#135 - BJ Miller, M.D.: How understanding death leads to a better life

1. 0:00 – 3:00

   Intro

   1. PAPeter Attia0:01

      [upbeat music] Hey everyone. Welcome to "The Drive Podcast." I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you wanna take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you wanna learn more now, head over to peterattiamd.com/subscribe. Now, without further delay, here's today's episode. [upbeat music] My guest this week is Dr. BJ Miller. BJ is a hospice and palliative care specialist. We talk a lot about what that means, but the reason I wanted to speak with BJ is I've been really thinking a lot about better understanding what end of life means and how understanding the end of life could help us better understand, frankly, what we want out of life. And by an amazing coincidence, BJ and I met very, very briefly many years ago in medical school, although I don't think he remembers it. But when I saw him again giving a TED Talk several years ago, I immediately realized, "Hey, that's the guy I met at a party, you know, 20-some odd years ago," and, uh, became really interested in his work and then reached back out to him and said, "Hey, would you be interested to sit down and talk about this?" And so in this discussion we talk a lot about his personal story because you can't really avoid it, and frankly, his personal story is a big part of why he ultimately chose the life path he did, which is doing something that many of us, including people who go into medicine, would find just too difficult to do, which is basically help patients die as a means to reach this culmination of their life. We get into all sorts of things, the difference between death and dying, the difference between palliative care and hospice, the differences between loss and regret, what the medical system that we're a part of is good at and what it's not so great at. We talk about what really happens at the end of life, how enlightened or transcendent is it, and he tells a number of stories that are quite moving about patients and also from his own life. And finally, we, uh, conclude with a discussion on both the hastening of death and also what he's most optimistic about, including the use of, uh, psychedelics. This is another one of those episodes that I think people at the surface might think, "Gosh, I don't really have an interest in that." I would encourage you to push through that. I think it's natural to find this topic unpalatable, and I think that's exactly why people need to listen to this. So without further delay, please enjoy my conversation with BJ Miller. [upbeat music]

2. 3:00 – 14:30

   BJ’s accident leading to the loss of his limbs and his experience inside a burn unit

   1. PAPeter Attia3:03

      Hey, BJ, it's a real honor to be sitting down with you even though we're not in person together.

   2. BMDr. BJ Miller3:08

      Thank you, Peter. I appreciate you having me, bud. I'm looking forward to this.

   3. PAPeter Attia3:12

      Now, I don't know if you remember this. In fact, you can't have remembered this because I'm not memorable in the way that you are. But we've met a few times at parties in medical school.

   4. BMDr. BJ Miller3:24

      No shit.

   5. PAPeter Attia3:25

      You went to UCSF and I went to Stanford, and I don't know if we were the same class, but we were pretty close. What year did you matriculate at UCSF?

   6. BMDr. BJ Miller3:34

      '97.

   7. PAPeter Attia3:36

      Yep. So we were the same class, and I don't recall you guys ever coming down to Palo Alto, but we sure as hell went up to San Francisco a lot.

   8. BMDr. BJ Miller3:45

      For social reasons or for school?

   9. PAPeter Attia3:47

      No, just for social reasons.

   10. BMDr. BJ Miller3:49

       Oh, yeah. Yeah, yeah.

   11. PAPeter Attia3:50

       We just had friends in common and stuff like that. And so it's almost 25 years ago, and I remember one of the things that stood out was you had a dog, right?

   12. BMDr. BJ Miller3:59

       Uh-huh. Yep. [chuckles]

   13. PAPeter Attia4:00

       [chuckles] What was your dog's name? I don't remember.

   14. BMDr. BJ Miller4:03

       His name was Vermont, like the state.

   15. PAPeter Attia4:06

       Got it.

   16. BMDr. BJ Miller4:06

       Yeah. Wow, I'm so psyched you remember him, Peter. He was a huge part of my life. I can tell you that's beautiful.

   17. PAPeter Attia4:15

       So I will admit something, BJ, which is that I never had the nerve to come up to you and say, "Hey, what happened?"

   18. BMDr. BJ Miller4:26

       [chuckles]

   19. PAPeter Attia4:28

       'Cause it wasn't subtle, right?

   20. BMDr. BJ Miller4:30

       Yeah. No, it's pretty, [chuckles] it was pretty bleedingly obvious. Yeah. [chuckles]

   21. PAPeter Attia4:35

       So as I would learn later, your life changed shortly after Thanksgiving in 1990, right?

   22. BMDr. BJ Miller4:43

       That's right. You got it, bud. Yep.

   23. PAPeter Attia4:46

       And that change, which I think on the surface would sound like a change for the worse, maybe wasn't for the worse after all. Can you tell folks what happened that night?

   24. BMDr. BJ Miller4:57

       Yeah. I mean, it was a big moment in my life as you're pointing to, Peter. Yeah, I mean... And there's a lot to talk about it. So I'll try to just kind of parlay the basic facts and then we can talk about any of it. So I'm just back from Thanksgiving holiday and I was very happy to see my friends. We were all kind of that early college-- We were just basically in love. We couldn't wait [chuckles] to see each other. We-- Being away for Thanksgiving break was a bummer really. So anyway, come running back and we immediately decide to go, a handful of us would go out and have a drink and just run around. I was actually on my way to the computer lab to print a paper when it kind of got intercepted and off we ran to go have some fun. Nothing crazy. It was-- We didn't go nutso. But we were heading to the Wawa market, which on the East Coast is sort of like a 7-Eleven. Late, open all night place to get a sandwich kind of joint or chips or whatever. Anyway, so we're walking to the Wawa market, and this is at Princeton University where there's a commuter train that runs right up along campus, you know, 'cause Princeton's sort of a bedroom community for New York and Philly. And so this commuter train was, it was called the Dinky of all things. It was just sitting there, non-operating hours. So it was just sitting there and we stumbled across it and just decided to climb on top of it just relatively innocently for things we had done but felt much stupider. Um, but anyway, we decided to jump on top of it, climb it, climb a ladder, and just stand up on it like you would a jungle gym or a tree or something. And when I got up on top of the train, I had a metal watch on, and the electricity arced to the watch when I stood up 'cause I got close enough to the line, and that was that. Electricity entered the arm, my left arm, and then ground down, and eventually there was a big explosion and whatever else, and that was that. I survived that, but ended up losing both legs below the knee and that one arm below the elbow. Very touch and go in the burn unit in Livingston, New Jersey, St. Barnabas Hospital for, I don't know, maybe a month or so. Then I was in there another month in the burn unit, and then eventually out of there and into rehab, and then a long process of reentering the world. But anyway, that was my big-- the thing I call the cosmic spanking, that big, big moment that just came along and completely reoriented me, changed things around.

   25. PAPeter Attia7:15

       Do you remember the actual shock, or is that sort of so traumatic? A lot of times trauma patients, for example, when they're hit by cars or sustain a significant gunshot wound, especially if it's followed by a prolonged period in the ICU, they suffer some antegrade amnesia, so they forget things in front of them, not so much behind them. But a lot of times that includes the actual event. So what is the last thing you remember? Do you remember actually climbing up on the train?

   26. BMDr. BJ Miller7:46

       I don't, no. I remember the night is all very fuzzy. I remember sort of snippets from the hours preceding, but I don't have any recollection of approaching the train or getting on top of it. This is just pieced together through stories from my friends who were with me. But the first memory I have around the accident itself that night, I can picture a lot of it, again, because my friends have told me, but my own memory really began in the hospital that night. I was taken to the local ER where they just did basic things that are called fasciotomies, which as you know, with electrical burns, you burn from the inside out. So you've got all this heat running around in your system, and it'll keep burning you. So they've got to vent that heat. Basically, the local ER, they cut these fasciotomies to vent me and then stuck me in a helicopter to go to the New Jersey's one burn unit at St. Barnabas. I can remember being loaded into the helicopter vaguely. I was very tall. I was, like, almost six five, and I just remember the pilots [chuckles] just awkwardly trying to get me into the cockpit because I was too long. So all the amputations I had were surgical. So at that night, my legs were burned. I still had them.

   27. PAPeter Attia9:00

       So then you get to a burn unit and you're with now a team of doctors and nurses who have seen the worst of things. For what it's worth, just as a bizarre coincidence, in general surgery, which is what I went to do after medical school, you rotate through all the different disciplines of surgery. It's quite random. You'll spend a month on this, a month on that, a month on all of these different things, and my very first month of internship was in the burn unit. I had never done any of that during medical school, so to show up on day one at sort of the premier burn unit of Maryland, which basically meant it was the referral center, so if you got burned in Pennsylvania, you were still coming down to Hopkins. I mean, it was another world.

   28. BMDr. BJ Miller9:49

       You got it, brother.

   29. PAPeter Attia9:50

       I mean, it was very difficult to get used to doing dressing changes on patients and just seeing the amount of pain people were in when they suffered these burns. And the other thing that was remarkable, at least to me, was how otherwise alive people could look when they came into a burn unit, but yet how poor their prognosis could be based on the amount of surface area that was burned. We basically had actuarial tables that would say, "Well, he has this much of third degree and this much of second degree, and even though he's sitting here actually able to even communicate with us, this person has a very high likelihood of not surviving this injury."

   30. BMDr. BJ Miller10:33

       Yep. It's interesting that you say that because one of the early memories pieced together for me by a nurse, uh, with whom I became very close, was when I landed in the bay at the burn unit. This was not uncommon, but apparently the techs and the team were sitting around basically taking wagers on whether I was gonna make it. And it's probably based on very much the same kind of what you were just describing. That sounds kind of harsh, but I'm sure it wasn't. I think that was just, as you know, these things get depersonalized in that setting almost by necessity. It's a brutal setting. But anyway, we can talk more about that. But I'm in a way glad, Peter, to know that you know what a burn unit is like. It is an other world that I've always struggled to impart to people what it's actually like in there. It is a wholly unnatural place. I mean, nature is completely kept at bay.
3. 14:30 – 28:15

   Coping with his amputations—being tough, the grieving process, and the healing properties of tears

   1. BMDr. BJ Miller14:30

      in a way 'cause I had to, but also as a comment of how skillful they were at their work.

   2. PAPeter Attia14:35

      Do you remember the actual discussion you had with the doctors about the need for amputation? Because obviously, when the fasciotomies are performed initially, it's with the hope of salvaging the limbs. Presumably, at some point, they came to the realization that trying to salvage the limbs was actually gonna threaten your life due to infection. They had to go. I've been around those discussions. Do you remember that?

