Peter Attia MD354 – What the dying can teach us about living well: lessons on life and reflections on mortality
EVERY SPOKEN WORD
145 min read · 28,832 words- 0:00 – 1:38
Intro
- PAPeter Attia
I want to understand more about living, and I have a, an idea that we could learn a lot from people who are dying.
- BMBJ Miller
One thing to get right out of the gates here is bodies die. Living things die. I think a lot of us absorb a notion of death that it's some foreign invader-
- PAPeter Attia
Mm-hmm
- BMBJ Miller
... or something that comes out of the woods and grabs us, and otherwise I was just fine, and then not.
- PAPeter Attia
[laughs] I'm wondering if I should be in palliative care right now, by the way.
- BSBridget Sumser
Yeah, I mean, the reality is-
- BMBJ Miller
[laughs] I mean-
- BSBridget Sumser
... palliative care is just good healthcare.
- PAPeter Attia
Yeah. [laughs]
- BSBridget Sumser
It is just-
- BMBJ Miller
Yeah, that's one of the crazy things
- BSBridget Sumser
... whole person-
- PAPeter Attia
I mean, it's a rebranding, but yes
- BSBridget Sumser
... and, yes.
- BMBJ Miller
Yes.
- BSBridget Sumser
Yes.
- BMBJ Miller
It really does.
- PAPeter Attia
Are there certain regrets that people have shared with you more often than others?
- BMBJ Miller
What they all seem to have in common is they regret not letting themselves feel, artificially or accidentally putting a wedge between you and anything.
- PAPeter Attia
How much have either of you followed the, the sort of psilocybin work, the Roland Griffiths work?
- BSBridget Sumser
I think it can be amazing.
- PAPeter Attia
Medical decision-making, power of attorney, things like that.
- BMBJ Miller
So one sort of public service announcement here is advance directive's very important, and-
- PAPeter Attia
You can download a form online.
- BMBJ Miller
Yes.
- BSBridget Sumser
Yeah.
- PAPeter Attia
Like, this is a free-- You don't need a lawyer to do this.
- BMBJ Miller
No, you do not need a lawyer to do this.
- PAPeter Attia
Yep. What about the role of forgiveness?
- BMBJ Miller
I would say more commonly what I see people needing to learn how to do is forgive themselves.
- 1:38 – 13:06
The personal journeys of BJ and Bridget into end-of-life care, and the connection between living and dying
- PAPeter Attia
BJ, amazing to have you back again, and Bridget, great to meet you-
- BSBridget Sumser
Yeah, thanks for being... Yeah
- PAPeter Attia
... for the first time. Thank you guys both for, um, for coming out here. Um, you know, BJ, you and I go way back. You're a previous guest on the podcast, and, and we've, we've spoken a little bit about some of the topics we're gonna get to today. But when, when I reached out to you a few months ago to talk about this idea, um, you immediately suggested bringing Bridget along.
- BMBJ Miller
Mm-hmm.
- BSBridget Sumser
[laughs]
- PAPeter Attia
So, um, let me just share with folks what I wanted to talk about, and I would love for you to share why you felt that this would be a great three-person discussion as opposed to a two-person. So-
- BMBJ Miller
Mm.
- PAPeter Attia
I reached out to you and I said, "Look, um, BJ, I wanna, I wanna understand more about living, and I have a, an idea that we could learn a lot from people who are dying." Um, and people who listen to this podcast know that I think that quality of life matters as much and potentially more than length of life, and a big part of that probably comes down to things that people think about during their life and during the end of their life, and maybe that there, maybe that there are regrets that people have that, that only surface at the end of life. So anyway, I kinda ran this idea by you, and, uh, actually, I think I ran the idea by you as do you even know anybody that would have-
- BMBJ Miller
Mm
- PAPeter Attia
... thoughts on this? And you said, "I'd love to talk about it," and-
- BMBJ Miller
Mm
- PAPeter Attia
... so.
- BMBJ Miller
Yeah. Well, first of all, thanks for having us, Peter. It's good to see you, buddy. Um, and I just love the setup for this conversation. Um, I think we're very happy to be talking to you in general, but also to kind of continue to form the it's not quality of life versus quantity of life-
- BSBridget Sumser
Mm-hmm
- BMBJ Miller
... kind of false dichotomy that you've done so well to r-r-reapproximate. Um, so we're really happy to be here and talk about this stuff. So, but why Bridget? I mean, so for me, um, a couple thoughts. I mean, one is I just love Bridget and her mind, and we get to work together in myriad ways over the years. And the subject, uh, you'll, you'll hear us again and again, we're gonna thwart the idea that there's an objective, an approach to death that is the way to go. Um, you're not gonna hear us citing much data because there, it's not a very well, it's not an easily studied phase of life, and o- what data do exist tend to be qualitative. Uh, but this, with all that subjectivity, it feels really important to have other voices sharing s- uh, their point of view on, on sort of a similar outlook. Um, so, uh, that's in part why Bridget. And also, too, for both of us, which is, Bridge, I don't mean to speak for you, but I think the, uh, one of the things we should get up front, too, is first of all, I haven't been, uh, my work in the last four years has pulled me farther away from being at a bedside, you know? And but either, both of us have spent many countless hours in hospital bedsides and other places that we'll be drawing from. But I think to get to the questions that you're interested in answering, so much of the work preparing for dying begins earlier in life or w- one way and another. So the idea that I think for your audience to imagine deathbed scenes, that in the final moments there's this great epiphany or a climax of some sort can happen, but that's really not the norm. A lot of the action is in the days, weeks, months, years preceding the death moment. I mean, death is a moment. Um, and so one thing I think we wanna get across as you've brought quantity and quality of life, we need to bring dying and living together. They are part of a whole. They're not at odds. And so that, so, a- and so when do we begin dying, Peter? Like-
- PAPeter Attia
The second we're born.
- BMBJ Miller
Exactly.
- PAPeter Attia
[laughs]
- BMBJ Miller
So in some ways, all of us have some access to this subject already. Bridget and I are just a little bit closer to it on some level, so.
- PAPeter Attia
Bridget, what drew you to this, uh, to this space? I, I'm sure this is a question you get asked the moment people-
- BSBridget Sumser
Mm-hmm
- PAPeter Attia
... find out what you do.
- BSBridget Sumser
Yeah.
- PAPeter Attia
It's, um, it is an uncomfortable place to, to stand.
- BSBridget Sumser
Yeah.
- PAPeter Attia
What, what's drawn you to it?
