The Language of Serious Illness: A Podcast with Sunita Puri, Bob Arnold, and Jacqueline Kruser

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are delighted to welcome Jacky Kruser, who’s a pulmonary critical care doctor and health services researcher at the University of Wisconsin.

Welcome to the GeriPal podcast.

Jacky: Thank you. It’s a pleasure.

Alex: And we’re delighted to welcome back Bob Arnold, who is a palliative care doctor, VitalTalk co-founder. He’s at the University of Pittsburgh. Bob, welcome back to GeriPal.

Bob: Great to be here.

Alex: Bob’s a little low energy today I could tell. [laughter[

Bob: It’s your shirt. [laughter]

Alex: It’s my shirt?

Bob: The fish.

Alex: You have to be calm in reaction to my loud aloha shirt?

And Sunita Puri, who is an author and palliative care fellowship director at the University of Massachusetts Chan School of Medicine. Welcome back to GeriPal, Sunita.

Sunita: Thanks so much for having me. It’s great to be with you both.

Eric: So this is a second of three podcasts on communication. The first one we published last week on miscommunication. This one’s going to be on the language of life-sustaining treatment. And then next week we will be talking about surgical communication around similar topics. So before we get into that, we always start off a song request. Sunita, I think you got a song request for Alex.

Sunita: Yes. So I requested Alex to play Meet Me in the Woods by Lord Huron. Because, to me, when I think about what it’s like for people to go through a serious illness or what it’s like for us as providers to guide people through a serious illness, it’s often like being in the woods where we have to ask people to meet us where we are sometimes filled with uncertainty and they are filled with uncertainty and the path ahead is too. But somehow, I think no matter what the outcome, we always find a way through the dark.

Eric: Now I’ve got a really important question for you.

Sunita: Yes.

Eric: This was not your first song request, was it?

Sunita: No, it was not. [laughter]

Eric: I love, by the way, the wonderful reason why you chose that song. So I’m super excited to hear it. But what was your original song request?

Sunita: I believe my request was California Love, which has nothing to do with the topic of this podcast, but it’s selfishly something that I thought would be fun to open this podcast with.

Alex: And maybe next time we’ll do that. But learning Tupac on guitar and then all those lyrics, it’s a lot. But when we’re recording three podcasts this week. But next time, maybe we’ll try. Maybe, no promises, maybe.

Sunita: Honestly, I’d be happy to provide the vocals. I’m very well versed. [laughter]

Alex: Great. All right. Here’s a little bit.

(Singing)

Eric: That was wonderful. Excellent song selection, Sunita. So I’m going to start off with you. It’s the double questions now. You recently published an article in the New Yorker titled, I can’t even read my own, what was the title again? I can’t read my own handwriting today.

Sunita: It happens to me all the time.

Eric: The Hidden Harms of CPR.

Sunita: There we go. Yes.

Eric: You’ve done a lot, you’re a prolific author. You’ve written in a lot of places, including your own books. What prompted you to write this piece in the New Yorker?

Sunita: So I think, as I wrote about in the piece, I’ve always felt like when I look back on my training, and this is not, by the way, I just want to be clear. Eric and Alex trained me very well. This was before my rotation with Eric and Alex, but I felt like I just didn’t have a good way of helping people think about serious decisions when it came to what was most important for them, but also what we would recommend. I felt like I was always told to present people with a buffet of options and, really, without guidance, ask them to choose, which is, it would always make me feel sick to my stomach. And I described a code that I led as a senior resident. And what I talked about in that scene in the piece is just how I knew that this man was going to die of his disease, which was metastatic cancer that had led to multisystem organ failure.

And yet I still offered CPR to his wife as though it were a choice between life and death, when I think everybody knew that there was nothing reversible happening. And so a cardiac arrest was the natural and inevitable outcome of what was happening to him. And I led the code, and we could not save his life. And I went and vomited in the bathroom afterwards, sickened not only by what I had seen happen, what I had done to this man, but also by my own shame of not being able to have a real discussion with his wife about what it would mean if his heart stopped. Not the theoretical potential for his heart to stop, but that actually the significance of that would be the end of his life. And I have gone through my not-so-long career, but it’s coming up on nine years now, seeing the way that we have talked about CPR in such problematic ways, in ways that really do not enable true informed consent.

