medical faculty formed connecticut hospice and then hospice of course began to grow throughout the country there are now three thousand five hundred auspices not necessarily institutional hospices they may be outpatient facilities but whatever it is they are available and they are covered by medicare and we'll talk a little bit about that in a moment one third fully one third of dying americans use a hospice in one form or another before their eyes and that's a huge increase from what it was when this book was written a million people a year have been patients either as outpatients at the hospice facility or actually as in patients there so there have been these remarkable i think changes another piece of progress which was occurring already when this book came out in one nine hundred ninety four was the principle of advanced directives which i'm sure everybody here your with the patient self determination acted been passed by congress in nineteen ninety eight the patient self determination act allow us if a patient cannot make a decision for himself or herself for someone to be appointed a health care proxy or to have what's called by the lawyers durable power of attorney to make decisions for that patient then an additional factor an additional improvement has been the fact that virtually every hospital in this country now has an ethics committee ethics committees are charged with solving problems that have to do with ethical responsibilities of physicians of nurses of the administration of a hospital and the responsibilities of the hospital  physicians to the patients they consist by and large of what we call wise heads senior member or members of a hospital faculty of a hospital staff will always be a lawyer or two if they're lucky they've got some very good people from the clergy and there's a representative of the community so every hospital has such a thing and if any family or any patient feels that their personal human humane rights are being challenged or violated they can turn to the bioethics committee of any hospital for a judgment and then finally there's a factor that is vague but very very important and it grows out of some of the other things i've been saying for the past few minutes the whole idea of a return to the days of hippocratic ideal is you know western medicine was really started about three hundred fifty years before the common era by a group of physicians who somehow became known by the name of one of their leaders hippocrates and if a critic doctors introduced a number of new things they introduce the concept of physical examination they introduce the idea that one doesn't become sick because the gods are angry with you and you're not going to get better because the gods say yes now you should be better they said you get sick because of some natural thing going on the your body or the something out in that climate that is doing it to you or that maybe of bunch of insects who come flooding in and bite you these were all new ideas but they also in addition to everything else brought in this concept of the physicians morality and goodness and how the physician himself and of course in those days it was always himself by his very presence can instill in a patient the will to get better we now know with modern studies of placebos that the placebo effect is probably about a third of the effect of the real medicines we take the like the digitalis and the antibiotics and all of this about a third of it and when it comes to the drugs that influence mood disorders like depression it may be a lot more than that the new york review of books recently ran two articles by marcia angell who used to be editor of the wing and journal of medicine arguing that antidepressants for example are pharmacologically much less effective than we have thought and the actual reasons people get better have to do with that placebo effect and the passage of time so you know this becomes another interesting thing to conjure with but the real question and the good question that i started to attack when they contacted me and said you know we need another chapter bringing things up to date your question is has how we die in america really change in spite of all of the progress are we moving forward or are we standing still and i concluded after all the contacts i made the places i visited the people i spoke to although both sessions i had with colleagues that the french were right you remember their old saying  insurers the more things change the more things stay the same and i must tell you that for every one of the ameliorations and improvements i've just described there are reasons to worry there are reasons to worry about the present but perhaps even more so reasons that we have to worry about the future a lot of them have to do with the technology of medicine how it has grown enormously larger rhythmically and he way you can a mention in these past fifteen years but some of them have to do with other things as well when you look at a medical school curriculum i spoke earlier about all the changes we've had in the curriculum you realize that classroom exercises occur essentially only in the first two years then the kids get on the wards but the first two years there is time for classes t didactic work all other teaching after that is from observation from participation from going on rounds little seminars where people sit around discuss a topic or grand rounds were a major topic is discussed but actual classroom exercises occur only in the first two years or early markable thing happens at the beginning of the third year and this hasn't changed in sixty years students go on the wards it's a very exciting time it is breathlessly exciting and it turns out after looking at this whole picture that the classroom doesn't translate very well to the intensive care unit what people learn about humanities and ethics and responsibility to the values of the patient what they learned about the humanities disappears in the thrill of the chase in this book how we die i talked about what i call the riddle be exciting the riddle of diagnosis and therapy suddenly they give your white coat stethoscope and your doctor might come on we've got a feeling that is if you've ever flown a spitfire in combat which i never did i imagine it must be exactly like that in fact i always i always call the interne spitfire pilots and there are those messerschmitt you know up there the bacteria in there who knows one they're shooting them down and it's great fun and and