- BSBridget Sumser
You know, we all have our places in the world, um, and while this is an uncomfortable place maybe from the outside, for me, it is a pretty comfortable place, and that was sort of what got me there. I had many people in my life die Um, and I was in pretty close proximity to those deaths, and I wasn't freaking out. Um, and so there was something in me. I looked around, and a lot of other people were freaking out, and I was sort of like, "Oh, this is weird. Am I unaffected? Am I guarded in a way that makes it so I'm kind of numb?" And no, actually, it was more just that there was something in me that was okay around dying and also really curious about it. Um, so that's how I got to this work.
- PAPeter Attia
Can you say a bit more about that? What, what... If you're comfortable-
- BSBridget Sumser
Yeah
- PAPeter Attia
... what were some of the experiences you, you had growing up?
- 13:06 – 27:08
What dying looks like: the physical, cognitive, and emotional realities at the end of life
- PAPeter Attia
So a moment ago, you alluded to the idea that, um, kind of movie deathbed scenes-
- BMBJ Miller
Mm-hmm
- PAPeter Attia
... are probably the exception and not the rule.
- BMBJ Miller
Mm-hmm.
- PAPeter Attia
I wanna kind of explore this idea a little bit more, but I also wanna help people maybe understand, uh, at the population level what death really looks like. So on this podcast, we talk a lot about causes of death, right?
- BMBJ Miller
Mm-hmm.
- PAPeter Attia
People who listen to me are very familiar with the Four Horsemen, and we know about cardiovascular disease, and we know about cancer, and we know about neurodegenerative disease, and we can talk forever about these things. But we don't really talk about the very, very end, perhaps with the exception of a fatal myocardial infarction.
- BMBJ Miller
Mm-hmm.
- PAPeter Attia
Um, and about 50% of MIs are fatal. Um, but about 50% are not, and they're just setting you up for maybe heart failure or something else. So as difficult as it is, I'd love for you to sort of explain the mechanics of, of death, of-- And we can start with the more common cause of death, which is cardiopulmonary death. We could talk about brain death after. But I'd, I'd love for both of you to sort of describe what's happening both medically, socially, cognitively, like to the, to the individual through that process.
- BMBJ Miller
Peter, do you mean like the, the f- the moments leading to the death, the, as a body's shutting down?
- PAPeter Attia
Yeah. In those final hours-
- BMBJ Miller
Mm-hmm
- PAPeter Attia
... what is really happening? What does it mean to die of cancer, right? Like, well, you know, I think for many people, it's a very foreign idea that this woman had breast cancer. Okay, there were cells in her breast that all of a sudden acquired mutations. Those cells escaped from her breast and went to other parts of her body. But there's still a bit of a disconnect. Why did that-- why did the invasion of those cells to her bones and her lungs end her life?
- BMBJ Miller
Well, Bridge, you want me to talk a bit, little about sort of the medical, physiological stuff? Yeah. And you can talk about some of the social- Yeah, that sounds good. Does that sound right? Yeah. Well, starting with the sort of more kind of cut and dry, more f- anatomical, physiological things happening as a body's trying to die. And I like that phrase, trying to die, because we often find ourselves intervening in a body that's trying to die. It is one thing to get right out of the gates here is [chuckles] bodies die. Living things die. It's, uh, it-- I think a lot of us absorb a notion of death that it's some foreign invader or something-
- PAPeter Attia
Mm-hmm
- BMBJ Miller
... that comes out of the woods and grabs us, and otherwise I was just fine, and then not.
- PAPeter Attia
[laughs]
- BMBJ Miller
Mm-hmm. Um, no. Um, and as you know better than any, uh, of us, there are all sorts of things we can do to promote life, and there are a lot of ways we're wired to, to hang on to life and to run from anything that's a threat to us. Those are all true and all natural. Um, b- but included on the list of natural things that we do is die. So I, I, you know, it is-- That's what a body's supposed to do. I just wanna get that clear. [laughs] There's nothing wrong with you for dying. This is the way- Mm ... it's supposed to go. So your body knows how to do this. Mm-hmm. So let's talk about what the body knows how to do. I mean, in general, uh, depending on the cause of death, whether the pathway might be cancer, as you're mentioning, or heart disease or neurodegenerative diseases, there is a final common pathway of a body kind of shutting down, and it tends to shut down by organ system, you know. And it doesn't follow a neat and tidy pathway. It can happen kind of spontaneously in a kind of a moment. They're here, and then they're gone. But very often, especially these days, most of us, like 80-plus percent of us, will die of chronic illness. We will meet the thing that eventuates our death well in advance of the death. So we'll get that diagnosis that someday will be the thing that ends our life. Um, that's so-- That's its own. We could talk about that. That's its own kind of ball of wax that comes with that fact, whereas in the old days, many of us, most of us died more spontaneously. You're very alive, then you're very dead. Not a lot of in between. So in this in between thing, to get to, finally to your question, Peter, um, is, um, this sort of shutting down phenomenon. So in-- oftentimes, if we're trying to prognosticate, help a person or a family get a sense of how much time is left, um, we're looking at things like, are they in and out of bed, you know, much? Are they getting up and out of bed? So if you're asleep on the couch or in the bed 50% of the day, you know, um, and if that's sort of a progressive process, more and more fatigue, more and more tired, that usually, in the context of chronic illness, tells us we're heading towards the end. Um, an interest in food and fluid is a big one. So a body trying to die, a GI tract that's on its way to shutting down, will stop sending s- hunger signals. And this is a big one for the audience to hear because a lot of us You know, food equals nutrition equals nourishment equals life. So if we see someone we love or ourselves not eating, the impulse would be, "Well, put some food into us."
- BSBridget Sumser
Mm-hmm.
- BMBJ Miller
That's life. I don't want someone to starve to death is often what we hear.
- BSBridget Sumser
And also love, right?
- BMBJ Miller
Yeah.
- BSBridget Sumser
That's how we show our care and-
- BMBJ Miller
Exactly. Symbolically, the act of feeding another is, you know, the nourishment, the love, to your point, Bridget, comes with it. There's so much around food. But then before we cut over to Bridge to explain more, that's, that good piece of the puzzle. You know, the body, again, is sending you a signal, "Don't put food in me because it will hurt." If a gut is not able to process the food, it sits in place and can cause pain. Same with fluids. If we're forcing fluid into a body that's trying to die, that fluid will pool and cause trouble. So the judgment to call when to push the food and fluid and when not is up to really a dialogue and a sort of a song and response with the patient. Once, you know, you might try a little bit of fluid, and if that ends up in their lung or ends up swelling, then we pull back. But back to your question, so as a body's trying to die, it will stop sending signals for that food and fluid, and that's to be generally respected, not pushed past. Um, mental status, so people often get really fuzzy in their thinking or all, uh, and, and delirium is very common. Um, so oftentimes they'll, they'll be disoriented, think it's 1912 and they're in a forest somewhere when they're in a hospital bed. Um, so that's very common.