And I’ve noticed how we can say things like, you’re not a surgical candidate or you’re too weak to get more chemotherapy, but we can never really talk about CPR as a medical procedure in the ways we talk about other procedures and can make recommendations and offer reasoning about those procedures. And I think when COVID started, I was in a number of meetings about how we were going to think about CPR from this point forward, given that it was would really expose healthcare workers to easy transmission of this virus that we didn’t fully understand yet.

And all of a sudden I was seeing reasoning pop up around limiting or reconsidering how we offer or talk about CPR based on things that we’ve always known, like its low likelihood of benefit in end-stage ARDS, which is what we were seeing. But we’ve always known that, and it took COVID to really bring some of that to the forefront. And so at the time, what I was really interested in is how will COVID change the way we talk about CPR because it is bringing forward truths we’ve always known, and that’s where the genesis of the piece came.

Eric: And can you tell me about Ernesto?

Sunita: Yes. So I first want to just say thank you to Ernesto’s family. I try to send them any interviews I do, but I always really want to acknowledge that they gave me permission to write about their struggle and to write about his and to use his name. So I just want to acknowledge them for letting me do that. He was someone who, like many people I took care of early in the pandemic, I never heard his voice. I very rarely went to see him because the unit was locked to basically everyone but the unit staff. And I met with his family over Zoom, which was how many of us had to meet with families during that time. And he very quickly decompensated after getting sick, and was intubated, and sent to the ICU. And this is someone who had taken very good care of himself, who had recently retired, who his wife said was just meticulous about his medications.

He wanted to enjoy his retirement with his grandchildren to the fullest. And then he got sick a month and a half later, and they had not had any discussions about what he would want because he’d always pretty much been well. And so in the series of conversations that I had with his family over Zoom over several weeks, the challenge was to help them understand how this virus had made him so sick, had basically made his lungs irretrievably sick by that point, and what it would mean to define what we could do for him, but also what was potentially things that would only extend his death rather than bring him back to a quality of life that he would value.

We were doing a lot of this without a whole lot of guidance, as is common, I think, from family, because all they knew was who he was. They didn’t know what he would want if he were sick. And so there was a lot of fumbling around in the dark trying to guide and support them while also really trying to make recommendations that would in some ways organize a conversation better than having questions like, Would he want us to do this? But rather, if this is what you’re telling me his life, this is how he inhabited his life, this is what he would want to go back to. Then this or that procedure may not make sense for him.

Eric: Yeah. And in your piece, you also talked about a couple of instances of working with residents in their own training. I think one of the residents you asked how would they broach a subject, and he said wording like, “Unfortunately, he still needs a ventilator.” You talk about this too, even in your own training, where even around CPR, the training is like he might need a ventilator if he couldn’t protect his airway. And I wonder, because I read that need part a lot in this article. We’ll talk about “want”, too, because I heard “want” also. But I’m going to turn it over to Jacky.

Jacky, first, did you have a chance to read Sunita’s article because it was fabulous? When you see that and you just wrote a wonderful first author piece in JAMA on Reconsidering the Language of Serious Illness, what’s the red flag for you when you see that need word?

Jacky: Yeah, I think as we started having conversations about this paper and building out our understanding about the problems of need, one of the things we started with, we were really concerned about the idea we didn’t want to say, oh, this is a bad word. We need to strike it from our vocabulary and leave sort of a gap in the clinical vernacular about how we talk about life-sustaining treatment. And I think from very early on, and I think some of this is because of our co-author, who’s a linguistic anthropologist, really taught us to think carefully about why it just rolls off our tongues in the intensive care unit. Why it’s such a natural way to explain the condition of someone with an acute critical illness that’s threatening their life.

Eric: Why is it?

Jacky: And it is because someone is coming in with a lack of something essential. That is what we do in the ICU. And we’ve done a couple of studies where we’ve looked about why people write why someone’s coming to the intensive care unit, and we talk about this on rounds, what’s their indication for ICU? And it’s always centered on a need for a particular life-sustaining treatment. And one of the things we started to worry about as we were formulating our plan for this paper is this intervention focused, sort of the primacy of the intervention, and talking about life-sustaining treatment and CPR as sort of the focus of the conversation instead of what it means to have a life-threatening illness or to be faced with an acute condition from which you might die and from which we’re worried you could die from. And it is that link, that sort of inextricable link between the life-threatening problem and the solutions that we have, which just continue to grow.