   3. BMDr. BJ Miller15:00

      I do. I do. I do. My first memory, real vivid memory before-- besides that helicopter moment, was the night before my initial amputations. And the part I remember about it, which was maybe five or six days in, Peter, that's when I was hemodynamically stable enough, and more to the point, the demarcation of viable tissue versus unviable tissue was a little bit more obvious, so surgeons had a fighting chance to remove the right amount. So Dr. Mansour was the main surgeon, an amazing, amazing person. I remember he came in the night before and said something. All I remember is of a conversation, and then I remember falling asleep. I fell asleep in my little room, and somehow... You know that feeling, Peter, where you wake up from a dream and there's a moment of reorienting yourself, and maybe it wasn't a very pleasant dream, and you take a little second and you get your bearings and you go, "Oh, oh, it's just a dream. Oh, thank God," [chuckles] you know? Classic thing is people show up, like, taking an exam naked or something, so they're late for their wedding or some moment you wake up and, "Oh, thank God that was a dream." I remember I woke up in the burn unit having that sensation. Strange, I remember I looked around and I had this weird feeling like, "Oh, this whole amputation thing that I was just hearing about was a dream. Oh, I'm fine. [chuckles] Gotta go to the bathroom." So I, in my haze, managed to extubate myself. So not an easy thing to do. Extubate myself, pull my central lines out of my neck, unstrap my arm from the bed. And all the while, I can remember this so clearly, I'm looking around my room with all these cues that obviously I'm not in my bedroom, but for some reason, I'm just thinking, "Oh, yeah, this is my room. I'm just gonna go to the bathroom now." And I got up and out of bed eventually and started walking to the door with all these alarms going off in the middle of the night. Somehow, I don't know where the nurses were, but there was a gap there, and I started walking to the door just to take a leak on my crispy little feet, and the Foley catheter line ran out. And as you know, they're usually attached to the bed, so when that line ran out, it yanked on that Foley, and that's a pain that I won't soon forget. And that catheter ball was not deflated. We can explain this for your listeners. But anyway-

   4. PAPeter Attia17:24

      I was just about to say, we're gonna hit pause and explain everything you just said, but let's start with the extubation. So you have a tube that is in your airway and a machine that is breathing for you. So the act of pulling that out means you now have to breathe on your own, something you have not been doing for the previous week. That alone could have killed you.

   5. BMDr. BJ Miller17:46

      Yeah. Right.

   6. PAPeter Attia17:48

      You then pulled out a bunch of central lines, which if not compressed-- So central lines are very, very long intravenous lines that go into the main veins inside your body, veins that most people don't even realize they have, called the vena cava, subclavian vein, et cetera. To pull those out without the appropriate protocol of compression could also lead to internal hemorrhage and all sorts of crazy things. You're dodging death. You're three for three on this.

   7. BMDr. BJ Miller18:18

      [chuckles] Yeah. I mean, it was-- Yes, in retrospect, I smile almost with pride because it feels-- it sounds so daring. I mean, obviously, at the time I had no freaking idea what I was doing, but now it sounds-

   8. PAPeter Attia18:28

      You're unkillable.

   9. BMDr. BJ Miller18:29

      Yeah. [chuckles] Exactly.

   10. PAPeter Attia18:31

       But then the thing that finally gets you is a catheter about the size of an HB pencil that is in your urethra up to your bladder, which stays in place with a balloon that's dilated to the size of a very large gumball, and said gumball prevents the catheter from ever coming out. And before we take these catheters out of the urethra, which is by itself unbearable, I myself have had one, we have to deflate the ball because trying to pull a gumball-sized device out of the urethra would be tantamount to torture. But of course, you just went ahead and through the force of walking towards the door, basically removed your own Foley catheter minus the balloon removal or-

   11. BMDr. BJ Miller19:25

       Yeah

   12. PAPeter Attia19:25

       ... yeah.

   13. BMDr. BJ Miller19:26

       [laughs]

   14. PAPeter Attia19:27

       You're still alive, but all of a sudden that dream-

   15. BMDr. BJ Miller19:30

       But not happy.

   16. PAPeter Attia19:32

       Yeah. It is amazing that you're right, that you must have done this all very quickly to make it happen. So now you're sort of having that moment of maybe that wasn't a dream.

   17. BMDr. BJ Miller19:43

       Mm-hmm. I will never forget this. It was a clarity, that world, all the haze cleared up instantly when I felt that Foley dislodge from the bladder. But incidentally, it didn't come all the way out, so it's somewhere halfway.

   18. PAPeter Attia19:55

       Which is even worse.

   19. BMDr. BJ Miller19:57

       Yeah, it was just terrifying. So I immediately fall to the floor and I'm screaming and now a nurse comes in. I don't know what the delay was. Incidentally, that poor nurse, we never saw her again. She was never assigned [chuckles] to my room again. Poor thing. Part of her explanation, she was avoiding my room, she admitted in some ways because she had a son my age and looked just like me, and it was really hard for her. Anyway, so eventually... So I'm on the floor now screaming, trying to break the catheter line, which is impossible. But it's the only way I could-- I thought I could break the tension. But anyways, they came in, got me back in bed and all that stuff. [laughs] And away it went. But to your question, Peter, it was instantaneous that I realized this wasn't a dream, and all the relief that had just... I had experienced moments ago in the other direction just immediately went away and I was very, very clear on where I was and what was happening to me instantaneously. It was a wild, wild moment I won't soon forget.

   20. PAPeter Attia20:55

       So what kind of a mourning process did you go through post-operatively when you come out with both of your legs amputated and your left arm?

   21. BMDr. BJ Miller21:06

       Short answer is my mourning process took me a while, and, uh, my conscious mourning process was delayed because I, at that time, embodied the sort of absorbed the American notion that no, what you do is you pick yourself up, you get on back on the horse immediately. The less you acknowledge what's gone on, the better. The tougher you are, the faster you'll be functional again, et cetera. So early on, I didn't do any mourning, not consciously. I was kind of going the other direction, joking around, making light of it, and both a moment of somewhat of denial and also probably something pretty poignant too. I remember when I came out of that first surgery, so I didn't know that there were people... I knew my parents were there. And oddly, Peter, I don't know how this was possible, but my parents moved into the hospital. Somehow they got a room in the hospital from Chicago. They lived there all the time I was there. I don't know how the hell that... Never heard of that, but they did. Maybe they had huge wings of St. Barnabas that weren't being used. I'm not sure. But I knew my parents were there. So I come out of the OR, come out and I'm heading-- They're wheeling me back. The leg amputations were what they did first. And I knew whatever the case is, I had absorbed what Dr. Mansour had told me the night before eventually. I woke up from that surgery with no surprises. But I'm wheeling back to my room, and there's a s- brief moment where you're going from the OR suites back into the burn units, and then you go through this little hallway, and I come out. It was packed with people. My friends and some friends had flown in from Chicago. I was so moved. I had no idea that they were there, and it was just a brief second. There was no time to talk, but there was just a lot of love. I just remember their facial expressions. I was very, very moved. And then I went back into the room, and I remember my mom came in and we were sitting and she was crying. And my mom had polio. She'd been disabled my whole life, most of her life. And I just remember, this is gonna sound, I don't know, it was part denial driving it, but I just remember my thought when my mom came in was, my response to her was, "Oh, Mom, well, now we have so much more in common. Now we're both disabled." Almost like a cheeriness. I love my mom very much. We're very close, and I honestly felt like I was joining this ranks of folks that I always knew existed and felt very much a kinship with the disabled community by virtue of being close with my mother. My first response was this weird kind of immediate acceptance. But I had to go back, and it wasn't a thorough acceptance. It was where I wanted to be, but it wasn't really where I was. But anyway, that was my first s- statement. It took really weeks. It took actually my nurse kind of trying to work on me. I remember a time maybe a week or two later where one of the nurses with whom I was very, very close, Joy Varcardopone, and Joy came in one day and she was just really moody with me. She was just, like, throwing... She was just strangely moody, and I was just sort of joking around. And anyway, she's, like, throwing bed pans around [chuckles] and it's like, "Joy, what the heck? What is-- What's wrong? What are-- Are you okay?" And she's just basically let into me. She's like, "I am just sick and tired of you not taking this seriously. You're just joking around. You haven't even cried. This is a big, big deal. You're not being real." And she just let into me. She let into me until I finally cried. It was the first time I had cried. I was weeks in. It was the most magical thing, Peter. I will never forget that one either, in part because it was like a dam had broke and so much came pouring out, and it felt so good. It felt like such a relief. I hadn't realized. I hadn't consciously fought back tears or tried to be tough. I just thought that's what I was supposed to be doing, and I was on otherwise on autopilot too. But what was also weird about those tears was for the moments the tears were falling, I had really no physical pain. I've never looked into this, but I wonder what the connection is between the act of crying, not just feeling sad, but actually crying and anesthesia. It was a fascinating moment, but it really moved me, and it began my relationship with a-- began letting in that this was a bigger deal than I had managed to let it be. I offer that to say the mourning, the grieving was very gradual. It took me a while to wake up to my own feelings about it all. That took months and years, really.

   22. PAPeter Attia25:34

       Do you think that that was mostly a sadness and a loss that came through expectation of these are things I wanted to do that I will no longer do, and I am sad as a result of that? Or do you think it was tears from a different sadness, a sadness that's more born of anger? Like, how could this have happened? It's such a random event. I've done far stupider things in my life. Like, why was I wearing that watch? You can sort of go through all those things. Like, do you have a sense of where you were in terms of that dam, the floodgates opening?

   23. BMDr. BJ Miller26:10

       Yeah. Yeah. My sense is, Peter, and it's a sense driven by most of where how grief materialized for me over the months and years. But my sense is for a number of reasons, I did not have a lot of why me moments, and there's a lot to say about that. But to answer your question, no, I think it was more like, first of all, the physical pain. I hadn't really let myself... I had just been literally gritting my teeth. And for as vulnerable as I felt, as so exposed as I felt, I was looking for anywhere where I could look or feel or act or present as strong. And that's the only way I could think of, I think, was to kind of to keep this stuff in. And so I think part of it was a release around just the physical pain. And I think the rest of it, it didn't have a lot of clarity around the object of my sorrow. But the sorrow I really think was had to do with embarrassment for doing this, for ending up here, putting my parents through so much pain. I could see it in their faces. Slowly began to see what it did to friends too and others around me. It's the feeling, I think a lot of the pain or a lot of the tears had to do with here I was taking so much from so many people. I was embarrassed about that and ashamed about that. I think that was a big part of it. And I think there was also an image. I had just kind of come into my body as a nineteen-year-old, and I think there was a sadness. I didn't know if I would ever have sex again, what women were gonna think of me, what my friends would think of me. I'd been around disability my whole life, and I'd watched how cruel people could be and the projections they make. And I think part of it was the more tears that I knew what I was gonna be walking into with that. I think, yeah, all of those things. But low, low, low on the list, Peter, were the why me questions. I owe a lot of that to the prep work that my mother, my family life had set in. It was always much more the question of why not

4. 28:15 – 40:00

   Going from art history to medical school: the value of a diverse background in medicine

   1. BMDr. BJ Miller28:15

      me. If anything, I felt guilty for having too perfect a life before that.

   2. PAPeter Attia28:19

      Separate from all of this, BJ, there's another kind of really transformative event in your life that has to do with your sister. When did that take place?

   3. BMDr. BJ Miller28:28

      So that was ten years later. So that was-

   4. PAPeter Attia28:31

      So you're in medical school.

   5. BMDr. BJ Miller28:33

      Yeah. Exactly.

   6. PAPeter Attia28:34

      And I wanna come back to how you got to medical school, but can you tell me a little bit about your sister and the relationship you had with her in the ten years that followed this and then ultimately her demise?