- PAPeter Attia
And BJ, delirium is not uncommon in the hospital.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
A lot of times with otherwise very healthy patients who are in the hospital to get surgery-
- BSBridget Sumser
Mm-hmm
- PAPeter Attia
... uh, the loss of circadian rhythm, the use of narcotics-
- BSBridget Sumser
Mm-hmm
- 27:08 – 33:09
How historical perspectives on death contrast with modern experiences of dying
- PAPeter Attia
of the things I've been thinking a lot about lately is how people died hundreds of years ago and thousands of years ago.
- BMBJ Miller
Hmm.
- PAPeter Attia
So let's use thousands of years ago, before, before the advent of any medicine at all. So admittedly, they weren't living that long, and admittedly, um, you know, life expectancy would've been into the mid to late 30s. Um, but people always confuse that for meaning nobody lived beyond that. Of course, that's not true. It just means so many people died young, right? Like infant mortality was through the roof, tons of trauma and infection. But clearly there were people that were living into probably their 60s.
- BMBJ Miller
Hmm.
- PAPeter Attia
And I'm sure some of them were dying of cancer, right? So I wonder, absent any medicalization of death, what death looked like then. Do we know anything about this?
- BMBJ Miller
I mean, I don't from the books.
- PAPeter Attia
Hmm.
- BMBJ Miller
I mean, I can imagine, but, and I think we knew that people died more acutely.
- PAPeter Attia
Mm-hmm.
- BMBJ Miller
But to your point, that's probably because they just didn't ha- they didn't know they were harboring a tumor or-
- PAPeter Attia
Yep
- BMBJ Miller
... atherosclerosis or whatever else. [laughs]
- PAPeter Attia
Mm-hmm.
- BMBJ Miller
So it looked like they were... And, and I think suffering, I think an average human had a different relationship to the day-to-day suffering and pains that went with being alive.
- PAPeter Attia
[laughs]
- BMBJ Miller
And I think, and modern life has been tempting, has tempted us with the idea that we could always be comfortable, and that pain is a problem to root out and fix quickly. Get back to the norm, which is comfortable always, which is just crazy talk. So I think part of it is we've induced people's pain by offering these fixes to them. Um, by virtue of having something to offer your suffering, we might be more primed to tune into our suffering and seek that fix for it. And we've kind of pulled this ourselves forward over time through modern life in such a way that, uh, back in the old day, I don't imagine that people were so distracted by their daily aches and pains. Um, so I'm kind of getting off your question. I don't think we know, at least among us, I don't think we know from a historical... Like, I couldn't tell you factually what used to be the case. But watching patterns and knowing that human nature hasn't probably changed so much in the last couple hundred years per se, I think one is that people harbored a much, they lived closer to death. Death, well, they didn't... And lived closer to pain. And so in some ways they suffered less because it didn't have, wasn't tainted by a sense of injustice or why me. I'm projecting.
- PAPeter Attia
Hmm.
- BMBJ Miller
But that's my guess.
- PAPeter Attia
Which is, which is an irony, because as I think about a person dying in their 80s today, I think of that as kind of a remarkable privilege.
- BMBJ Miller
Oh, yeah.
- PAPeter Attia
Like that we could be alive in this period of time where we could make it into such an old age. But yet at the same time, it feels like a tragedy, even though-
- BMBJ Miller
Yeah
- PAPeter Attia
... ironically, the tragedy is those people that were dying thousands of years ago. I, I wanna ask you a question, Bridget, unless you wanted to say something else about that, but I was gonna ask you a question about pain.
- BMBJ Miller
Hmm. Please.
- PAPeter Attia
Okay. So-
- BMBJ Miller
Yeah
- PAPeter Attia
When you're talking to somebody who makes the decision to enter hospice care or palliative care, and I, I wanna come back to making sure people understand-
- BMBJ Miller
Mm.
- BSBridget Sumser
Yeah
- PAPeter Attia
... the similarity and difference there.
- 33:09 – 38:42
The difference between palliative care and hospice care
- PAPeter Attia
Given how much there is to unpack there-
- BSBridget Sumser
Yeah
- PAPeter Attia
... and now I realize I wanna go into all of that-
- BMBJ Miller
[laughs]
- BSBridget Sumser
Yeah
- PAPeter Attia
... let, let's take the step back and-
- BSBridget Sumser
Yeah
- PAPeter Attia
... help people understand the difference between palliative care and hospice care.
- BSBridget Sumser
Yeah. Great. Um, so, uh, I sort of think of it as like palliative medicine is the big umbrella, palliative care is the big umbrella, um, and hospice care is sort of like the very end or the, the sort of, um, backside of the umbrella. Um, palliative care is a medical specialty usually provided by a team for folks with a serious illness. Um, serious illness can be defined lots of ways and is defined differently in different health systems, uh, kind of depending on how they're staffed and how their palliative care programs are kind of created to function, what, what purposes they're serving. But, um, some of the, and BJ, you jump in at any points, but, uh, some of the big differences is that, um, with palliative care generally, there's no limitation around, um, any disease directed or modifying therapies you might be, uh, pursuing. Um, and you don't have to be dying inherently, um, or even clear that you're facing death. You could be diagnosed with a very serious cancer that actually has pretty robust treatments, and you could live for quite a long time. Um-
- BMBJ Miller
Meaning many, many years.
- BSBridget Sumser
Many, many years. Yeah.
- PAPeter Attia
So, so in that situation, what is the objective of the palliative care team?
- BMBJ Miller
Mm.
- BSBridget Sumser
Mm-hmm. Um, to think really holistically about who is this person, um, where are they in their lives, how do they make sense of what's going on, what do they understand about their illness, who's supporting them, um, all really grounded in this, are there ways that we can help this person feel sort of as well as possible, um, to treat the symptoms related to serious illness, to treat the symptoms related to the treatments of different serious illnesses, um, uh, but in the context of a whole life, which means, you know, you could have, on, on a clinic day, you could be seeing two people that seem on paper generally the same, right?
- PAPeter Attia
Mm.