And our technology in an ICU, it feels like it has almost no balance these days. It continues to improve. And so we link the life-threatening problem with its solution. And we think that that word need is doing a lot of the linking. And so when we came up with our particular sort of alternative phrasing, instead of just taking need out of the vocabulary, we really wanted to think about how we could create space in that rapid urgent environment where there’s often not a lot of time for conversations, but what is a clear way where we can create space, either true time and space or just space for deliberation quickly? And that’s really where we wanted to focus the paper on this idea of what does it mean to be faced with a life-threatening illness.

Alex: Before Eric asks the next question. That anthropologist you mentioned, I think he’s joining us on our next podcast. Is that Justin Clapp?

Jacky: That’s right.

Alex: Yeah, from Hopkins, is it? Yeah.

Jacky: He’s at the University of Pennsylvania.

Alex: Oh, University of Pennsylvania. Great. So he’s joining us on our next podcast. So listen for that, dear listeners. And that’ll be with Justin and Gretchen Schwarze about communication and surgery. Should I bring Bob into it?

Eric: Yeah.

Alex: Bob, I can tell you’ve been writing, you have things to say or questions to ask. Hit it, Bob. Oh, are you muted? We can’t hear you.

Bob: I haven’t been quiet for six whole minutes, probably since Jacky has met me. So first, let me point out, there’s a long history. James Tulsky did a study in the late 80s looking at how residents at UCSF talked about code status, where the paradigmatic way was, if your heart stops, do you want us to resuscitate it? 20 years later, Wendy Anderson did exactly the same study and found that residents at UCSF used exactly the same language.

Alex: Wait, what’s the linkage here?

Bob: We haven’t done a good job of teaching people how to think about these conversations. The problem is I think that we are so scared of our power as clinicians and we’ve been so taught that we need to respect autonomy that we leave people, as Sunita pointed out, lost in the woods. No one wants CPR, I’ve been a doctor as long as all of you put together. I have never had a patient come into the hospital and say, Doctor, regardless of what you do, do a little CPR that’ll make me feel better. The problem is that we’ve reified CPR, and we’ve been afraid to give our opinion based on where people want to end up. And so having a conversation about what’s important, telling people how often it works, and then making a recommendation are all okay things for doctors to do. And the problem is that we’ve stopped teaching doctors how to say, given what’s most important, here’s what makes sense and here’s what probably doesn’t make sense.

Alex: Were doctors ever good at that?

Bob: No, because the problem was before autonomy, doctors told people what to do based on their own values. Now doctors are unwilling to understand patients’ values and make recommendations, taking the science to it. So they act like bad waiters. They’re like, they just offer options without context. And given that the culture of medicine is always to do more, the context will always push people to try something.

Eric: Well, I guess given that, how much, would love your thoughts too on this, Sunita, with your New Yorker article, how much is this, us verifying CPR versus we see the same conversations with intubation while you acknowledge that with dialysis, sometimes we say no? I would say most of the time we offer CRT in the hospital. So there’s all these life-sustaining treatments that we may just give as menu options. Do you want it? And if somebody chooses and we think it’s a bad idea, we get moral distress, we wonder why they chose it. But we gave it as an option.

Sunita: I know. Yep. I point this out a lot more nowadays to the resident teams that consult. If the consult is for “code status,” I always ask them, take a look at your past conversations. You’ve had three documented conversations to “clarify code status.” What you’re asking me to do at this point is to make the family choose what you think is right because you know at some level that, from the beginning, a code didn’t make sense for them. And yet, it’s so hard to be able to draw a boundary. And I think there’s a lot of symbolic and fantastical value around CPR.

We think it’s like the pinnacle of medical heroism. It’s such a physical act, showing just how strong doctor’s moral resolve is to save a life. And it just has because of the media and because of the life it’s been given in that way, we can’t talk about it the way we talk about intubation in a way because what people envision as CPR being indicative of is different than what people envision intubation being indicative of. In the same way that no one’s going to fight you or no one’s going to say, yes, do that colonoscopy because George Clooney did it on ER.