   7. BMDr. BJ Miller28:46

      It's a good segue. It's a link of... The way I grew up was I was no stranger to pain. I was around it, and there are all sorts of reasons to feel like that life was inherently hard. And that was something about I felt almost a perversion that I could feel happy ever. That felt-- That almost felt wrong. I don't know how to explain it, but part of my growing up was growing up with a sister. I have one sibling, Lisa. Lisa was four years older than I am. Wild, brilliant, fascinating, just intense person. And our whole family life so much centered around her and her moods and her thoughts. So I was enamored with Lisa. She was my older sister. She seemed so smart to me. She had emotions around things that I hadn't even thought of, and she had these developed psychological, emotional responses. I just felt like she must have insights in the world that I just couldn't see, and she had such conviction. And she was harsh, harsh, harsh, harsh. That conviction, older sister I wanted, I aspired to her, so I chased her moods around. Anything she told me, I took at face value. I mean, she owned me in so many ways as her younger brother. And she was very troubled, and part of my adulthood was coming into realize that Lisa wasn't just full of conviction. Lisa was also full of some other things. And so in my twenties, here I am going to med school. I'm finally learning to lo- to have some separation from chasing my sister's moods around. And then in December, December first of two thousand, roughly almost exactly ten years after my injuries, Lisa decided to kill herself. Lisa decided to leave the planet. So yes, that was another one of the major, major life events for me, and that was deep into medical school. And one of the things that precipitated my deciding to leave medicine, that I was gonna get out of medicine at that point.

   8. PAPeter Attia30:48

      No, I didn't know that actually.

   9. BMDr. BJ Miller30:50

      Yeah.

   10. PAPeter Attia30:51

       I wanna come back to this. Can we talk for a moment though, just to make the connection of how you ended up deciding to go into medicine? Because when you were in your freshman year at Princeton, I get the impression that medicine wasn't even on your radar, correct?

   11. BMDr. BJ Miller31:08

       That's right. You got it. Yep. No interest. It hadn't even crossed my mind. Yeah.

   12. PAPeter Attia31:13

       So after returning to Chicago, going through a very lengthy process of rehabilitation, you re-enrolled at Princeton a full year later, correct?

   13. BMDr. BJ Miller31:26

       Almost. Yeah, the following fall. So I went back in September of, of 1991.

   14. PAPeter Attia31:32

       And you changed your major to art history. Is that also correct?

   15. BMDr. BJ Miller31:35

       You got it. Yep.

   16. PAPeter Attia31:37

       Why did you do that?

   17. BMDr. BJ Miller31:39

       I had been theretofore, if that's a word, I had been studying Chinese language and was g- heading for a major in East Asian studies. But when I was away, when I was in that, you know, the burn unit, such a, it's like a torture chamber interspersed with like incredible boredom. Like you're just so [chuckles] you're just so... And this was so wild when I look back on these, I'm sorry, I'm just a quick digression. So this was the first Gulf War was happening. It was so strange. I was watching a war, remember it was like a televised war, such a wild thing, bored stiff, in horrible pain to and from that tank room for daily debridement. So horrible pain interspersed with slight relief and boredom. No touch with the-- there's not even a window. Such a weird thing. And I would toggle between, on the television, between watching the war [chuckles] and some cooking show. It was just the strangest-- I don't know why I bring that up. It was just how I spent my days. [laughs] But now I forgot your question, brother. What were you asking me about?

   18. PAPeter Attia32:41

       The decision to change to art history.

   19. BMDr. BJ Miller32:44

       Oh, golly. [laughs] How did I get to that? But anyway. Well, I know, 'cause I'm sitting in this bed bored stiff, and of course, even with my little structures that were still in place that kept me from crying or acknowledging a lot of things, of course there was no getting around some stuff. And I was beginning to let into my consciousness and my daily thinking, like, you know, sort of preparing, imagining my life down the road. When am I going back to school? Will anyone want to be friends with me? Ah, la, la. But I'm basically, bottom line is I'm sitting there very much pondering the value of my life. What am I now? Am I less of a person? Do I have less to offer the world? What will people see in me, want in me? You know, so basically questions of meaning and questions of identity. Who am I? What do I do with myself now? What can I do? I found myself in that mix just sitting there pondering questions like the meaning of life, not in a recreational or intellectually kinda Ivy Leaguy write a term paper way, but in a way that was very obviously relevant and therapeutic and, and practical. These existential issues became very practical and I-- and that's where they belong, by the way, I think. So sitting there, one of my friends and closest friend, Justin, would come visit me at the burn unit eventually, and we found ourselves talking about art as this thing that humans do. So I was looking for meaning making, what humans, how humans work with pain, how do humans work with things they can't control? And that led me to thinking about art. Why do human beings make art? Why do we take the material of our life and create with it and fashion something from it that wasn't there before, but now exists thanks to us? It's kind of a stunning impulse that human beings have. Whether you're making art that's gonna hang in a museum or you're just futzing around your house, we are a very creative species. That was lighting up for me as very important and telling, and that maybe, maybe the art world had something to teach me. So when I went back to college that fall, I rejoined my class. I just had to finish the exam somewhere in the summer, and I had a free semester. I was supposed to be in China the second semester of sophomore year anyway. I didn't have to do much to jump back in with my class, and that was very important to me. I wanted to be back with my buddies. That was a real driver. So anyway, I head back to Princeton, join my class, and change my major to art history, to studying art. And that was a really consequential decision, one I'm actually very proud of.

   20. PAPeter Attia35:20

       I've talked about it before on this show. I think it's even come up during a discussion where someone asked what's the best major that I would recommend for someone who wants to go into medicine, and I, I don't have great insight on this, but the one thing I generally suggest is anything other than pre-med because I think whether you study art history or engineering or a foreign language and a foreign culture, you're probably gonna get something out of it that you would never get if you studied pre-med, yet most of everything you study in pre-med you're going to pick up in medical school. Which is not to say that studying pre-med is not a good idea, but that's my two cents is that the people who came in with totally different backgrounds often were people who didn't actually plan on going into medicine, as is the case in, in yours. The stories are usually pretty interesting. So when in the journey of art history do you then realize you wanna make what I think is even probably a greater stretch or leap, which is to actually go to medicine?

   21. BMDr. BJ Miller36:23

       Yeah. So let me first see your two cents and raise 'em mine. Unless we want medicine to simply be the stuff of technicians, a technical pursuit, which of course it is in many, many ways. I teach in med school. I haven't as much lately, but I've spent a lot of time teaching in schools of medicine and nursing and love it, love it, love it, love it. And if we view medicine As a technical pursuit simply, then okay, pre-med focus, great. But the trick is, of course, in medicine is our job is not just to... It's one thing to know details about molecules, how they work, but it's a very different thing to know why it's amazing to have molecules in the first place. And if you have not thought one way or another, it doesn't have to be art, it doesn't even have to be through school per se, but you better find a way to, if you're gonna go into the healing professions, the clinical professions, you better find a way to delve into why life is amazing and horrifying. Why is it so hard to let go of? Why is it so hard to love life when you know it's going away? What is this all about? In other words, questions around meaning and identity. One way or another weak physicians, and you can see what happens in a healthcare system that's, has somehow has crowded those thoughts out as somehow being irrelevant. You're left with a lot of zombies. You're left with a lot of people with pulses, but have no idea why it's amazing to have a pulse in the first place. So anyway, I can go on and on and on, but boy, I really, really, really love the notion of people who study humanities then going into the healing professions. I think it's-- Some people see that as like a left turn, like, "Oh," but I couldn't make a bigger case for art history was some of the best preparation for medical school I could imagine.

   22. PAPeter Attia38:16

       I think you're bringing up really great points, BJ, and I think medicine needs all of the above. You need people who have probably gone incredibly deep on a very narrow subset of science. You need people who come in with engineering backgrounds. You need people who come in with humanities backgrounds. And I haven't, to be honest with you, paid much attention to how medical schools are doing these days in terms of recruiting talent, what the war for talent looks like in medical school versus business school versus law school versus other graduate schools. But I would hope that they've figured out what you're saying and are making adjustments in that direction.

   23. BMDr. BJ Miller38:53

       I think they are. I know UCSF, my alma mater, has. They've really invited folks like myself. I didn't do any of the pre-meds at Princeton. I did all the pre-med work after college. And UCSF has purposely attracted a lot of folks who are starting med school a little later in life, have some other life experience, et cetera. Something of a trend there. I'm with you, right, it takes all of the above. Medicine is also a technical pursuit. I guess even if someone wants to be a pre-med major, take that more conventional route, my advice to them is just make sure you actually love it. Just make sure you love the nuts and bolts so you're not just doing chemistry just as a means to the end of medical school. You find something to study that actually cultivates you loving something. Uh, I think that's a major, major distinction. That could be engineering, that could be art, that could be chemistry.

   24. PAPeter Attia39:41

       Yeah. I've always felt that the history of science is also equally beautiful, and so when you're studying physics and you're studying chemistry, to be able to study it through the lens of how the people who discovered it went along their journey probably creates or at least fosters some of that intellectual curiosity and passion

5. 40:00 – 47:15

   How BJ’s new body liberated him

   1. PAPeter Attia40:00

      that I think can be found across multiple disciplines. But still, I wanna get a better sense of what made you decide to take a very bold step, which is, I think, to leave a comfort zone of you've now spent four years doing very well, and you've got this degree in art history from one of the best schools in the country, and you now decide to presumably go back and do a post-bac year to do a bunch of pre-med courses to go and do something that seems about as orthogonal from that as anything. I'm sure it had a lot to do with your experience, but can you speak specifically to what it was and how it, for the lack of a better word, marinated over the previous four or five years?

   2. BMDr. BJ Miller40:43

      Yeah. No, absolutely. I can track this out. So one of the things the injuries did for me, cut to a spoiler alert, one of the therapeutic endeavors here, one of the ways to get through something is in some real ways to let yourself be changed by it. I knew enough that thanks to my mother and the disability rights movement, that the goal for me was to not get back to where I was before the injuries. First of all, practically speaking, it wasn't possible. I wasn't gonna get my old body back. Also, why cut myself off from all those lessons and all the experiences that happened during that period? It's not something I could forget, but nor is it something I would want to forget. It's too dang rich. So the idea was really always I knew versus the sort of normal language and thoughts around disability, and it's like that it's something you would want to overcome, put behind you. And I think a lot of lay people or able-bodied people think the highest compliment they can offer a disabled person is, "Oh, I look at you, and I don't see disability at all." I know what they're trying to say, and we can talk, we can open that up too if you want to down the road here, but what people are trying to say, but in a way, it's not really a compliment. I don't want people to ignore major parts of me just to look at me. I'm not getting over these injuries. Every day I'm reminded this is not something of the past. It's something I live every day. So when I hear comments like that, and you just feel like you're so aware that you're not-- someone isn't really seeing all of you, that's problematic in a number of ways. So I knew, I knew that I wanted to work with these experiences. So that was a major, major theme. And medicine lit up as just theoretically as a way to put these experiences to use. And the linkage between studying art and studying human endeavor and the study of medicine was not such a big leap. The interest, the through line, the basso continuo for me was just being very interested in human beings, human pursuits, human endeavors, and human creativity. Art was one application of those interests, and medical science was another. As I pondered what I wanted to do, I thought, "Well, gosh, medicine would be interesting." If a doctor walked in to see me in the shoes that I'm wearing now, that would affect me in a positive. This was some way I was actively looking for an outlet where my injuries weren't something that someone would look past or forgive, but were actually in some way something of an advantage. And in this way, for me in medicine, I can tell you that having this silhouette, having this body has really been an advantage in a lot of ways if the goal is empathizing with your patients and their families, if your goal is seeing yourself as a fellow human being next to them, if you know or believe that's where healing happens, then this kind of stuff is the best prop I've got going. I really feel for my able-bodied clinicians who don't have some obvious source of pain and suffering that imparts to your onlookers, imparts to your patients that you've been through some stuff. You've scraped a barrel. So anyway, I'm going on and on about that. But to get back to your question, that through line, I knew, I had a hunch that that would serve me in medicine just as it did in art, and that I could apply these lessons into sort of a, sort of a therapeutic application of studying perspective and meaning-making. So medicine lit up as a potential thing that I could do that would be fascinating, I could make a living, and I could exercise these lessons in a novel way.