- BSBridget Sumser
Similar age, you know, demographic backgrounds, diagnoses, and be dealing with really different things when you walk in the room. Um, what would you add?
- BMBJ Miller
Yeah, I mean, no matter how you slice it, the goal is, is the focus is quality of life-
- BSBridget Sumser
Yep
- BMBJ Miller
... period, whether it's palliative care or hospice. And by the way, for both Bridget, so it's inherently interdisciplinary, as Bridget was saying. That's why Bridget's a social worker and I'm a medical doctor, but we work with chaplains, nurses, music thanatologists, potentially art therapist volunteers. It's, when the subject matter is suffering and quality of life, you know, there's no one discipline that has a lock on that stuff. So, but whether it's palliative care or hospice, the focus is really on helping someone feel as well as possible, and that is an inherently ho- holistic question because it gets at their identity-
- BSBridget Sumser
Yes
- BMBJ Miller
... it gets at their physiology.
- BSBridget Sumser
As well as possible as defined by them.
- BMBJ Miller
Yeah.
- BSBridget Sumser
Right? And so for someone, that could mean very aggressive pain management, and for someone else, they could have a different relationship to the experience of pain, and they wouldn't put that at the top of the priority list. They might put more concrete or relational kind of supports You know, higher up on their list. So our, you know, the beauty of our jobs and our work is to meet this person in this moment in time and identify what's up for them, what's most important, and sort of where, where it is that we get to meet them to work towards quality of life as defined by them.
- PAPeter Attia
So what is the transition then for an individual from being under the broad umbrella of palliative care into a more narrow, defined level of care as hospice?
- BSBridget Sumser
Yeah. I mean, I think there's the, there's some idea... You know, there's some, like, uh, world of ideals in that, and then there's what actually happens. And the reality in this country is that, um, folks are admitted to hospice very, very late. You know, the length of stay, um, on a hospice program in this country is something like a three-week average, and so it's actually quite little bit of time. Um, and when I think about when hospice is a good fit for folks, I think about, um, wanting to stay out of the hospital.
- PAPeter Attia
Mm-hmm.
- BSBridget Sumser
Being in a place where they are ready to or being forced to grapple with the reality that there is not, um, anything left to do to change what is happening in their body, to change the cancer, to delay the neurologic illness, um, uh, and/or folks that are more explicitly ready to be supported in their end-of-life care or in their transition.
- BMBJ Miller
And are just done with-
- BSBridget Sumser
Yeah
- 38:42 – 43:20
The systemic challenges surrounding hospice care: why patients often enter it too late to receive its full benefits
- PAPeter Attia
Now, you're saying the average length of stay in hospice, and, and really there are, as, as, as I'm aware of it, and so correct me if this is not correct-
- BSBridget Sumser
Mm-hmm
- PAPeter Attia
... there seem to be three paths to hospice. There's hospice in your home, where you go back to your home and a hospice team comes there and cares for you in your home.
- BSBridget Sumser
Yeah.
- PAPeter Attia
There is a palliative care ward inside a physical hospital that provides hospice care, but it's still within a hospital. And then there are outpatient hospice facilities, dedicated facilities for hospice that are not hospitals.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
Would those three encompass the, the, h- how hospice care is delivered, or is there another one?
- BMBJ Miller
Sort of, in terms of sites of care.
- PAPeter Attia
Okay.
- BSBridget Sumser
[laughs]
- BMBJ Miller
This is where it starts to get really wonky.
- BSBridget Sumser
It's complicated, yeah.
- BMBJ Miller
It's complicated.
- PAPeter Attia
Mm.
- BMBJ Miller
You can shut us up, Peter. So many different, there's so many tributaries.
- BSBridget Sumser
Mm-hmm.
- BMBJ Miller
But to kinda back up a little bit, it may be orienting for your audience here. So as Bridget's, um, totally correct, palliative care is the larger umbrella. Um, hospice is the sort of subset of palliative care devoted to the final m- months of life. So to be real clear, same philosophy in a lot of ways, but by insurance and reimbursement lines and by policy designation, you can get palliative care alongside curative intended care.
- PAPeter Attia
Yes.
- BSBridget Sumser
Mm-hmm.
- BMBJ Miller
You cannot do so in hospice. When you go onto hospice, you have to give up that curative intended care, like we were saying.
- PAPeter Attia
And not just that, I mean, you can't have an IV line, right? Like-
- BMBJ Miller
Gener- generally speaking.
- PAPeter Attia
Yeah.
- BMBJ Miller
Generally speaking. So there is, it is a, th- the way it's set up is a crossroads. We'll make the point that dying and living look a lot alike, but in the man-made world of policy and healthcare structure, there are some-
- BSBridget Sumser
Mm-hmm
- BMBJ Miller
... important forks in the road. So one of them to go onto hospice is you no longer have access to or don't want curative intended care and things that go with it, and also someone somewhere has to cer- certify that should nature run its course, you likely have six months or less to live. So those are the two forks in the road to qualify for hospice. Palliative care, those are, neither of those applies for palliative care.
- PAPeter Attia
Yeah.
- BMBJ Miller
So that's a really important distinction. So I'm trying to kinda, uh, and one other point to make there is while palliative care is the larger umbrella, hospice is the older one. So we [laughs] started in this country with hospice.
- BSBridget Sumser
Mm-hmm.
- BMBJ Miller
And since the 1982, when Medicare got in the business, we had those restrictions, and then people in the ni- 80s and '90s realized, like, "Why are we waiting till the final weeks and months of life to deliver this kinda loving care?" And so the palliative care was born as a younger, bigger sibling to encom- to get outside-
- 43:20 – 47:55
How delayed hospice referrals and unspoken preferences often prevent patients from dying where and how they truly want
- BMBJ Miller
not wasting our time doing things that don't help us.
- PAPeter Attia
And, and we also get into these situations where, you know, my wife tells a story about one of her very close friends who died, uh, in 2018 from, um... She had an abdominal cancer, and her wish was to die at home.
- BMBJ Miller
Mm-hmm.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
She was readmitted, I think, for a bowel obstruction, and she was never able to get out of the hospital.
- BSBridget Sumser
Yeah.
- BMBJ Miller
Mm-hmm.
- PAPeter Attia
Right. So she died in the hospital, and-
- BSBridget Sumser
Yeah
- PAPeter Attia
... this is also probably not an uncommon situation where I think back to patients I took care of who heroic measures were done, right? So maybe someone had a, a, an aortic dissection or a ruptured abdominal aortic aneurysm. They're old. They already have organ failure. You go ahead and do it, but this is a person who was cognitively completely intact when they came in. Three weeks later, they're intubated. They're on dialysis. You can't transfer that person to hospice.