most of their teachers are very young too because who teaches medical students the residents teach the medical students the junior attendings teach the residents you don't get a lot of gray hair on the wards you get young excited enthusiastic people taking care of the sick when often what is needed as you well know needed much more is wisdom is compassion buddhist principles yes but principles for all of us wisdom it's funny i'm going to digress for a moment i used to love it in my last years of practice when the patient would come in who had looked up their disease or their plans surgery on the internet and they had all sorts of knowledge about it well of course what they didn't have was knowledge they had information knowledge and information are two very different things information is facts and knowledge is facts in context so that they're completely understood wisdom has to do with judgment how you use your knowledge and it has largely to do with what's inside you your life experience and clearly you have to have knowledge and experience you have wisdom those are prerequisites but that is far more to it than that patient somehow think that if they can google a damn thing for you why do i have to pay twenty five dollars twenty five tell us oh yeah you know what i mean for a consultation when i shouldn't have to do that so that the classroom doesn't translate well to the realities of the bedside and perfectly honestly it has not been my impression as i see these young people on the wards or people teaching them that what we have attempted to gradually soak into their psyches has stayed there it has dried up in the excitement of the new liquid in which they've submerge themselves the liquid of of salvaging a life because that's what it's all about it's all about heuer and it isn't about care and those are two very very different things so we have the fact that the classes have to be in the first and second year because the kids don't have time to come off the wards and sit down and talk about tolstoy they just they just can't do it or talk about ethics what about the great influence of the hospice movement and the  movement in two thousand and ten when i finished my survey and just before that last chapter was published in the new edition of how we die there were one thousand three hundred men and women who had passed their specialty boards in palliative care one thousand three hundred people you know how many dermatologists there are all eight thousand five hundred it's a shocking figure there are seven hundred thousand doctors in america and all of those only thirteen hundred are boarded  statistically there is one for every three hospices in this country so many of the outpatient facilities for hospice are not in any way supervised or involved with physicians except the patients individual physicians who may have different ways of looking at things which actually i'll talk about in a moment i talked about the fact that there is a medic here provision for patients who go into hospice hospice had a care will pay for hospice care but if you look at the law it gets a little scary because there are certain provisions that come along with it the physician must certify that the patient has less than six months to live i don't know too many physicians who are willing to pr way who are willing six months before death to say this person has less than six months to live there's also this very difficult psychological problem of a patient going into a hospice six months or five months or seven months before this almost arbitrary date how do you start that conversation how do you six months before death have someone face the reality that the rest of treatment is futile you just you just can't do that another provision for hospice care is that each patient admitted to a hospice unit must have a primary caregiver you have no many no idea how many people over the age of sixty five live isolated lives sociologists have written about this problem nobody to take care of them there is no full time caregiver for many many many americans who would be eligible for hospice and the other snare in all of this is that if the patient goes into a hospice unit he or she must from then on refuse any therapeutic care so the patient must agree from now on in no attempts at their a p will be tried well there's therapy in this therapy those there be in the attempt to cure disease but this therapy also in an attempt to relieve symptoms the classic example is people with a deposit in a bone where dose of x ray will solve the pain problem for example which can't do that there has been well one very recent article knowing the journal of medicine there been several other articles indicating that for lung cancer patients if you give therapeutic care on hospice care at the same time the patients live a little longer but that's not the issue they live better they live more comfortably and they live in a state of much better echoing the miti than they had before but if you have medicare covering your hospice can't you can't do that so there are all of these problems i talked about the physicians themselves i wrote about a problem and how we don't it hasn't changed one bit as far as i can tell the tremendous reluctance of many many physicians to recommend that patients take on hospice care i think one third of americans is not a lot it sounds good when you compare it to fifteen years ago but it really isn't isn't a lot and that isn't enough doctors have different motivations for this we tend as many of you know to be a little power hungry we don't like to give up control of a patient some of us i'm afraid actually think in financial terms about control of a patient but for most of us it's something else you don't want to turn a patient over to somebody else because you feel a sense of responsibility but more importantly you have this oath already and that's one of the reasons that there are physicians in every community in america who refuse to refer patients to hospice now i talked about advanced directives patients can decide if i have to be integrated do i want to be intubated if i'm on a life sustaining drugs without which i would die do i do i want to keep that up well that's fine and you can go to your lawyers office and write out your advance directives you can do it when you come into the hospital this is been known since the law was passed hundred two one quarter of americans have taken advantage of that's all just one quarter of americans so if fance directives