   3. PAPeter Attia44:15

      So it makes unbelievable sense, actually, and I suspect it changed many things for you. I mean, look, if you just described yourself as a six-foot-four handsome guy who goes to Princeton, you probably are a pretty ambitious guy. You're gonna go off and study foreign relations and do all sorts of cool things, and then everything kind of gets taken away in an instant. How does that change your relationship with your own ambition or what it means to try and fail? Had you ever failed at anything, by the way? Athletically and sort of academically? Even in the '90s, I imagine getting into Princeton was almost impossible.

   4. BMDr. BJ Miller44:59

      Yeah, I exceeded in ways, but also so true. I mean, I just had some green lights right in front of me. I had this amazing education. I had some basic abilities. I could make a case for us that I had suffered and struggled in various ways up until that point, and some things hadn't always gone right for me. But they're on such a, such a different scale. They're such a different scale. But even as a kid-- So in some ways, no, I really hadn't experienced loss in some big way. But what I had experienced was loss through people and others that I cared about, watching post-polio syndrome take my mother's physical function down, watching my sister struggle. So in some ways, part of my charge as a young person was I hated that I didn't have more wrong with me. I felt there was a mismatch. I felt at odds with the world. I felt this pain around me, but I didn't really feel like I had my own access to it. My problem was I didn't really have anything to complain about. I knew that life was really, really hard for many, many people, and internally my life was hard just imagining that, and in some ways getting this new body, and in some ways I have to say I made it such, I cultivated this idea. But in a way, I got the body that much more mirrored how I felt inside: fragmented, broken, confused, unintegrated, different. In some weird ways, this body really, the physiognomy of my body actually suited me in some real ways. I chose that. I ran with that. It was true, but it also was a way for me to get into this body eventually and quit wishing it were something else. By building on what this body was showing me, I knew the clever thing was I knew what I was doing was building a case that this was the right body, that this was a good body. This is the one for me. And then you can imagine that really cuts down on the regret and the second-guessing, and if only I had four limbs, then I blah, blah, blah, blah. That's the kind of mindset I was heading for and trying to cultivate. Now here again, brother, what did you ask me that I went down on that [chuckles] tangent?

   5. PAPeter Attia47:07

      No, actually, I was talking about this idea of this could have actually liberated you a little bit.

   6. BMDr. BJ Miller47:12

      Yes. Yes.

6. 47:15 – 55:30

   How losing his sister to suicide and his disillusionment with medicine altered his path

   1. PAPeter Attia47:15

      And I think you've articulated that very neatly. I want to come back to your sister. We all do this when we get to medical school, is we start to learn things that explain things we've seen in our past. For example, it's the first time you would have learned, I suspect, on some detail what the polio virus looks like and what a virus does, how it is that your mom actually came to contract this virus, and how a vaccine ultimately would go on to make sure people wouldn't get that virus. And I would learn about the cardiovascular disease that ran so deeply in my family and really understand the pathology of this. At some point, did you start to suspect that your sister had, whatever you want to call it, formal mental illness? Or did you not think that that was the case at all? Or how did you think about your sister once you were in medical school and you began to learn about mental health in a somewhat formal way?

   2. BMDr. BJ Miller48:12

      Quick answer here is no, I didn't. The only time I actually let myself do that sort of the pathological overlay was after the fact, after she had died. Leading up, it's telling, I mean, leading up to that, even through medical school, studying manic depression, something that she was posthumously diagnosed with, oddly, it never registered as me reading about someone like my sister. Somehow, and I referenced this a little bit earlier, was somehow the way she was or the, our dynamic, and it wasn't just me, it was my parents too, and her psychiatrist too. She was a master manipulator. She could have anyone thinking exactly what she wanted them to think, and particularly me as her little doting brother who just looked up to her. If I absorbed anything from Lisa, it was that Lisa was right. Lisa had it right, including her angst and her pain, that the world is a painful place, and Lisa was reflecting that. If anything, I saw Lisa was the standard. She was right. Everyone else was wrong. But I just kind of rolled with what she was selling. I did roll with what she was selling, and deeply, to the point where any idea of pathologizing her just completely bounced off my head. It didn't register as relevant to her. She was the right one until she ended her life, and then that prompted all sorts of revisiting that thinking. Also then eventually, you know, my parents, what they did to try to make sense of all this, they went through her diaries with a psychiatrist, and it was in that act, I didn't join them in that, but I received the news, and I believe it, which is she was just textbook bipolar. I mean, just outrageously textbook. And sometimes I'd get-- And my quitting, wanting to quit medicine did have some... This was right after Lisa died. On the list of why I want to get out of medicine, I was like, "Jesus, I can't-- I didn't even see right under my nose. I'm trying to become like a healer person, and I can't even acknowledge that my sister's sick?" It just was demoralizing on some level. But, but I also comforted myself. She had a shrink for better than a dozen years who didn't notice this, who didn't-- was, who was somehow shocked that Lisa killed herself. Weirdly, I did-- [chuckles] I remember on the one hand here, I didn't see any of these signals coming, and at the same time, I remember where I was when I got the news of her death. I was with my dad in a car and my buddy Justin. My mom called, and my dad picked up in his kind of usual sing-songy way, and there was a pause, and then he immediately starts bawling. I knew instantaneously that Lisa was gone, and when I heard it was suicide, there was not a single cell of surprise in my body. That's just an observation. Also, I'm telling you two things. On the one hand, I didn't see it coming, and on the other hand, I completely saw it coming. I don't know how to reconcile those two, but that's just the case.

   3. PAPeter Attia51:09

      Hmm. So you're in your last year of medical school when this happens. You've now alluded to this twice. Were you not planning to do a residency at this point, or was this the event that sort of tipped you to not pursue your residency that following summer?

   4. BMDr. BJ Miller51:25

      Well, all through med school, I just assumed, 'cause I wasn't so enamored with medical science per se. That was just a bag of tricks. I was interested in gaining a career or work that allowed me to continue thinking about these things and work with others and serve others around these ideas of identity, of loss, and trauma. And I just figured the best place for me to exercise that would be in the rehab setting. So I was sort of beelining for physical medicine and rehabilitation. So deep into medical school, UCSF didn't have a program, so I went and did an externship somewhere, uh, a rotation elsewhere out east. And during that, I'd already begun to apply for residencies in rehab medicine at that point. And I-- [chuckles] So then I here I did a rotation, having already committed to this field, and I hated it. The rotation was-- I just [chuckles] really did not enjoy it for all sorts of reasons. One, it was, it was all mechanical, this idea of like rehabilitation. First of all, the phrase is problematic. Rehab, like the goal would be to get back to where you were before the injury, which I've been saying I just don't believe is true. It's importantly untrue. And this idea that it was so mechanical had nothing to do with the personal transformations that happened. And that's where I realized I was so interested. And that plus I realized as I was walking out of patients' room that I kept hearing nurses say, "Look, Timmy, you can be just like BJ. He's a doctor now." I could hear myself being served up as a poster child. And I didn't like the mechanics of the job. I didn't want to be a poster child. Ipso facto, I was like, "I got to get out of this." And one of my promises to myself going into medical school, having learned what I had learned was, "Hey, life's short. Life's important. Life's hard. Life's beautiful. I'm not gonna just get stuck somewhere and have a sacrificial life." I know a lot of our colleagues in medicine who went into it because their parents were doctors, and they hated it, but what else am I going to do now? I've gone this far. Or one way or another, they just sign up, willfully sign up for a life of misery. I knew I wasn't going to do that, so I promised myself. And at this point, another thing I learned from the injuries which was so critical was the ability to-- I was much less afraid now, I was much less afraid of failure. I was much less afraid of falling. So you asked me earlier if I had anything really go wrong before in my life. In some ways, the answer is no. I was a very frightful, melancholy child, sensitive, but which ended up manifesting as fearful at times. Now I was going the other direction, man. Fear, I had a totally different relationship with fear. I saw falling as a skill. So anyway, the bottom line there was I was willing to try medicine and willing to dump it, and in fact, it felt empowering to do so. It was a reminder that my life was bigger than just a job choice. Anyone's life is. So there I am, deep in med school, already applying for residencies, I said, "Screw this." And so as I promised myself, so I called, dropped out of the match, talked to my dean, said, "Hey, I'm finished. I'll graduate, but you know, I'm, I'm gonna go do other things." She talked me into-- She said, "Okay, okay. All right." I had begun to be disillusioned with medicine before my sister's death, but that was sort of the straw that broke the camel's back. As you've referenced, I think we bring in idealism one way or another into the healing professions, and then you have to [chuckles] go through this process of disillusionment where the practice of medicine isn't necessarily jiving with the ideals that you bring into it. And that can be very stressful, but I do think it's important for any trainee at one point or another to go through some disillusionment. My response to that disillusionment was to get the hell out of it. Especially as I realized I didn't like rehab medicine. And again, Lisa's death was just like proof that I'm just not-- I don't wanna do this, and I'm not cut out for it. But then I got talked into doing my internship that first postdoc year, and my family was in Milwaukee at the time. I had gone away. I had left home when I was 15, and gi-given Lisa had just died, given I didn't know what I was doing in some ways,

7. 55:30 – 1:02:15

   Discovering his path of palliative care—distinct from hospice—in medicine

   1. BMDr. BJ Miller55:30

      I said, "Okay, well, I'll move in with mom and dad. We'll recongeal as a family, spend that year together, and I'll bang out my internship and just get that done and be done and move on." But it was during that internship that I stumbled into palliative care, and that's where everything changed again.

   2. PAPeter Attia55:47

      So BJ, what is it that you saw during your internship that both made you change your decision leaving medicine and also concentrated or focused you on an area of medicine called palliative care?