- BMBJ Miller
Right.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
Right? I mean, because the moment you turn off-- 'cause they can't have the ventilator. You can't have the dialysis.
- BMBJ Miller
Right.
- PAPeter Attia
The moment you turn those things off, the person expires, so they're going to expire in an ICU.
- BMBJ Miller
Yeah.
- PAPeter Attia
Never what they wanted probably, but they're... So, so how often do you f- do you, in your experience, are people in that no man's land where they now have missed the window to go into hospice?
- BMBJ Miller
All I can say is not uncommonly. I don't have numbers to cite, but that is not an uncommon story. Um, and that's why if the second I hear someone say, "I never wanna die in a hospital"-
- PAPeter Attia
Mm
- BMBJ Miller
... my ears go up as a potential refer. Like, then this person-
- BSBridget Sumser
Yeah
- BMBJ Miller
... should really, we should really look to get this person to hospice as soon as possible.
- PAPeter Attia
But, but BJ, I've never met anybody who wants to die in a hospital.
- BMBJ Miller
Oh, I-
- PAPeter Attia
I mean, I'm gonna, I'm gonna go on record right now and say I don't wanna die in a hospital.
- BMBJ Miller
Mm-hmm.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
Now, I hope that my death is 35 years away, 40 years away if I'm lucky.
- BSBridget Sumser
[chuckles]
- PAPeter Attia
I don't wanna die in a hospital.
- 47:55 – 59:30
The realities of home hospice: challenges, costs, and burdens placed of families
- BMBJ Miller
care plan.
- PAPeter Attia
Yeah. Let's give a couple of examples of where that discussion has relevance.
- BMBJ Miller
Hmm.
- PAPeter Attia
Right? So now let's go back to a couple of these examples. So you're, you, you've had that discussion when a person is still in palliative care before transitioning to hospice. Are you sometimes waiting to have that discussion in hospice for the first time?
- BMBJ Miller
Which conversation, Peter?
- BSBridget Sumser
About where?
- PAPeter Attia
Yeah, where.
- BMBJ Miller
Oh.
- BSBridget Sumser
I think it depends. I mean, I think it depends on the kind of clarity or adamance a person comes into. So it might be one of the first conversations-
- PAPeter Attia
Mm
- BSBridget Sumser
... you have, right? If somebody's had a really visceral experience in their own life, it could be the first thing they're thinking of with the diagnosis of, um, you know, advanced cancer or something. Um, and it may be a conversation that's happening sort of weeks into hospice, depending on how things have evolved with the family and/or how they're changing. Um, so I think, you know, I do wanna just step back, which is like I have seen very beautiful hospital deaths.
- PAPeter Attia
Yeah.
- BSBridget Sumser
And I've also been connected-
- PAPeter Attia
Yeah. I think the reason I'm so jaded is-
- BSBridget Sumser
Yeah
- PAPeter Attia
... when you come from where I came from, you're running codes on people who are dying.
- BSBridget Sumser
Of course. Yeah
- PAPeter Attia
Right? You're... They're dying while you're doing chest compressions on them, and you're shocking them, and you're-
- BMBJ Miller
Breaking ribs and you're doing-
- PAPeter Attia
Yeah, yeah.
- BSBridget Sumser
Yeah.
- PAPeter Attia
And, and so yes, I, I should-
- BSBridget Sumser
Yeah
- PAPeter Attia
... really clarify, I'm coming at it from a very narrow point of view-
- BSBridget Sumser
Sure
- PAPeter Attia
... that has maybe, maybe skewed my view too much. Maybe.
- BSBridget Sumser
Sure. I mean, we're all-
- BMBJ Miller
And that's worth a conversation
- BSBridget Sumser
... we're all informed by-
- PAPeter Attia
Yeah
- 59:30 – 1:10:15
How proactively engaging with the reality of death can avoid unnecessary suffering and promote a more peaceful ending
- BMBJ Miller
... it's, it's, yes-
- PAPeter Attia
Absurd
- BMBJ Miller
... absurd. Yes.
- BSBridget Sumser
Well, and the la- you know, if we're thinking about the last weeks and months and the swirl that's happening because you're getting sicker, all of these things are changing in your life, your, you know, so much is changing, you're probably, your, your touch with the healthcare system is really high. That in that time to also get really sober, maybe for the first time, about what's important to you, where do you wanna be, can you see this thing clearly? Like, it's almost an impossible time to do-
- PAPeter Attia
Mm-hmm
- BSBridget Sumser
... that.
- PAPeter Attia
So let's, let's focus on that for a second-
- BSBridget Sumser
Yeah
- PAPeter Attia
... because this strikes me as a cultural issue.
- BSBridget Sumser
Mm-hmm.
- BMBJ Miller
Mm-hmm.
- PAPeter Attia
Right? It, uh, and you, you two live in this world. Um, I would say I'm adjacent to the world, but I don't live in it, and most people aren't even adjacent to it.
- BSBridget Sumser
Yeah.
- PAPeter Attia
So death is a really foreign thing. The reason I suspect that this can gets kicked down the road so much, so much in fact that after all the can kicking, people get to the end of their life, there's no road, and there's just a pile of cans. So what is it culturally that prevents us from talking about this when we're 50? When we're 60, when we're 70.
- BSBridget Sumser
When we're 30.
- PAPeter Attia
Yeah. Like-
- BMBJ Miller
Mm-hmm.
- BSBridget Sumser
Mm-hmm
- PAPeter Attia
... why, why is it? Because it's, it's become such a... I don't, I don't know if I wanna say it's a black box. I don't wanna th- say it's a mystery, but, but it's just something that we don't want to talk about. And as such, I fe- I really believe that that's why we get to that three week, "Okay, fine. We're pulling the plug. It's three weeks," and you fall off a cliff kinda thing.
- BMBJ Miller
Mm-hmm. Mm-hmm.
- PAPeter Attia
Um, do we know anything about other cultures? You know-
- BMBJ Miller
Mm.
- BSBridget Sumser
[laughs]
- PAPeter Attia
Do we know h- how is it in Japan? How is it in Europe?
- BMBJ Miller
Mm-hmm.
- PAPeter Attia
How is it in, in, in other parts of the world? Do we know anything about how, how end of life functions there?