And that person came back to life. And I think our own fantasies of lifesaving play into that as well. I really think that doing CPR, whether it’s indicated or futile, is part of a rite of passage in a way for physicians. And we have to do it enough to realize that we are taking away somebody’s sacred right to have a say in how they die, simply because we are offering something. And when we offer something, people hear it will have benefits. And if we don’t explicate otherwise or we don’t say, what is the benefit you’re looking for and say whether or not this procedure or something else will fulfill that, then we’re really not getting informed consent. And I think a lot of that leads to extreme moral distress. At least it did for me and for colleagues of mine who were like, “I don’t know that I want to be a doctor anymore after doing this to somebody.”

Jacky: One of the ways we start, when I think about this need problem that a lot of doctors use it as a headline, which we know from Bob, thank you, that that’s a great best practice in communication is to provide a headline. But then what ends up happening is that headline, it creates an implicit indication that we think doing CPR or intubation is what should be done. And then we spend the rest of the conversation trying to-

Eric: That’s because they need it. The headline is that they need CPR.

Jacky: The headline that, What would you like us to do if your mom needs to be intubated? For example. And then we think we’re going to create space for deliberation after that type of headline. But when the emotions are running high and people perhaps can’t, we think that they’re following us. But then we get to the end of the conversation, and it ends in conflict. And I think if we take a step back, perhaps it’s not surprising that sometimes this problem is posed as the clinicians want one thing and the family wants another thing. And why are we at odds? Because I think no one wants a harmful, ineffective procedure for their loved one, and no clinician wants to provide, I don’t think a harmful, ineffective procedure. So it doesn’t make sense, sort of, why are we at odds here? And that’s why, I think, thinking about these words, they’re unintentional and they’re latent in their effect, but they’re so pervasive that it’s important.

Eric: Well, Jacky, let me ask you this. You work in the ICU, right? How often do you feel like, oh, this is ineffectual; it will not happen? It just will not result in what they’re hoping for maybe life extension versus it’s kind of low. Maybe there’s a one-in-1,000 chance it would work.

Alex: So you’re saying there’s a chance.

Eric: From dumb and dumber, so you’re saying there’s a chance. And if we only pose it as the low chance of success, why not? If the alternative is my loved one is dead, why not do this one in a million chance even that this thing could bring him back?

Jacky: Right. I think to answer your first question, it’s easy in the ICU to get swept up in the physiologic effectiveness of our treatments. It’s really easy to feel like you’re doing something important because we have a lot of tools at our disposal to change numbers to support physiology. And it’s harder to take a step back and question, but I think it is true. The more experience I get, the less helpful I find, or the more helpful, I guess I’ll frame it in a different way, is acknowledging the uncertainty at hand and framing conversations with the range of expected outcomes instead of the sort of dismal outcomes of one particular intervention per se. And I guess the other thing, I’m a little hesitant to bring this up, but as the token ICU doctor in the room, I just want to sort of put in a plug.

We know from epidemiologic data that for people who die in the ICU, which again is a subset of the population we’re talking about, it’s only a small number that receive CPR at the end of life. So I think we’ve looked at, I think it was a collaborative of 68 ICUs, and about 10% of people who died in the ICU received CPR in the last hour of life. And there was a study across Europe that showed it was maybe even lower, around 6%. So I just do want to provide a little bit of context, that I think for many, there are probably many reasons. Most patients who die in the ICU do not receive CPR at the end of life. So that’s the one plug, I’ll say.

Alex: Bob used the hand raise feature in Zoom, which is the first time in almost 300 podcasts that that has happened, which is awesome.

Eric: Or that we noticed it.

Alex: Right. Bob, take it away.

Bob: I just want to point out there’s a difference between one in a million and the fact that on television, CPR works about 70% of the time. And so patients think it works about 70% of the time. There’s a study from the group in Denver, in the VA, that shows just being more honest about how often it really does work changes veterans’ preference about CPR. Second, Doug White’s done really amazing work that shows that patients and families get that we are not able to read the future.

So when a patient says to me, isn’t there a chance? I’ll first say that’s the hardest question for doctors because we’re always predicting or guessing about the future. I can tell you what our opinion is and why we have that opinion. And yet, if your dad was the kind of guy who would go for a one-in-a-million chance, let me tell you what he’d have to go through to have that chance. I’m okay with people doing that. I’m okay with people spending time in LTACs. I’m merely a experienced travel guide who really should let them understand the path and the journey that they can go on. So I think the problem is we don’t do a minimally decent job of helping people understand that journey.