   3. BMDr. BJ Miller56:02

      So a couple things happened. One of the things I just sort of stumbled into this elective during my internship. We had basically one month of an elective time, if I remember correctly, maybe even more, but I had spent a little time with a hospice doc at one point. Actually, my best friend's mother was involved with hospice, and she turned me onto the idea. But again, I was so hell-bent on rehab medicine, figuring that was the place for me, and wasn't sure that I had anything special to offer beyond that sort of rehab setting. But I had absorbed that hospice was simply just where people go for the final days of life. That was, um-- I thought I understood what that meant. But anyway, stumbled into this palliative care elective at the Medical College of Wisconsin, which just happens to have been one of the early adopters of palliative care. David Weissman, an oncologist there, had built one of the early great palliative care programs, just happened to be there. And on that first day, we went and saw a patient. I watched David talk to her about code status. This is in the hospital. It was a woman with heart disease, advanced heart disease, and David was trying to talk to her about her wishes, what kind of care she wanted for, and trying to impart how serious her heart condition had become. Tricky conversations, very emotionally, psychologically loaded content, really tricky. The zone that medicine traditionally does not handle very well. And so I had seen all these counterpoints, but out here I'm watching this guy sit with this woman, sits on the edge of her bed with her, just immediately this very different rapport. He's talking to her like a human being, not hovering over her like a superior, someone who's there to fix her. He was there as a fellow human being, and it just showed it in his body language and his tone and his word choice, and it was beautiful. And he said to her-- And I just watched how she responded to him, and it was remarkable. And he said something to her. He tried to get to the code status question. He said something essentially like, "When you die, do you want us to help that process along and make sure you're comfortable through that process? Or do you want us to really fight that? Do you want us to go to war with that notion and do our best to pull you back?" Something along those lines. But the magic moment was him looking at her in the eye and saying, "When you die." Of course, as human beings, that's a very reasonable thing to say 'cause we all die. It's not if, it's when. [chuckles] In the medical setting, that is not the way these conversations generally work. I was so moved by watching this, and he had dared to acknowledge this woman's death, and what I saw on her face was not shock, horror, anger, but relief that this man was talking to her plainly about her life, and it was so gorgeous, so poignant. That moment really, really stuck with me. And as I got went home that night, I remember thinking about it. It's like, well, this is what I've been looking for. This is-- In this world, we take, in palliative care world, illness, disability, death are normal. They're not anomalous. This field treats these life events as normal life events, which of course they are. The starting point for palliative care is something's happening that you can't fix, that you can't change, and that was for me all along. In rehab, you could see it would be similar. Like rehab, the event's already happened. Something's gone wrong. Now what do you do? I knew I was interested in the now what, but here this field was digging into all the-- It's not just the angle of the joint it was concerned with, but the, the angle of the thoughts and the way that we see ourselves and the words we choose to describe our place in the world and how we either suffer from those words or how we really can find ourselves doing something more therapeutic. And it was such a craft. It was such a, a stump of words, not of a, of an instrument. So anyway, I really was really, really moved, but the first axis that opened up was, I'm not here to fix people. I'm here to be with people as they find their way, as they deal with things that they can't control, and that was a hook for me in so many ways.

   4. PAPeter Attia1:00:17

      How would you explain to someone the difference between palliative care and hospice, which I think many people use interchangeably, but I don't think they really are interchangeable, are they?

   5. BMDr. BJ Miller1:00:26

      They are not. Thank you, thank you, thank you. A quick public service announcement 'cause it's a really big problem for a number of reasons. But palliative care is simply the interdisciplinary pursuit of the quality of life. Within the context of serious illness, palliative care is that mode of care which helps you feel as well as possible emotionally, physically, spiritually, you name it. My job is to help you deal with the facts of your life and to feel as well as you can. There is nothing in the definition of palliative care that makes it that you need to be dying anytime soon. Time is not mentioned. There's-- Death is included in this, but it's not the focus. It's simply the pursuit of quality of life, and if you need to pose it like we do in medicine. You need to have an object of your efforts, an enemy as it were. The thing we're after in palliative care, the thing that we treat is suffering versus disease, and there's a lot to that. We can unpack that. But so that's palliative care. Hospice is a subset of palliative care, which is that mode, that type of care, but reserved for the end of life, the final months of life. So hospice really is essentially end-of-life care. It's palliative care that's applied at the end of life. But that's just hospice. But palliative care, there's no mention of time. You just have to be struggling. You just have to be interested in quality of life. You do not have to be dying anytime soon. This is a huge, huge distinction because of all of our death phobia, because they think palliative care and end-of-life care or hospice are the same. No one wants to talk about it. No one wants to face that because of all the baggage around death. So consequently, people suffer for years where they could get a lot more support from palliative care. But because of this misunderstanding, they don't elect palliative care because they think that's only relevant for them if they're dying soon,

8. 1:02:15 – 1:10:00

   Our complicated relationship with death, and how acknowledging it can release its grip and improve living

   1. BMDr. BJ Miller1:02:15

      and nothing could be farther from the truth. So does that make sense?

   2. PAPeter Attia1:02:18

      It really does, yes, and I appreciate that distinction.

   3. BMDr. BJ Miller1:02:21

      Good.

   4. PAPeter Attia1:02:22

      What do you think it is about us as a species, I can only speak to us because other species I don't think share our metacognition, but why are we in such denial about death? It's been said by so many people, we are all terminally ill, and yet most of us, myself certainly included, don't act that way at times. We tend to fixate on things that absolutely don't matter. For many people, there's frank denial of this thing. It's out there. It's some sort of abstract idea, but it's certainly nothing that warrants any attention in terms of decisions one makes today. That's really the first question I have, and then there's other things I want to explore here with you. But what is your take on our just inability to look at death?

   5. BMDr. BJ Miller1:03:07

      I think for starters, I know in my field and elsewhere, for folks who have kind of dared to turn their attention to mortality or have been forced to, then you look back on the rest of the world and you see a world so invested in ignoring this part of life that it can feel a little perverse, and I think a lot of us are quick to say the world's in, or Americans in particular are in denial. And there's some truth to that for sure. But I also think we should cut each other some slack. Just physiologically, neurohormonally, we are wired to run away from death. Any threat to our existence, we have deep wiring that makes us fight that thing or flee it or go limp. So we have that impulse in us, and then I think on top of that, there is as old as human beings has been this acknowledge that we die, that any adult in this world, maybe not even just adults, one way or another, human beings eventually come to the realization that death happens, including their own death. And I'm not sure that any other species has to live, has to walk through life feeling that. So it is quite a predicament we humans have. It's elemental. It is at the root of the Judeo-Christian tradition. It's a root of many religious belief systems, a lot of philosophy of thought. It's at the root of song and artwork. I mean, this is a huge, huge subject that humans really, really struggle to wrap their heads around. So I just want to give us plenty of breadth, and I don't want us to be ashamed that we haven't figured out this death thing. So on top of those old threads, in modern times, in the last 150 years, medical science, we're sort of a victim of our own success. Medical science has gotten much better. It's easy to be seduced. My life has been saved by medicine. It's easy to believe that medicine can forestall death perhaps indefinitely. So you throw all these things together and social cues around anti-aging this and that, and you got to stay healthy and beautiful forever, and put all that stuff together, and we've conspired to set up a pretty tricky relationship to this piece of our nature. No harm, no foul, but I think the reason to push back on this is, A, people die much more miserable than they need to because they haven't dared to look at this thing called death before it's too late, and because also we have a healthcare system that it's not an intuitive thing to navigate anymore. And thanks to our technology, it's not impossible to end up on a series of machines and that by some definition of life, you have a pulse, but that's not a life that a lot of us want to live is hooked up to machines. So we have this weird technological moment that you can kind of live forever by some very reduced definition of life. Anyway, there's a little bit of a rundown why it's so dang hard to turn our attention to this. But when people do, and I'm coming to the climax here, brother [chuckles] , but one of the things you learn, whether through religious and philosophical thinking or frankly in clinical thinking, whether by choice or by force, once you have to actually try to stare this thing called mortality, this thing called death in the eye, not only do you realize that, hey, maybe it's not so terrifying after all and that you can do it, but it has a secondary effect of once you come to terms with your time is precious and that time is relatively short or at least not endless, it has a secondary effect of helping you really, really appreciate what you have. The fact that it ends is what makes it precious. So there are reasons why we don't look at death, and there are some really good reasons to help each other find a way to do so.

   6. PAPeter Attia1:06:58

      I think that's just such an eloquent description of what I consider to be a huge dialectical challenge, which is the problem that I focus on, BJ, in medicine is how to live longer and how to do so without requiring the heroics of medicine at end of life. So just as you became disillusioned with medicine, so too did I. But it was for a slightly different reason, which was, boy, we sure do put a staggering amount of resources and effort into things that with probably one-tenth of this effort could have been forestalled or prevented altogether. And I didn't think I could do anything about it, so I left for a period of time before ultimately coming back to it. But I think that what you said is I completely agree that we can do both, right? We can do everything in our power to maximize our lives here, just as medicine allowed you to live that day. There's a very good chance at a different hospital under different settings, you would have died 30 years ago, but you didn't. Now, you're still going to die, just as I am, of course, and everyone listening to this is going to die. So we can do both. We can figure out a way to live the best life possible, the longest life possible, should we choose that to be the case. But none of that diminishes what you've said. And I, I think that's the part that a lot of people don't appreciate, is that it's one or the other, and it can't be both.

   7. BMDr. BJ Miller1:08:28

      Amen. You just hit on a real kind of a root cause. One of the ways we struggle so much these days is from our structures, our constructs, our ways of thinking. And as long as we think it's either life or death, that either you love life and try everything you can do to extend it, or you love death and just completely accept that it's gonna come today, these false dichotomies are the problem. And I'm so with you, and it's one of the reasons I'm so excited to be invited on your podcast, but is because our relationship with death is maybe a problem or just under-realized. But if there's a problem here, it's the false dichotomy. It's the either/or thinking when the both/and thinking is really where it's at. So I love that you and others are trying to think through how to live longer and live better. I love life. My relationship to death, even my acceptance of death, is only to do with my love of life. It would be a real shame of a shortcut that if in order to prepare yourself for the inevitability of death, you somehow stop loving life. You somehow welcome depression, so therefore you wouldn't love life so that much, so therefore you're ready to die because life kind of sucks. It could be so, so much better than that. And if we can find a way to include death into our view of reality, like I don't love death. I love reality, and reality happens to include death. Therefore, I'll deal with death. I'm in no way concerted around it. I'm in no way

9. 1:10:00 – 1:14:15

   The different distinctions around the fear of death, and how BJ helps his patients negotiate fears

   1. BMDr. BJ Miller1:10:00

      incentivized to make death happen. Again, I appreciate you having this conversation with me. I think there's a lot to be learned by pushing past the either/or of this.

   2. PAPeter Attia1:10:10

      You've spent more time with people who are closer to death than almost anybody listening to this, certainly. You're in a profession that very few people go into. As you've pointed out, there are many reasons for that. Do you get the sense that when someone is at the end of their life, they are more afraid of death in the sense of being gone or the act of dying and presumably what the actual mechanism of death and/or suffering is?