- BMBJ Miller
A little bit. Culturally, there's a lot to study. I mean, often it'd be so fun to take a couple years and really study the anthropology around dying and which cultures, how cultures do this differently. We've been dying a long time.
- PAPeter Attia
[laughs]
- BMBJ Miller
Um, you know, so, but one thing I think we-
- PAPeter Attia
It's our greatest skill.
- 1:10:15 – 1:21:27
How palliative care is misunderstood and underutilized—especially in cancer care
- PAPeter Attia
me ask you a question. Let's assume, um, we, we put you in a role where you're, you're a, you're a, you're an advisor that walks through the oncology ward, okay? Outpatient oncology. So they bring you in for a consultation with... A- and maybe you tell me this is actually not a bad idea. But they just say, "Look, we're gonna bring you into the outpatient onc ward on Tuesdays, and we just want you to meet the patients," okay? Now, these are patients that are in all stages of oncology. So let's assume that this is a breast, uh, cancer ward, or not ward, a clinic, and that means you are dealing with women who have just been diagnosed with pre-cancer, ductal carcinoma in situ, DCIS, all the way up to women who have progressed through every intervention and are now facing completely unresponsive stage four cancer.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
Okay. You are introduced to, uh-
- BSBridget Sumser
Yeah
- PAPeter Attia
... Jodie Smith. She's 42 years old. She's a mother of two. And she has, uh, she was recently diagnosed with what is turning out to be a stage three breast cancer. So she has a mass in her breast that they have removed, and at surgery they also found lymph nodes under her arm, but the workup of her, the rest of her body found no evidence of cancer. So she is now gonna undergo, uh, chemotherapy plus or minus radiation, and by the way, I'm not entirely familiar with the odds on this, but let's just say it's a 50% chance cure rate.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
So in, there's a 50% chance that this is never gonna come back. There's a 50% chance it will come back, and by the way, if it comes back, she will die from this. Um, it will go on for years, but-
- BSBridget Sumser
Yeah
- PAPeter Attia
... but it, it will come back in a distant organ. What would you say to her when you introduce yourself and let's just assume she understands why you're there and what you do.
- BSBridget Sumser
Yeah. Yeah.
- PAPeter Attia
So if she says to you, "Do I really need to meet you? Shouldn't I be meeting my cancer doc?"
- BSBridget Sumser
Yeah.
- PAPeter Attia
What would you say?
- BSBridget Sumser
I mean, the do you need to meet me question is interesting. Um, you know, I think what I would want to know is what has this meant, like, what has this experience meant to her so far, right? Like, what is-
- PAPeter Attia
So let's say she says, "This has been the most jarring, terrifying thing I have gone through in my life. I'm 42."
- BSBridget Sumser
Yeah.
- PAPeter Attia
"I have a seven-year-old and a five-year-old that are my world. It has never crossed my mind that I wouldn't be a grandmother, and I'm now being told there's a 50% chance I won't be a grandmother."
- BSBridget Sumser
Mm-hmm. Mm-hmm.
- PAPeter Attia
But I'm a fighter-
- BSBridget Sumser
Yeah
- PAPeter Attia
... and I have faith that these are amazing doctors, and it's a coin flip, I'm gonna get heads.
- BSBridget Sumser
Yeah. I mean, I would join her in that. I think I would also want to normalize the fact that she has never imagined anything other than being a grandmother. I mean, I think so much about those initial, you know, encounters or meeting of somebody is about rapport building, right? You have to get into a back and forth so that they feel you as another person there that's curious about their experience. And, you know, you were quick to kind of like add context for me, but, you know, actually the process of someone feeling comfortable to say like, "I've always imagined being a grandma and I'm gonna be a grandma," right? Um-
- PAPeter Attia
Yeah, that, that's probably three discussions, right?
- BSBridget Sumser
Sure. Well, I mean, at least-
- PAPeter Attia
Yeah
- BSBridget Sumser
... there's at least I probably maybe know her kids' names or she's told me some, like-
- PAPeter Attia
Yep
- BSBridget Sumser
... you know, she's asked me-
- PAPeter Attia
I'm skipping ahead. Yeah.
- BSBridget Sumser
Yeah. But it, it's a, it's a okay skipping ahead, but it's also skips over into like-
- 1:21:27 – 1:33:50
Palliative care in the case of Alzheimer’s disease: emotional support, future planning, and family involvement
- PAPeter Attia
So how would your interaction change if I put you into a neurology clinic and you were meeting people who were all newly diagnosed with Alzheimer's disease?
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
So now we have people who-
- BSBridget Sumser
Yeah
- PAPeter Attia
... show up with cognitive impairment-
- BSBridget Sumser
Yeah
- PAPeter Attia
... but they're still pretty-- They're still good. They're actually still okay. But they've now had that amyloid PET scan-
- BSBridget Sumser
Yeah
- PAPeter Attia
... that demonstrates the buildup of amyloid in their brain, and certainly to the eye of a skilled neurologist, the diagnosis is unambiguously clear. It's a clinical diagnosis, of course.
- BSBridget Sumser
Yeah.
- PAPeter Attia
And they've now been given the diagnosis, "You are in the early stages of Alzheimer's disease. Um, we don't know the speed at which this is gonna progress."
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
Um, but we know that it's more or less monotonically going to get worse.
- BSBridget Sumser
Yeah.
- PAPeter Attia
What are you asking that person?
- BSBridget Sumser
I mean, this is a very, uh, beloved space of mine that I've gotten to spend more time in in the last few years, and I, I, um, I think for a lot of people, one of my first questions is, you know, w- what do you understand about what's ha- Like, what have the doctors told you? What do you understand, right? Because, um, a person may have had many visits with their neurologist, and the neurologist has given very clear information, but-
- PAPeter Attia
Yeah, let's say-
- BSBridget Sumser
... their retention-
- PAPeter Attia
Let's say that this person-
- BSBridget Sumser
Yeah
- PAPeter Attia
... for the sake of this case study-
- BSBridget Sumser
Yeah
- PAPeter Attia
... watched their parent die of Alzheimer's disease.
- BSBridget Sumser
Yeah.
- PAPeter Attia
And there's a strong hereditary component here. And they now understand. They were-- Let's just say they've been in denial for the last year while they were-
- BSBridget Sumser
Noticing some changes
- PAPeter Attia
... in the throes of-- E- exactly.
- BSBridget Sumser
Yeah.