Eric: And I love that, Bob, because it just reminds me of, again, we’ll have Gretchen Schwarze on next week to talk about surgical communication, but the focus of best-case, worst-case scenario, which fundamentally to me is about telling a story. Telling a story of what the best case looks like, telling a story of what the worst case looks like. And what I’m hearing from you, and correct me if I’m wrong, potentially more important than the numbers, which are really hard to quantify at times. Is that you are talking about what the journey would look like. Is that right?

Bob: Yeah. It seems to me that one is I need to talk about what the journey would look like, and two, I need to be quiet and hear and build with them a story of what’s most important for your life or your loved one’s life as we think about the future given what we know about them.

Eric: Sunita, I got a question for you. You started off this podcast talking about a really bad situation as a resident where you felt extreme moral distress.

Sunita: Yes.

Eric: What do you think, I know it’s impossible to ask this question, but would you still have that same level of moral distress if you knew what you knew now how to have these conversations? You talked about what’s important to them, what they’re hoping for, what outcomes really they’re hoping for; make it to their granddaughter’s birth in three months, and that they would be willing to go through a tremendous amount even if there is a small chance of survival, even if it meant prolonged stay in an ICU and an LTAC. If I can hold onto that hope to making my granddaughter’s birth, that would be important to me. Would you have that same level of moral distress if they made that choice?

Sunita: No, because I think the thing that really got to me and what I see residents, and fellows, and even other attendings struggling with is enabling true informed consent. And I think that comes out of what Bob just described, which is talking about what we know, hearing what people are hoping for, and while acknowledging the mystery and uncertainty of what’s yet to come, helping them to feel heard, but also asking them to hear us during the journey if we have to share some difficult truths about whether or not getting there is going to be possible. Because I think that’s the other thing I’ve learned and didn’t know as much as a resident is that a conversation about something like this is never a one and done. We start at one place, point A, and let’s say point B is the place they want to get to for the birth of their grandchild or wedding. Between A and B is the dark interval, which is, to me, the most fascinating part of being on a journey with someone and helping them with decision-making is that we don’t know what’s going to happen.

I know where you want to go, and I know where you are now. We should be probably checking in weekly to make sure this conversation is ongoing because that way as things change, we can reframe what you might be hoping for and reframe the ways we may be able to help you endure what’s happening to get to point B. But I think what I didn’t know was that when somebody makes a decision to get to a certain event that the work isn’t done then. And I see, I mean, I did this myself, so I’ll put myself on the hook here that I just didn’t have a sense for the longitudinal relationship that we need to build with people. And oftentimes in palliative care, we’re the constant presence when the other teams are rotating, when the other attendings on teams, when the residents are rotating. So we can help be the through line and understand and help people understand that wanting something doesn’t necessarily mean it’s going to happen, but we can keep reframing what we want and what we hope for as the body shows us what it can endure.

And I think that’s the other piece of this that I didn’t know as a resident how to express was that we can hope and want for so much, but really we have to know how to interpret what the body is trying to tell us. And the image I’ll often use, which the listeners aren’t going to be able to see this, but at least all of you will, kind of have the treatments that we’re offering to help people get to point B. And then there’s the body. And if this happens, if my two palms interlink, that means the treatment, the body’s able to accept the treatment to advance in some direction.

But if we are at a standstill, then that’s the body showing something too. And I think tracing biology as well as goals is something I just didn’t have any appreciation for when I was a trainee. And it’s become much more, it’s come much to the forefront of my mind in the past few years than it has before, as an accompaniment to what people are hoping for in their lives, but also recognizing that we have a thousand tricks in medicine, but ultimately medicine can never win against nature. And I think that’s a part of what we have to help people come to an understanding of. I think that’s part of our responsibility.