   3. BMDr. BJ Miller1:10:45

      Yeah. It's a really great distinction, a very helpful one clinically. Presentation may be someone's freaked out about dying or some existential anxieties. But of course, as is the case with these things, it pays to look a little bit more closely and tease some things out here. And one of the major things to tease out is, are you afraid of the dying process, like you're mentioning here? Like, the suffering you imply that must happen during the dying process, is that what you're picturing, and therefore, is that the source of your anxiety? Or is it, are you really afraid to be dead? Whether your belief system suggests there's a judgment day and a reckoning, perhaps a hell, perhaps who knows what. Are you afraid of what may be coming next? Are you afraid to be gone? Are you afraid to miss out? Does it freak you out that the world will go on without you? A major pull here or a major divide or crossroads, let's say, is are you afraid of dying or are you afraid of being dead? The former, one of the reasons to tease this out is the former, afraid of dying, well, we know a fair amount about that. There's physiology to mark. There are medications to help. There are ways to help a body come down for a gentle landing, as I say. There's no need to be miserable and in pain at the end of life. For the most part, we can do a lot with medications. We can do a lot to ease the suffering at the end of life in the dying process. So the answer, if that's your fear, then the answer is reassurance. If your concern is being dead, well, I don't have answers for you, but I can, as a fellow traveler, I can accompany you there. We can think about that together. We can talk about it, and then we can make a life that responds to that big question. So if you're afraid of, your belief system has you afraid of a judgment day, well, let that spur you to behave a little differently in the time you have left. Or let that help you wade into non-duality. Let that help you wade into the world beyond yourself. That's my favorite response. If anyone's interested in living forever, my favorite means to living forever is to think about the world beyond yourself. Invest yourself in the world beyond yourself, so when your self dies, that thing you love keeps going. Anyway, this is where it gets really, really fascinating, the relationship between self and other and what to do about that. Religious thinking, spiritual pursuits, this is what can open up when you admit that you're freaked out to be dead.

   4. PAPeter Attia1:13:08

      It's such an interesting way you explain the idea of, again, for me, it's very clearly the latter, not the former. And I guess that's just because I have the luxury of medical training, and I understand where and when one can draw the line for themselves with respect to what measures are taken, how heroically they are, and, and obviously the power of medicine to greatly reduce the suffering. But it's this other piece of missing your family, missing out on future generations, leaving behind people you love. To me, those are the hardest things. And of course, your point is you can live through those things, but you have to do something about it. It doesn't happen automatically. You have to make the investment. And the irony is the time to do that is while we're alive.

   5. BMDr. BJ Miller1:13:57

      Amen. Just gave me chills. You just completed the circle. Yep.

   6. PAPeter Attia1:14:01

      Which almost suggests that palliative care needs to begin much earlier in life.

   7. BMDr. BJ Miller1:14:06

      Amen. Which is why it's such a shame that we forestall and keep it at bay when it's this thing that could help us so, so much, whether actually a palliative

10. 1:14:15 – 1:23:00

    The major design flaws of a “death phobic” healthcare system

    1. BMDr. BJ Miller1:14:15

       care referral or a palliative care mindset. But one way or another, finding our way into this subject while we've got plenty of road in front of us is absolutely the right, best way.

    2. PAPeter Attia1:14:25

       You know, it seems that there's a continuum where you have life, you have acute illnesses, more life, acute illnesses, chronic illnesses, life and death. The hospital and the entire medical system is really only geared to treat with the acute problems. It has virtually no tool dealing with life or even chronic conditions, and certainly not death. I don't want to get into the why is that the case. We can sit here and debate about incentives all day long. I, I think it's straightforward. I mean, I think we understand that the incentives are such that reimbursement follows the treatment of acute conditions and to some extent chronic conditions. I guess the more relevant question is what would have to change to realign the focus of resources to make it such that medicine could be more about helping people live and then helping them die when that time comes?

    3. BMDr. BJ Miller1:15:31

       As a part and parcel of helping them live, then relate those two things. So I think a couple answers to your question. I think one is in a big office somewhere at HHS when they're trying to redesign a healthcare system and even redraft a mission statement. I would challenge HHS, I mean, to read the definition of palliative care and tell me why the definition of palliative care isn't the mission of all of healthcare. So one answer to your question is you can see that both the strengths of the healthcare system and the trouble that comes from it is a design flaw. Because you and I both know healthcare is littered with people who really, really care, and they're trained to the hilt, and yet the care we're able to mete out too often falls short. I don't think the problem is the people. I think the problem is there's a design flaw. And for my money, the design flaw has to do with the system is focused on disease, not on the people dealing with disease. And the second you make it about the person living with the disease, not the disease itself, well, you've welcomed all sorts of things into the mix beyond just their physiology and anatomy. You've welcomed their social, emotional, and spiritual lives into the mix. You've also welcomed your humanness into the mix as being relevant, you as a clinician being relevant beyond just your technical skills, which will push back on burnout for one thing. You've also made yourself in service of a human condition, which means for us clinicians, the expectation management, we're not expected to work miracles. We know that at someday everyone's gonna die, and that that's not a failure for us. We didn't-- the person didn't succumb to the disease, and we doctors didn't fail to make them live forever. Then once we align healthcare with the human condition and with serving human beings, so much of the trouble will work itself out because we will be designed around the right thing. So that's one answer to your question. I think it's that simple and that hard on some level. And then medical-- of course, medical training would have to follow suit and revisit how we think about these things. I mean, for example, think about your medical school training, Peter. A hundred percent of your patients die. Any rotation that you ever go through, no condition befalls a hundred percent of your patients. But a hundred percent of our patients suffer. A hundred percent of our patients die. And given that, wouldn't you think that a responsible medical school curriculum, that we would start and end, day one and the last day would be around conversations like we're having now? That palliative care would not need to be a specialty. It would be baked into how all of medicine works. So for my money, that's a major thing that needs to happen. Policy will flow, et cetera. I also think to make that happen and to not wait for that happen, that we human beings, we people, irrespective of our professions, need to kind of come together as a society and to take these issues on, especially right now when we're all so polarized and so divided and so aware about the things that we don't have in common with each other. What a perfect time to revisit where we actually do have so much in common. And where we do have so much in common revolves around everything we're talking about right now. Black, white, rich, poor, young, old, I don't care. These issues affect all of us. This is a genuine way for us to work on the points in common. So we can make political comments about why now is right for that. The healthcare system itself can't keep doing what it's doing and can't keep death the enemy because it's going to lose that war again and again and again.

    4. PAPeter Attia1:19:04

       And the one way you can keep score on that is just cost.

    5. BMDr. BJ Miller1:19:07

       Yep.

    6. PAPeter Attia1:19:08

       Cost alone is a metric by which we're losing. Healthcare is obviously one of two things that will either bankrupt the United States if they can't print their way out of it or create sort of seismic economic shifts. And I do think that part of it is, as you said, we've taken the wrong strategy in a war that probably ought to be deemed more of a truce Then put our resources in the wrong place.

    7. BMDr. BJ Miller1:19:33

       Can I ask you a question on that, though?

    8. PAPeter Attia1:19:35

       Yeah, yeah.

    9. BMDr. BJ Miller1:19:36

       Why would you say that we are so focused on acute care and not on chronic care if most everybody is gonna die of most of chronic conditions, et cetera?

    10. PAPeter Attia1:19:46

        I should say, I think we do focus a lot on chronic care. I just don't think we're good at it. So what I meant to say was, I think where medicine is very good is on acute care, and I think where medicine is really bad is on chronic care, and I think those are the two things it works on. It has nothing to do with sort of healthy life to prevent acute or chronic issues, and it has nothing to do with death. So that's sort of, yeah, just thanks for asking me to clarify that. But yes, I think we disproportionately focus on chronic despite our relative lack of success with it.

    11. BMDr. BJ Miller1:20:19

        Why do we keep doing that? Do you have a sense?

    12. PAPeter Attia1:20:22

        Well, I think in some cases, we don't know what to do to prevent the condition. So certain conditions never show up as acute. Cancer does not show up acutely. I shouldn't say that. It kind of does, but it doesn't really fall under the rubric of acute care medicine the way appendicitis does. But we don't really have a great sense of cancer. You know, we know smoking and obesity are the two greatest risk factors for it, but there's many other risk factors, including chance, that we probably don't understand. And even the ones that we do understand, like obesity, we don't really have the infrastructure to help with prevention. So you talked about how in medical school, we didn't have a single course on dying. We also didn't have a single course on nutrition or exercise or stress management or the psychology of eating and our relationship to food and how you can help patients make better choices with nutrition and things like that. So I don't buy the narrative that we have an obesity crisis just because sort of people are fat, dumb, and lazy. I think we live in a toxic food environment, and we don't have a healthcare system that's really geared to help people out of it because, frankly, physicians aren't compensated to do that. You just don't have the billable structure in which you can do these things. So instead, I think we focus on where our tools are, and our tools are drugs. Drugs become a good tool to use in a chronic condition setting.

    13. BMDr. BJ Miller1:21:53

        Right. Uh, I think I'd add to that, maybe encapsulate this list three ways. One is the design flaw that we're death phobic and we see ourselves as victors when we cure something, when we fix something. So chronic illness, by definition, is something that we can't fix. So I think it presents us with a sense of failure, which I think is an emotional barrier to developing it further. That's one big piece of the design flaw. I think a second big piece of the design flaw is the way the busyness of medicine goes. We are left to see medicine as a series of transactions, which in acute care makes a lot more sense. In chronic care, it becomes part of the experience. You're not kicking this thing out of the body. You've got to learn to live with it. So illness and health becomes protracted over time and therefore becomes an experience. But we're wired for transactions. We don't have the systems and structures in place to be cultivating experiences together with our patients. That's the second thing, and I think the third thing is this reimbursement, and we're incentivized away from thinking about care over time. So anyway, I just want

11. 1:23:00 – 1:33:45

    Common regrets, the value of time, and other insights from interactions with patients in their final moments of life

    1. BMDr. BJ Miller1:23:00

       to complete that question for both of us. I think that's why we're where we're at.

    2. PAPeter Attia1:23:05

       Yeah, I appreciate that structure that you've put to it. I want to ask you about patients that you interact with during hospice. So these are now going to be the patients who are probably in the final months of their life, and that could be cancer is obviously a very common pathway that you'll interact with hospice patients. Is that the most common proximate cause of death for hospice patients in the United States?

    3. BMDr. BJ Miller1:23:29

       Cancer?

    4. PAPeter Attia1:23:30

       Yes.

    5. BMDr. BJ Miller1:23:30

       No, it is no longer the majority. Until recently, it's less than fifty percent now. Progressive neurological illnesses are on the rise, cardiovascular, organ failure. But yeah, fewer than fifty percent of deaths, the hospice deaths are cancer at this point.

    6. PAPeter Attia1:23:45

       What do patients say most to you? When I was in medical school, I did a stint at the National Cancer Institute, and then I went back there for my formal training fellowship. And people that came to the NCI to where I was, and I suspect to elsewhere in the NCI, were generally patients who had progressed through all forms of treatment, all standard treatments. So they had metastatic disease that had failed to respond to any form of treatment, so therefore, they were at the NCI for experimental treatment. And at least for the type of cancer we worked on, the survival was between ten and twenty percent, meaning eighty to ninety percent of the people we met were going to die very soon, within six months, typically. I remember obviously feeling very attached to many of them and also spending time with them and asking them questions like, what do they wish they could do? How do they want to spend this time that they have left? And sometimes they would share regrets, and I, I always remember thinking, "I wish I could write a book about this, just interviewing people like this." But it felt, it didn't feel right to me. It was one of those things that just felt like it should be shared, but I wouldn't know how to share it. I suspect you've had more of those discussions than you can remember, and I wonder what things you've learned from them.