- PAPeter Attia
They were like, "Oh-
- BSBridget Sumser
Yeah
- 1:33:50 – 1:42:20
The importance of having an advance directive: defining what matters most before it’s too late
- PAPeter Attia
questions you're gonna ask that patient as their cognition is declining, and y- things that you need clarity on from them, their wishes. What do you want to understand?
- BMBJ Miller
Well, you brought up advance directives and advance care planning.
- PAPeter Attia
Yeah.
- BMBJ Miller
And so let's just spend a moment on that. That's r- we should all, if you're 18 in this country, you should have an advance directive. Uh, you know.
- PAPeter Attia
And my guess is virtually nobody who's young and healthy has one.
- BMBJ Miller
That's true.
- PAPeter Attia
Okay.
- BSBridget Sumser
I mean, virtually anyone who's older and isn't healthy has one.
- BMBJ Miller
Exactly.
- BSBridget Sumser
[laughs]
- BMBJ Miller
I mean, you know, we ask these questions in studies and also just c- casually if you give a talk. "Yeah, how many people have an advance directive?" You know, maybe 20% of people raise their hand. "How many people think an advance directive's really important?" Like, most people raise their hand. So there's a, none of us, many of us are not doing the thing we know we're supposed to do. We just, it's this, this deferrable thing, like life insurance. Ah, you know. Anyway, so one sort of public service announcement here is advance directive's very important, and-
- PAPeter Attia
You can download a form online.
- BMBJ Miller
Yes. Yeah.
- PAPeter Attia
Like, this is a free...
- BSBridget Sumser
Yeah.
- PAPeter Attia
You don't need a lawyer to do this.
- BMBJ Miller
No, you do not need a lawyer to do this.
- PAPeter Attia
Yep.
- BMBJ Miller
So, um, and the most important thing to come out of an advance directive, if you had to pick sort of one of the questions that gets asked, it's probably the proxy. If, God forbid, you a- all of a sudden you're in an accident or something happens and we can't ask you, Peter, what kind of care is important to you, who do you want speaking on your behalf in such a moment as that?
- BSBridget Sumser
Mm-hmm.
- BMBJ Miller
And that's probably the, the most important question to get clear on.
- BSBridget Sumser
And you know, why would a young per- a young, healthy person think about that? So, uh, my first advance directive, I was in my late 20s when I actually finally did it, even though I'd been in these conversations for a long time. And I, I one day was imagining, you know, something unexpected happening, not being able to participate in a conversation, lying in a hospital bed. I was imagining my parents, who do not speak to each other, trying to make decisions over their child.
- PAPeter Attia
Hmm.
- BSBridget Sumser
And my, you know, d- casual partner at the time, you know, mostly casual partner at the time kind of sitting there trying to figure out how they belonged in the scene. I was like, "I don't want that for them."
- PAPeter Attia
Mm-hmm.
- BSBridget Sumser
Regardless of what happens to me and my body or, you know, what they actually choose. Like, to actually put myself in the position of the people that those choices would default to-
- PAPeter Attia
Yeah
- BSBridget Sumser
... like, I didn't want that for them. I didn't, I didn't... You know, if I was at all sentient, I definitely didn't wanna hear it, but I, I didn't want them in throes of totally unexpected grief to be trying to negotiate that relationally, right?
- PAPeter Attia
It's an awesome responsibility. I, um, I'm very honored to say the, the number of people that have asked me to be the decision maker for them, I can't imagine how many have asked you this, BJ, but I mean, there are more than a dozen friends who have asked me this.
- BSBridget Sumser
[laughs]
- 1:42:20 – 1:48:43
The differences between how young and old individuals experience dying from cancer
- PAPeter Attia
What are the differences that you have both experienced in, um, dealing with dying cancer patients between those that are, quote unquote, "old" and those that are young? I mean, of all the chronic diseases, cancer obviously disproportionately strikes the young.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
Um, you know, people in their 40s and 50s don't really have to worry about heart disease and neurologic disease for the most part-
- BMBJ Miller
Mm-hmm
- PAPeter Attia
... but they're far from clear of cancer.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
And, um, you know, there was actually an article out recently that even suggests that the incidence of cancer is rising in young people.
- BSBridget Sumser
Yeah.
- BMBJ Miller
Mm-hmm.
- PAPeter Attia
Um, so I'm curious as to what you've learned about, about living and dying from through the lens of cancer in the tragic cases, which I'm just using this term sort of loosely, where everybody agrees the 40, 50-year-old dying of cancer is tragic versus the part of life when someone is in their 80s and 90s and dies of cancer.
- BMBJ Miller
Mm-hmm. Well, one thing that leaps to mind in my experience with younger people, um, I mean, you can get very philosophical and say, what is an old, what is old?
- PAPeter Attia
Yeah.
- BMBJ Miller
You know?
- BSBridget Sumser
[chuckles]
- BMBJ Miller
You know, and I've seen some kids die.
- PAPeter Attia
Oh, which, I mean, that's a whole new level of-
- BMBJ Miller
Whole new level of sorrow and senses of tragedy on some level for the parents very often, but if-
- BSBridget Sumser
A very different level of engagement or awareness-
- BMBJ Miller
Yes
- BSBridget Sumser
... potentially
- BMBJ Miller
... I have, but I have and, uh, right, and actually the child, the kid, the young person, I have seen some We wanna be very careful to not be judging and grading deaths. This is why the problem of good death is a, a really problematic construct. But, and in terms of something instructive to learn from, uh, I've seen some younger people die so beautifully and adapt so remarkably to the reality that they're living. It's just stunning. It puts-
- PAPeter Attia
Why, why, why do you think that is?
- BMBJ Miller
I mean, my sense is because, and you could say because they haven't yet been around on this planet long enough to develop such concrete notions of identity. "I am BJ. I am this. I am not that." You know.
- BSBridget Sumser
Expectations.
- BMBJ Miller
Expectations, senses-
- PAPeter Attia
When do you think that kicks in, BJ?
- BMBJ Miller
I think it's a spectrum. It develops-
- PAPeter Attia
Like late teens, early 20s?
- BMBJ Miller
I, I would say something like that is our sense of it as we individuate, and our identity sort of set up as something relatively independent compared to our earlier years. But, you know, I certainly feel different about myself n- now than I did when I was 19. But, but to your point, I think these sort of-
- PAPeter Attia
Mm.
- 1:48:43 – 2:01:34
The difference between pain and suffering, role of medicine in pain relief, and why emotional healing is essential at the end of life
- PAPeter Attia
to something you said a second ago. You brought up kind of anticipation of loss and death, and then the actual event and the loss once that person is gone. And obviously, those two states exist for the surviving. Only one of those states exists for the dying.