Alex: And it’s a beautiful analogy and metaphor, and I’m glad that you described it for our listeners. So you got that when the body and the goals are aligned, then the fingers are sort of interleaved with each other. And then, as Sunita was gesturing with her hands when they are not, when the hands are sort of in opposition to each other as if the body is creating a barrier. I’m just trying to explain it a little bit more. Hopefully, our listeners-

Sunita: I just go off on tangents, so I’m glad-

Alex: If our listeners are confused, go to YouTube and watch the YouTube version, and then you can see what Sunita was doing with her hands. But Sunita, I just want to say it’s a beautiful description, and I love hearing your journey as you’ve thought through this and worked through these concepts. And I worry, I’m not sure that appealing to, we haven’t engaged in complete informed consent if we haven’t done this. I’m just not sure that informed consent is the right bioethics principle here, because it’s so patient-centered, focused in that it’s does the patient have the information and then have they consented? And that, there seems to be sort of an evolution and thinking around this and a shift more towards a shared decision-making principle. Just wonder if you have any quick reactions to that before we move to Bob, who I think has something to say.

Sunita: Oh, yeah. I mean, I think that the way, when I think about informed consent, I think about it as a fluid process between the provider and the patient. So I think consenting to a course of treatment involves that two-way conversation. So in my mind, I think of it as shared decision-making. I’m probably just using a term that’s a little more archaic or based solely on autonomy rather than the interplay between autonomy, beneficence, and nonmaleficence. And I think those three ethical principles really come to constitute shared decision-making.

Jacky: One of the ways that I started to think about this the more I practiced in the intensive care unit was some of the inadequacies of the shared decision-making and informed consent constructs in that they focus on individual decisions and sort of these individual moments of disarticulated intervention-focused decisions. And what we see in the ICU, and I think it’s true for many patients with sort of chronic complex medical conditions, is that this is, and to Sunita’s point that she brought up earlier, that this is a longitudinal dynamic context that changes, and it feels like there are sort of minor decision points that accumulate along the way, but sometimes those can be distracting. And so if we sort of overly focus on individual decisions, we lose track of that longitudinal context that Sunita was so nicely demonstrating with this pathway and this notion of walking through the woods. And I think one way that has really captured the imagination in critical care is the notion of a time-limited trial.

Where I think in its best application sort of counters the problem of nihilism in critical care where people may presuppose or overly pessimistically prognosticate about the likelihood of a patient to benefit from ICU care or apply sort of stereotypical principles around age, about who should or shouldn’t be admitted to an ICU, or we don’t leave care open-ended and imply unintentionally through need statements and want statements that the context is open-ended, and perhaps I think what we’re working on is whether this might be a new path forward with some structure that balances those two problems.

Bob: I think as a travel guide, I need to know that there’s way more than science and bodies. They are existential in religious beliefs. So even if this isn’t working, the sciencing isn’t working on the body. There are many patients who believe and their families who believe that something else will work on the body, and we need to walk with them with beliefs that aren’t in our normal wheelhouse as a doctor. To a certain extent, we need to be more expansive in how we think of ourself as clinicians, where we’re walking with people, we’re letting them talk to us about their hopes, and their worries, and their fears.

We’re giving some biologic information if they want it. We’re reevaluating how that all impacts them. And I think part of the problem is for many people who are doctors, and I’m not talking to our palliative care geriatric audience, there is a sense of what it is to be a doctor is to fix things, is to save lives. And I think that part of the problem with our language is it shows what, as clinicians, we really put most of our values in, which is science, and fixing, and biologic abnormalities. And so we use this language, because it represents who we are as clinicians as much as anything else.

Eric: Yeah. And the ultimate question is to fix to what end or what goal that’s important to them. Helping them through that journey. I love the journey. Just thinking about it too, if Bob is my travel guide and he says, Eric, if you need some food, do you want to go to this steakhouse? It’s not very helpful if I’m a vegetarian; if that’s really the only option, I guess I need food. I guess I’ll find a baked potato at that steakhouse, versus Bob actually asking me beforehand, Tell me about your preferences; what’s important to you? And he can find out, I’m not a vegetarian, but if I was a vegetarian, probably the steakhouse isn’t the place that I should go to if I need some food.

Bob: I rounded with the palliative care fellow who was a first-year who’s just starting, and after a week, she said to me, “You are bossier than any doctor I’ve ever rounded with.” And I’m like, Really? She says, “Yeah, you tell people what you think would be most useful.” And I said, Do I do it based on their values or my values? She said, “Well, you do it based on their values.” And I say, I’m just being a doctor, then.

Eric: Yeah. Sunita.