    7. BMDr. BJ Miller1:25:00

       These vicarious deathbed moments, I have a lot of them. I think a lot of us in this field, and maybe in medicine in general, like to say how privileged we are to be in this position, how lucky we are to have our patients let us in to these very poignant moments. It's so intimate. So yeah, there's a lot to be said for those moments, including you're pr-- wanting to protect those moments and not necessarily ram them into a book. Although there, I'm sure, is a way to do that skillfully. The world could benefit from it. But the regrets that pop in that I see at the end of life, the conventional ones are sure you hear people say things like, "I wish I had spent more time with my family than at the office," and yeah, things like that. Yeah, sure, that comes up But in a way, by the time someone's actually in their deathbed, and again, these days most of us are dying from chronic illnesses, that means we have some protracted period of time to think about our death specifically. We will be introduced to the thing that will end our life months or years in advance. And so by the time those folks get around to their end of their life, they're beyond the sort of pat regrets. "I shouldn't have worked so much," for example. Oftentimes, if they're regretting anything, they're hanging on to anything, including regrets, it, it's more likely, "I wish I had loved, dared to love more. I wish I hadn't been so afraid. I wish I had just let myself be myself. I wish I hadn't been so hard on myself or criticized myself." Those regrets, they all have something to do in common, and the commonality is it's sort of like oftentimes the common pathway there is they wish they had let themselves come to terms with death earlier in their lives because it would have changed the decisions they made. I think one of the things that people come to realize on their deathbed, and one of the things that I saw at getting close to my own, was really grasping it in our guts that death is coming no matter what we do. Even in your work promoting a longer life, as you said earlier, doesn't mean that death isn't still coming. It's just coming later. Given that, this is the freedom that comes from reckoning with death, which is if, okay, you're telling me that no matter what I do, if I'm a good person, a bad person, I eat my veggies, I don't eat my veggies, I smoke, I don't smoke, whatever it is, either way, if I'm going down eventually, in other words, if failure is in this way, quote-unquote, failure is guaranteed, then in some ways the pressure's off. Like the pressure's on for me to take my life seriously, but the pressure's off for me to get everything just perfect. There's this biphasic effect that I see in myself and some of my patients, which is they see the grip that fear has had on them, distraction has done to them, and they realize that, no, man, the only thing I have to lose is wasting my time, and so I'm not going to waste my time. I'm going to take this stuff seriously. I'm going to say what I want to say to people. I'm going to do what I want to do because if failure is guaranteed, then I'm no longer-- it doesn't make much sense to be afraid of failure anymore or not be limited by it because I'm going to fall either way, so I might as well try. So I have the r- death gives me the reason to try and gives me the reason or the way of forgiving myself for, quote-unquote, failing. So it really, in this way, can be a real liberating force, and I see people grok that, and the regrets have something to do with not coming to that place sooner.

    8. PAPeter Attia1:28:26

       You presumably encounter patients who have the sort of proverbial dying wish. Never saw the Grand Canyon, and I really want to go and see it. Never seen the Mona Lisa, and I want to see it, or I've never taken this vacation with my family. How much of your work is trying to help patients navigate those wishes medically? For example, is someone strong enough to physically go to the Grand Canyon, and can you put in a last-ditch heroic effect to get them there? I mean, how much of that do you do?

    9. BMDr. BJ Miller1:29:01

       Some. I'm involved with an organization called the Dream Foundation out of Santa Barbara, and what they do for a living as an organization is help make those trips to the Grand Canyon or whatever those final wishes actually happen for adults in this country. It's beautiful. And I have been engaged in some of that with some patients, whether a handful of occasions where someone was here who may have lived here for a long time but grew up elsewhere and wanted to get home, as it were, back to the Philippines or back to somewhere else, and helping this sort of one last trip happen. I've been involved with that a lot. I've been involved with some bedside weddings in a hospital just before someone died. I've been involved with some trips done to the Grand Canyon. So some of that, that is true. Like some of my job, especially if I can be engaged with someone soon enough while there's still energy and time to work with, then making those sort of last wishes happen is great. It's fun. It's great work. It's powerful. It's delightful, and it's stunning. But I will say, and so I do some of that, but for whatever reason, I'm more engaged with people around letting go of that wish or that need to go see the Grand Canyon or whatever it w- may be, of letting go of the things that they're not going to be able to do or at least grokking that fact. So yes, sometimes the response is to mobilize energy to do that thing. I'd say more often and right alongside that wish is also helping them see the world and see themselves in the world in such a way that they can let go of those things that they never got to because they realize the things that they're not going to get to is a very long list. And on a developmental level, you've got to find a way to come to terms with all the things you're not going to get to do. So that's where I spend a lot of my time.

    10. PAPeter Attia1:30:56

        Movies lead us to believe that people become enlightened and hyper-transcendent at the end of life. But my experience with patients at the end of their lives is that oftentimes they're so heavily medicated that they're not really even able to communicate much with their loved ones, and that's the price we'll pay to keep them comfortable. Especially patients with metastatic cancer, the pain would be so debilitating it would be inhumane to let them suffer without those medications. And frankly, in the circumstances when we're lucky enough to do so, we can get expressed direction from the patients before they get there that, hey, I don't want to suffer, and I don't want a breathing tube put into my chest. I don't want to be intubated, and I don't want you to do chest compressions on me when my heart stops. I just want enough medicine to be comfortable. And so you don't have these sort of diving into a person's soul in the last day of their life kind of thing. Is that your experience also?

    11. BMDr. BJ Miller1:31:59

        Absolutely, it is. There are exceptions, but not many. The last day or two of life is not necessarily the greatest time to be digging into someone's soul. And I will say you're right about medications is a big piece of this. But I will also say, just for your listeners, a refinement here, again, pushing on the either/or kind of thinking. It's not either take meds and be comfortable or don't take meds and be lucid. Intractable pain is a great route to delirium, and even if you're not delirious, trying to have an exchange with someone when your body is in absolute agony is, is a pretty quixotic experience. I will say that another plug for palliative care is with very expert and judicial use of pain medications where we can often thread a needle and get someone comfortable enough, but not so overly medicated that they can't interact. We just want to name that refinement a little bit. Either way, Peter, your point's still taken. The very, very final hours of life, you're not generally reviewing much. You're not having big philosophical conversations at that point. In so many ways, whether by medication or force of the disease, it's too late.

    12. PAPeter Attia1:33:06

        Which I think speaks to what you said earlier, that there really is no time like the present to say what it is you want to say to people who matter. It's not the movie where your final breath is asking for forgiveness or telling somebody you forgive them or that you love them. That's very unlikely to happen.

    13. BMDr. BJ Miller1:33:24

        That's very unlikely to happen, as is anything sort of cleanly, like closure. I love pointing this out to folks. One of the things in my world and in palliative care world, one of the things you want to forestall with knowing so much pain's coming is you want to forestall the avoidable regrets and avoidable pains. But you're not necessarily going to get there in your final breath.

12. 1:33:45 – 1:39:45

    The story of Randy Sloan—a case study of playing life out

    1. PAPeter Attia1:33:46

       Tell me the story about Randy Sloan. How did you meet him?

    2. BMDr. BJ Miller1:33:49

       Randy was a beautiful young man. So I met Randy, he worked at a motorcycle shop. So when I first met Randy, one of my wishes for myself once I became an amputee was to get on a, back on a motorcycle at some point. I've always loved biking. I'd always wanted to get on a motorcycle. Every once in a while, I'd swing through a motorcycle shop and see if there was any way to convert a bike, and every time I walked in there, I couldn't get anyone to sort of take it on. I think they all just freaked out like, "No way, dude. We're not putting you on a death machine." Never, I didn't try that hard, but I never could get anyone really interested in. One day I walked into a place called Scuderia West here in San Francisco and just met a wholly different energy, and these guys were actually interested in trying to make it happen, saw it as a creative exercise, and that's exactly the spirit you need. And Randy was the mechanic who put his hand up as wanting to help make this happen. So Randy, he was a bike mechanic, and he took my bike, and he managed to figure out a way for me to operate it with just one hand by a series of modifications. And so he helped make this dream come true for me. And it was beautiful for both of us. He loved making it happen, and I sure loved that he did. Then we had this gorgeous, like, teary moment when I picked up the bike and rode off into the sunset. So it was just a beautiful but, you know, time-limited interaction with Randy. And then not that much longer, I can't remember now, months or maybe a year later, and Randy was in his mid-20s, by the way. Randy ended up, somehow his mother reached me and let me know that Randy was in the hospital and something really big time was going wrong. And Randy and I had remembered each other because we were both moved by this story, and his mom reached out, and he knew I was a doctor, so blah, blah, blah. Eventually, I got to Randy's bedside, and Randy had been walking up a hill in San Francisco, found himself a little out of breath, went to urgent care. They took an X-ray, and he had turned out to have mesothelioma.

    3. PAPeter Attia1:35:54

       Which is essentially unheard of in someone in their 20s. I mean, this is a cancer that is almost exclusively associated with long-term asbestos exposure in elderly folks, and I don't know enough about motorcycles to know if there was asbestos in them. But even if there was, you'd think this is something that would still be 40 years later.

    4. BMDr. BJ Miller1:36:14

       You're right. So total freakish. And even if he had had exposure, I mean, it's rare to find exposed to asbestos these days, much rarer. But at that age, you just don't have even time to develop the cancer. It takes a while after exposure. So just a real mystery how this young man came down with widely metastatic mesothelioma. Even at the time of diagnosis, scans revealed it was in his brain stem. He's one of these guys who went from walking, talking, to that day was in the hospital on death's door, and people scurrying around trying to make a plan what to do. I met him. I walked into that situation, and by the time I even got to the hospital, he had had a dose of whole brain radiation because brain stem lesion was very precarious, and they needed immediate care. So he had already been radiated within hours, and I walked into a situation. Here's a young man trying to deal with this diagnosis, come to terms with it, and all that it meant, and it meant that his life was measured in weeks at that point, right from the time of diagnosis. So I became his palliative care doctor, and we were together for the rest of the time, and we got him into-- I saw him into-- At that point, I was working at Zen Hospice Project in San Francisco. He moved in there with us, and he played his life out with us. It was an amazing experience. I think one of the most amazing things about it, besides sort of the medical, like mesothelioma and this young man, blah, blah, blah, the, the really interesting stuff was how Randy responded to this diagnosis. And he and his mother and I were all, it's just too, didn't make sense. It was too soon. So we were all gearing up to think that somehow treatment was gonna help him. It was a sober conversation. There was nothing that was gonna help him at this point. except for love. That one dose of whole brain radiation really threw him for a loop. I'm trying to talk to him about the fact, trying to bridge him to the point, to the realization that he has no good cancer fighting options. And you're watching this guy's world shrink miserably by the second. And to find a way out of this tailspin and to find a way forward, we had our dutiful kind of palliative care conversation, which included a question in there eventually about like what was really important to him. What about him that he want to protect as his body was falling apart? What did he love most about himself? Somehow the question to Randy became, what are you most proud of in yourself? As a young man in development, it seemed like an important question. And his answer was immediate. His answer was, I want everybody I ever come into contact know that I love them. He answered the question immediately. It was remarkable coming out of a 27-year-old bike mechanic. So there it was. I said, okay, we need to keep you as comfortable and conscious as possible for what time you have and be in a position that your friends and people can visit you. So that meant let's get you in the hospice house out of your teeny apartment, walk-up apartment where you have three roommates. Let's get you into this hospice house. Let's get you out of the charade of treatment. Let's treat your symptoms and open up your door and get as many people in here as you want. And that's what we did. He just had a steady stream of visitors. He just basically became this radiant beam of love for what time he had and just made sure to love as many people as he humanly could. And with that, his mother and his stepfather came out and got married at the hospice house around the time he died. He got in the bay one more time for a swim. He got to be with his dog

13. 1:39:45 – 1:45:45

    Hastening death with physician-assisted dying: Legality and considerations

    1. BMDr. BJ Miller1:39:45

       and he let everyone know what Randy meant was love. And that became his legacy. And he died smiling and quickly. This all transpired over what felt like hours.