haven't helped an awful lot plus there how many times have i seen or heard of doctors who refuse to obey a patient's advanced directives who say but this is a mistake this person didn't understand what we can do now and they continue the treatment or the other thing the great nancy from dubuque story you know we write about families the family this the family that the family is not a monolith the family consists of a bunch of people and they all have ideas so mom's in the hospital and she's got advanced directives that she doesn't want to be on a respirator and joe with whom she lives her son joe says ok that's fine here daughter mary who lives in the next town says that's what we're going to do that mom and i talked about this and just as they're about to stop the respirator in flies nancy from dubuque and she hasn't talked to her mother since three christmases ago and she's feeling dreadfully guilty and nonono we have to do everything  directives so there are problems with every one of these bits of progress what about ethics committees they want to be able to decide everything when advance directives come up when a doctor says i won't follow them you're going to the i think committee and they say there it is you've got to follow it and since the doctors on such committees tend to have a lot of gray hair people say whoa yes really wisdom is here will do what they say well i love talking to families who come to me and cause a lot do and say this happened or that happened i said well did you did you ever go to the ethics committee or you can go to the ethics committee you know and most of the time the response is what's an ethics committee most people don't know hospitals have ethics committees it's an amazing phenomena so that hasn't been much help either so who consults them very often it's doctors who've made up their minds about something and just simply want a group of senior people to say yes this is the right thing to do so they provide consent who are on these ethics committees do they have any training do they understand ethical dilemmas that have been written about in the bioethics literature or do they know the precedence to the cases they're talking about who knows some hospitals yes some hospitals no and then there's this other thing that has come up which is hospital government and insurance regulations this kind of thing didn't go on fifteen years ago do you know they did ministre toure's make rounds on every patient in the hospital a check every chart and they do it to make sure that every insurance requirement has been filled out so the hospital gets its money these are administrators who as a colleague said to me one day when we were talking about this problem they don't know who we are they don't know who the doctors are they don't know how doctors think about disease they don't know how nurses think about disease they don't know how ministers pastoral care workers think about this sees they're just they're trying to make sure patients are gotten out of the hospital as soon as possible then there's this other bugaboo called best practices which you read about in the newspapers well but i don't want to take all night talking about best practices but they are derived in very questionable ways to remember each individual is a distinct human being with a distinct set of problems the average medicare patient before he dies or she dies will have five major diagnoses they have prostate cancer they may have chronic lung disease they may have congestive heart failure they may have dementia and best practices are derived by studying patients who have one disease so that nothing contaminates and so there they tend to be unrealistic so many doctors have gotten involved in the his membership in the american college of surgeons as is behind his m b a you go into a big group practice and one of the doctors in the group has gotten an m b a doctors are busier than ever filling out insurance requirements  average length of visit as many of read is between seven and twelve minutes and in a doctor's office very often the doctor doesn't look up from her computer because she's so busy entering the material  how can people understand sick patients and then there are other rules and regulations but first let me quote a very senior faculty member at a major university center in a city other than my own quote much of the reconfiguration of health care has been hijacked by economic needs he's a doctor so famous for writing as a matter of fact that everybody here with know its name if i told you what it is some years ago a young woman named libby zion was admitted to the new york hospital by an intern at night and she was in a delirium a lot of other things were wrong with her and they gave her some sedatives because she was being quite wild and she never bothered to say she had taken cocaine very recently in fact she denied taking cocaine and she died and the hospital it was accused  not properly supervising its residents the residents work too many hours so in america now residents the people who really care for you with the minutes can only work eighty hours a week the that's a lot you may think it's a lot in the days when doctors were giants we used to work one hundred twenty hours week and you know why because a disease does not stay as it presents itself in the emergency room it changes hour by hour by hour by hour and during your training years you must just watch that disease develop you've got to watch it evolve to know exactly how to treat it you've got to watch it evolve so you wonder stand the patient who has it and you've got to watch it evolve so you can give proper treatment doctors have young doctors have become what one of my colleagues calls shift workers so this very little continuity of  care to add to that there are thirty thousand doctorates in this country who are called hospitalists so when you're admitted to a hospital your doctor who has known you in your value system and what you want at the end of life can't take care of you are assigned to a hospitalist who doesn't know you one of my friends who is a senior yell faculty member fell down got a concussion slashed the side of his face open broke facial bone and when i visited him on third day he had been seen by somewhere between five and seven doctors not his own and he didn't know the name of a single one of them so what about patients who are dying what about patients for whom the most valuable thing a doctor can give them is understanding and compassion by knowing