Sunita: Oh, I was going to, just to clarify what I had said before, it’s definitely not that we based things solely on biology, for sure. And I think we all have that understanding. I think, to be honest, I have sometimes I feel like I have been in situations where, like you were saying earlier, Jacky, there’s this idea of what we’re saying and then there’s the significance of it. And I think when we can’t marry fact and significance, especially when we’re trying to interpret what the body is showing us, then it’s almost as though I’ve at least observed that trying to understand people’s values as a whole impairs my ability to be a guide for them.

If I can’t tell them what we know on rounds, which is that, okay, his pressors are going up, that means something, right? His vent settings are going up, that means something. And I think sometimes, no matter, I mean, some of the situations I’ve been that have been the hardest for me is no matter how much I know that culture, and religion, and other things are influencing someone’s outlook on something that I sometimes, and it’s an ongoing question for me, how much do I honor that versus really explicate what the body is showing us while also honoring their different perspectives?

Eric: And you honor both.

Sunita: Yeah, exactly. But I was not good at that for a long time.

Eric: We have three or four minutes left. I wonder if we could do some quick lightning-round questions. My first lightning round question is to Jacky. Jacky, I still get stuck with, I know the need issue. I hear when I say need. I know, man, I just screwed up. I was going to say a curse word, but instead of if you need a blood transfusion, if you need intubation, if you need, it just goes on and on.

Alex: A feeding tube.

Eric: What words should be going through my head as far as an alternative? And I think you did a nice job in the paper, especially in the conclusion. Everybody, we’ll have a link to that paper on our show notes of the GeriPal website. Jacky, what’s the line or lines?

Jacky: I think, yeah, two things. Can I talk to you about what this means and can we talk about what to do next?

Alex: Great. That’s great. And I would also like to testify that it’s so hard to do. We read your paper on the last palliative care, the last time I was attending last month with a palliative care fellow. And we committed to eradicating the word need from our vocabulary when we’re talking with each other about medical stuff, and when we’re talking with patients, and when we’re talking with other clinicians who are consulting us, we failed. We couldn’t do it.

Eric: You really needed that word need.

Alex: And we were monitoring each other, right? So I monitored the fellow. He monitored me, and we’d be like after, “Did you hear that you used the word need?” “I did, really?” It’s so hard to do because it’s so deeply ingrained. But I love that it’s a pearl. And Sunita, I want to ask you the next lightning round question. You use the word body quite a bit today on this podcast. Do you use the word body with your patients and family members?

Sunita: I do because I think, again, I think we’re all saying something, which is such a nice confluence that we have our facts, but we need to explain what they mean. And sometimes I’ve found it very, very useful to help interpret what the body is showing us so that people can understand it, as it’s not as much about how hard they’re fighting, but sometimes it’s just about nature’s limits. And I try to talk about that to relieve them sometimes of the pressure of needing to put it all on their shoulders that the outcome of their life or the way their death is going to look is somehow their personal responsibility when often isn’t.

Eric: All right, Bob, question for you. We mentioned want several times and the problem with the word want, but we actually never identified what’s the problem with want. I want a lot of things, Bob.

Bob: The problem with want is it’s a fantasy word, right? And so if you ask families what their loved one wants, their loved one wants to get better. Who wouldn’t want to get better?

Eric: I want to win the lottery.

Bob: You want to win the lottery. I want to play with Bruce Springsteen. I can’t play an instrument, and I can’t sing. Want invokes no limits. And so what Gretchen has said is, if your dad was sitting here, what would he say? What would he think? Given what the doctors have said, what would he think about that? Because if you give want and you make it about a fantasy, you get an answer that, as a doctor, just makes you want to go, oh, no, I already said that they weren’t going to get that.

Eric: So when Alex asks for a song request, he should not be asking Sunita, What song do you want me to play? Because she’ll say, Tupac.

Sunita: You know it.

Bob: Exactly. So he should say what song that I have the ability and let me tell you what my abilities are.

Eric: Alex, you got one last lightning question?

Alex: That’s a good transition.

Eric: I know you’re ready.

Alex: No, I’m ready. All right, here we go. (Singing)

Eric: Bob, Jacky, Sunita, thank you for joining us on the GeriPal podcast.

Sunita: Thank you.

Jacky: Our pleasure.

Sunita: Yeah.

Eric: And thank you to all of our listeners. Again, next week we’ll have the third component of our communication podcast on surgical communication, wrapping up a lot of what we’ve talked about in the last two podcasts.

Alex: Thank you. Take care.