    2. PAPeter Attia1:39:57

       What role does euthanasia play? I'm ashamed to admit I'm a little bit ignorant about the legality of it state by state. Obviously, I know that Oregon is a state where it's legal. How many states in the U.S. have legalized euthanasia or some form of physician-assisted suicide?

    3. BMDr. BJ Miller1:40:13

       I believe the number is now nine. I have to double check, but there's still, it's unfurling as we speak. There's efforts going on in every state house, but I'm pretty sure the number is nine. The first was Oregon in 97, California in 2016, and others have followed suit. Montana, Oregon, Colorado, California, DC, others that I can't remember right now. It's coming slowly but surely state by state.

    4. PAPeter Attia1:40:40

       Has it demonstrably changed the practice of hospice or palliative care? Or is it almost moot because so much of threading that needle, as you described it, effectively, it doesn't happen maybe in as dramatic a fashion, but in the end-of-life care that you're discussing, for example, in the case of someone like Randy, if Randy had said, let's say a few weeks sooner, I want to go down the path of euthanasia, what would have been different than what he ultimately ended up doing at Zen Hospice?

    5. BMDr. BJ Miller1:41:17

       There was a moment there I could imagine he would have really elected it. The world was falling apart too quickly. It was too painful for a little while there for Randy to see straight. The process, we can talk, is a little bit of wonky. There's a two-week wait. You need to have two physicians. You need to write a letter. There are fail-safes because what the state wants to avoid is it making it too easy for people to do something that they otherwise might regret because I think many of us have moments where we'd just as soon get off the planet, especially when we're dealing with something like a terminal diagnosis. It's a funny thing where life's ending soon. Some folks have this response, well, okay, I'm dying. So they're, okay, now that I realize I'm dying, well, now I can't die soon enough. It's almost like once you pierce the veil of indefinite life, which people really long for, on some levels think they long for, then all of a sudden they're terminal and then they can't die soon enough.

    6. PAPeter Attia1:42:09

       It's sort of a final act of control and a bit of an F you to death. Well, you think you're inevitable. I'll show you.

    7. BMDr. BJ Miller1:42:16

       It's the quit before getting fired impulse in some ways. There are other ways. There are many things that drive the impulse, but that's a sort of a side note. But to answer your question, I mean, if Randy had enacted this procedure and ended his life, hastened his death before nature otherwise would have had it, well, Randy would have died sooner. Randy would have been able to schedule the moment of his death. It would have been something. And on some level that could have served him. But the realization that Randy had a mission to sort of prove love, to show love, to be love, he had a reason to keep going. There's a moment where if it had been too easy for him, he probably would have elected to hasten his death. But because he didn't and because he let it play out a little bit longer, he got to a lot more people. He had a lot more final moments with friends. He got into the bay and he had the pride of playing his body all the way out. He played every cell all the way out, which for Randy served him very, very well. And I think it makes the point one of the problems with the dying laws. And let me just pause there too, by the way, Peter, the language of physician-assisted suicide has gone away in favor of aid in dying or assisted dying to get rid of the word suicide, emotional baggage around that word. And importantly, these laws are for people who already have a terminal diagnosis and for whom death is coming soon. So it's importantly different. But if we had just ceded his wishes and said, oh, sure, you want to die, Randy, sooner or later? Yeah, we'll make that happen. Just in the name of helping him not suffer, we could have made that happen and it would have been a mistake in his case. Because as I think a lot of us know intuitively or explicitly, a meaningful life, a good life is not the absence of suffering. Suffering teaches us too much. It's too important a vehicle for us, actually. A full life requires it. And I don't mean to castigate anyone who does choose to hasten their death. For some people, it is exactly the right decision when it is seen as a meaningful response, not a flight from suffering, but a moving towards something meaningful. And for some people, a final act of will is very meaningful. But for more people, what ends up being more meaningful is them being more than their pain, being more than their suffering, and letting their body play themselves all the way out and dealing with and adapting every moment along the way, trimming their sails along the way, letting themselves be changed, letting themselves grow right up until the moment of their death. That's actually a more meaningful pursuit for the bulk of people.

    8. PAPeter Attia1:45:02

       It's really that pain matters more than being numb.

    9. BMDr. BJ Miller1:45:05

       Yeah. Yeah. When it comes down to it, when it comes down to it, for most of us, and this is a realization that came clear to me when I was in my hospital bed, pain is very obnoxious, and I don't like this stuff. We can be more than our pain. Pain isn't ultimately avoidable in a full life, like I said, and it can teach us some things. And really, I'd much rather feel some exceptions, and there's ways to paint this otherwise. But in general, I'd rather feel something, even if it's pain, than feel nothing. Anesthesia is a way-- A numbness is a way to die before we have to die. That seems to be a bigger tragedy to me than

14. 1:45:45 – 1:54:42

    The use of psychedelics in end-of-life care, and what BJ is most excited about going forward

    1. BMDr. BJ Miller1:45:45

       is death in the first place.

    2. PAPeter Attia1:45:47

       Have you had any experience with the use of psychedelics in end-of-life care? Are, are people doing any research on this? Obviously, I'm aware of the research on psilocybin in patients with cancer. I believe there was research done, um, helping with end-of-life depression. Are you aware of any other agents that are used besides psilocybin for that research? Anything with MDMA? I'm not sure if-- Which obviously I know MDMA is being used to treat PTSD, but what does the scope and breadth of that look like today?

    3. BMDr. BJ Miller1:46:22

       Substance is being researched along these in-- for end-of-life anxieties and fears of death. We're studying a patient population dealing with terminal illness or serious illness. I can't quote to you all the latest details of studies. There are studies ongoing for, yes, for psilocybin, but also for MDMA. And then related, similar but different, is ketamine and the way ketamine is proving its way to therapeutic, new therapeutic values. So yes, I'm most excited around the research around MDMA and psilocybin. And the research so far, we've got a little ways to go, but the data are pretty darn stunning. The impact is huge and offers access. The psilocybin stuff's the most remarkable, I think. One guided session where setting matters, dose matters, the integration process matters. It's not just people going out in the woods and having fun. But with this process, there are really no adverse to, events to speak of. People who are gripped by a fear of death, gripped by a sense of meaninglessness and not belonging and not feeling connected come out of this one session losing their fear of death, feeling part of something larger than themselves, having a totally different relationship to fear. Uh, this is one session. The effect lasts for months. It's not just a chemical effect per se. We don't have anything remotely like this to offer in medicine. The closest thing I have in my conventional work as a doctor is someone comes to me with death anxiety, two things I can do. I can talk them out of it and try to f- with enough time, we can find a new way of seeing themselves in the world, a framework that allows them to feel like they belong in their own framework. It takes time if we can get there at all. And the other thing I can do is if you're really anxious, well, I can numb you out. I can give you Valium or whatever else. I can put a wet blanket on your system. That's the best we've had to date. I don't have a intervention that helps me connect you to meaning, connect you to the cosmos, but these medications are offering exactly that and it is beautiful. So we've got a little ways to go, but I am thrilled for this potential.

    4. PAPeter Attia1:48:33

       Are these tools the things you're probably most excited about in, in your field in terms of being able to kind of revolutionize how you're able to help the patients who want or need that type of intervention? Or is there anything else that even rivals this?

    5. BMDr. BJ Miller1:48:50

       Yes. There are two things. So strictly speaking from a kind of medical, medication-y, medical physiology-ish kind of overlay, the medical lens, I would say the research going on around these substances, psilocybin, MDMA, ketamine, et cetera, are my favorite thing going. Maybe even bigger, maybe the other thing that gets me more excited is the work going on on the periphery of healthcare and outside of healthcare. That conversations like the one you and I are having, Peter, and I thank you for it up and down, one of the things we're doing is we're kicking the conversation beyond just medicine. It's like we were saying earlier about the design flaw that medicine focuses on the disease, not the person. And one of the great things that happens when we focus on the person is that we in medicine become part of something larger than ourselves. And we can partner with architects and artists and designers and other disciplines and death doulas and quasi-medical folks and alternative and integrative medicine folks. All of a sudden, we are part of a much larger family working on behalf of something much larger than even medicine. And that's where I get really excited, that people, that society, that culture is waking up to these issues. Death has become a medical issue It doesn't belong there. Suffering and death are way bigger than medicine. Medicine may have something to offer this. Getting back to your question, the thing that I'm more excited than anything else is the rise of commerce, multidisciplinary work, other institutions and vehicles tuning into this idea of life and death so that medicine doesn't have to carry all that water by itself. That people are gonna start taking care of people and not handing themselves over to doctors to do the trick.

    6. PAPeter Attia1:50:39

       PJ, I really want to thank you because your work and the work of people like you has actually had quite a profound impact on the way I think about life. I'm in the process of sort of barely putting the finishing touches on a book about longevity, and I've kind of come to the realization lately it's very difficult to do this without writing about death in some way, but not as an enemy, but more in a manner that is sort of symbiotic with life. So maybe not quite a friend, but certainly not a hostile combatant. I just think the way that you've been able to speak about this so eloquently for many years now has been a great benefit to not just the people you've helped, which is obvious, but I think those of us who are presumably a little bit further from needing that help.

    7. BMDr. BJ Miller1:51:30

       Peter, I can't wait to read that book, man. And that is right on. I think you will help so many people. Just this frame shift of finding a way to include death in your view of reality is one of the great services you can do the world, man. And I, oh, I can't wait to read it.

    8. PAPeter Attia1:51:45

       [laughs] Well, thanks, PJ, and thanks more than anything else for all of your time this afternoon.

    9. BMDr. BJ Miller1:51:51

       Thanks for having me, man. Thank you so much.

    10. PAPeter Attia1:51:53

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Episode duration: 1:54:42