their values by knowing their religious beliefs by knowing the way they relate to their families help them make decisions at the end of life it doesn't anymore exist young doctors are taught to treat by algorithms now patient has this symptom he gets this diagnostic test if it's positive he gets this diagnostic test if that's positive he gets this therapy the notion of judgment the notion of individual is ation the notion of putting hands on a bell watch television every doctor you see examining a patient with a stethoscope examines through the shirt just watch they never lift up the shirt to put the stethoscope on the skin but when that stethoscope was invented it was about a foot long it could be divided into and put it in your head band there is a lot of controversy about it one of the controversies was some people understood the metaphor they understood the symbolism and they were actually writing this is the first thing we've ever had in medicine that physically separates us from beijing and you watch this it's going to change we will be separated from patients and lo and behold that is what has happened with modern technology that's essentially it and it's gotten worse and worse and worse a new generation of doctors is being raised under such constraints suffocated by the man's being made of them the demands for objectivity the demands for for measurement that demands for calculation we live today in the age of the image as you well know the age of the laboratory the age of cost constraints empathy or autonomy caring simple unhurried kindness is not measurable and it is lost and it is lost own deaths what sort of psychological spiritual moral hope can they look too well in the book how we die i have a list of ways in which hope can be shared with people who are dying but since that book came out i read disturbing the peace by vaclav havel these were interviews made shortly after he came out of prison and he wrote a wonderful thing about hope that applies specifically to the case at the end of life and i want to read it to you as he rode in his book hope is not prognostication it's not a prediction it's an orientation of the spirit and orientation of the heart it transcends the world that is immediately experienced and it's anchored somewhere beyond its horizons hope in this deep in powerful sense is not the same as joy that things are going well or willingness to invest in enterprises that are obviously headed for success but rather an ability to work for something because it is good not because it stands a chance to succeed the more unpropitious the situation in which we demonstrate hope the deeper that hope is hope is definitely not the same thing as optimism it is not the conviction that something will turn out well but the certainty that something makes sense regardless of how it turns out in short i think that the deepest most important form of hope the only one that can keep us above water and urge us to good works and the only true source of the breathtaking dimension of the human spirit  efforts is something we get as it were from elsewhere elsewhere there is hope for the dying i believe in ho words this is an extra dimension of the human spirit and it has to do with our sense of the immortality in the sense that the memory of what we are and of what we stood for and of our values to those relief behind us our aim is to avoid the inevitability of the kind of death that's forced on us still in modern hospitals even though there are economic biotechnological forces that would have it otherwise we must resist sometimes we must resist forcefully and i have a few suggestions and one of these came up at this fascinating dinner that several of us had accompanies at a funeral the way it works out is a hearse will pull up six friends of the departed will carry the coffin to the grave site a distance perhaps sometimes as long as a fifth of a mile that is the accompan my argument is that when it becomes clear that there is death on the horizon that is when we as physicians as nurses as clergy as aid workers should begin to accompany the dying to the last moments that is when we should begin the discussion about what the end of life or in fact individual that unique individual must be it cannot wait for the last two or three weeks or two or three days you know most hospice patients are admitted within three to four weeks of dying that some of them are admitted the night before there is no will of there is no accompaniment there is no chance for people who are taking care of that during those last few moments to get to know them at all to know their value systems of their family value system so that's one thing that we must think about doing we must restore the pastoral aspects of medicine those hippocratic values that tell us that all of our patients are our moral and not just professional responsibility again as i said earlier that this is a calling and that death itself obviously is not a disease and it should not be medicalized there is a point when the function of the physician is as counsellor as pastor in addition to the other obvious pastoral help that is coming along we have to restore the pastoral aspects we have to restore that hippocratic philosophy there's a wonderful quote in one of his books it's called ethics where love of mankind is the result so love of the art they called medicine the art and they knew then that it was an art and we should remember now it is an art we need far more family physicians than we have and it is absolutely necessary to quantify medical income so that family physicians are not earning we need an up and down study of the american medical system the american medical education system and it has to be done by a large group of people and we must teach our medical students that they have to emphasize care as least as much as they emphasize cure and it is incumbent on those who do the study who do the study of american medicine to recognize what the old hippocratic physicians used as some of their values including the value of predicting as long before hand this one possibly can to recognize when death is imminent or at least on the horizon at that point to recognize also that death is not a disease and that death is not a matter and dodging is not a medical condition and once that is realized and accepted to continue to increase the way they nurture the patient and nurture the family and in this way to nurture ourselves because the real secret of healing is in the nurture thank you very much