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
They don't really, uh, have... So, um, tell me about the e-experience for the, uh, person who's going to die. What are, what are the things that they express to you as their greatest fears? How often is it, again, pain, physical pain? How often is it, um, not existing?
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
How is, how often is it leaving someone behind and their suffering?
- BSBridget Sumser
Mm-hmm.
- PAPeter Attia
Um, and then similarly, I, I'm curious as to what the anticipated versus realized experience is of the, uh, of the loved ones.
- BSBridget Sumser
I mean, I think for, for many people, there's real fear about the physiologic experience of dying, of pain and other symptoms, right? And I think one of the beautiful parts of our work is in, in the nature of people being linked to palliative care, hospice care, there's some ability to comfort that, right? That we are here, we are watching those symptoms, we're working with you. So-
- PAPeter Attia
Could we say that Nobody in the year 2025 needs to actually suffer during death. I mean, is that, is that too an extremist statement? For example, is there a pain that is so deep that it can't be reached by the most potent narcotic? Is there, is there a shortness of breath that is so significant that it can't be offset and palliated by-
- BMBJ Miller
Mm-hmm
- PAPeter Attia
... probably a narcotic as well? Like, uh-
- BMBJ Miller
If you... Sorry, Bridge, what were you gonna say?
- BSBridget Sumser
You know.
- BMBJ Miller
Well, just from a sort of medication-y po-
- PAPeter Attia
Yeah, medication physiology land
- BMBJ Miller
... yeah, at that end of the, uh, argument or conversation, yes to your question, I think we can say that no one in 2025 needs to die suffering as long as you include the potential for sedation to be part of that. It may take so much narcotic to quell your pain or your shortness of breath-
- PAPeter Attia
Yes
- BMBJ Miller
... that we are actively putting you to sleep. So if you include, uh, what's called palliative sedation, um, then I think that is a true statement.
- PAPeter Attia
Yep.
- BSBridget Sumser
I think I just wanna make a quick note on the use of narcotics in this setting. Like narcotic is a police term, right?
- PAPeter Attia
Mm-hmm.
- BSBridget Sumser
It's a, it's a term of law enforce- enforcement.
- PAPeter Attia
Yeah.
- BMBJ Miller
Yeah. It's, yeah, it's a good point
- BSBridget Sumser
And the medicines that are being used in this time are opioids.
- PAPeter Attia
Yep. Good point.
- BSBridget Sumser
And it's, it's only an important, I mean, not only, it's an important distinguishment because opioids are often one of the central medicines in managing the symptoms related to dying and related to serious illness at a certain point, and people, for good reason, in 2025, in the setting of, um, how opioids exist in our culture-
- PAPeter Attia
Mm-hmm
- BSBridget Sumser
... are scared, right?
- PAPeter Attia
Mm-hmm.
- 2:01:34 – 2:11:22
Dying well: the power of self-honesty and human connection at the end of life
- BMBJ Miller
Yeah.
- PAPeter Attia
I wanna pivot a little bit to talk about how to pull all of this together, right?
- BMBJ Miller
[laughs]
- PAPeter Attia
You, you guys have had-
- BMBJ Miller
Good luck, buddy
- PAPeter Attia
... decades of, uh, being at the bedside-
- BMBJ Miller
Mm-hmm
- PAPeter Attia
... for, um, experiences that I'm sure you look back upon and think that was, that was really a wonderful experience, right? That was-
- BMBJ Miller
Mm.
- PAPeter Attia
That, that, that patient passed out of this world, and their family escorted them out in the best way I can imagine, and I'm sure you have seen the opposite. I'm sure you have seen things that made you cry and made you think, "Ugh, I, I, I, I, I weep for all parties involved." What are some lessons we can take away from that? What are, I hate to call it do's and don'ts-
- BSBridget Sumser
Mm-hmm
- PAPeter Attia
... 'cause that's such a stupid, but you know what I mean. What are, what are some of the things-
- BMBJ Miller
Hmm
- PAPeter Attia
... that have, in the process We'll come back and we'll talk about insights that you've learned from the dying, 'cause that's where I wanna end it today.
- BMBJ Miller
[laughs]
- PAPeter Attia
But just from the process of the dying and their loved ones, tell me, tell me things you've learned that, that people should know, that, that w- that, that increase the probability of it being-
- BMBJ Miller
Mm-hmm
- PAPeter Attia
... as positive as it can be versus the opposite.
- BMBJ Miller
Wow, it's a toughie. It's a toughie. As we said, this subject just really thwarts a- any sort of ob- or, or m- you know, much objectivity or anything that smells reductive. Um, and in some ways, that's the death that we are, as pr- practitioners, are heading for, is something that the, it, uh, allows for... While we talk about a body or a person in decline, that's our medical bias towards the physiology and the bodily. It i- it's also very possible that c- people can have, be having this incredible emotional and social and spiritual growth, even as their body is in decline. So part of it is our sort of, uh, naming and overcoming the, the biases we're born into in this particular culture, in this particular world. Um, so a- and I think, but what, uh, one answer to your question is, it's so hard to answer, but, but for me-
- PAPeter Attia
[laughs]
- BMBJ Miller
[laughs] For me, it, these days, the word honesty comes up for me a lot. So the bullshit that we tell ourselves, the partial truths that we tell ourselves, the pieces of ourselves that we don't look at, that we don't allow in because we're either ashamed of or whatever it is, or blind spots, or we've bitten the sort of autonomy, independence thing so much that we don't let any sort of social reflection in. Um, you know, dying can be, is this sort of great accounting. It all has, it's all coming out in the wash there. So one thing that I see make a difference and head towards the do's and don'ts, if, if each of us can take into our, perhaps our responsibility, but also our privilege to know ourselves over time and to dare to look and to see and to be true to ourselves, to my, my way of thinking, if you'd asked me this question five years ago, I probably would've said something different, but that's the big, that's my big takeaway these days, is if you wanna be ready to die well, get real with yourself, and the sooner the better. And because one of the things you'll allow in is a m- a richer life, right? And, uh, one of the reasons why we would encourage people to think about death earlier in life is not just so to avoid the, um, defaults of a medical system that doesn't think about these things, but you also allow in the idea that y- both your bigness and your smallness, like, I'm one of a zillion people who's ever lived, you know, I'm a drop in the ocean, but also allow in that the ocean would be different without my drop in it. Like, that work of placing yourself in the world and feeling in right size to it all requires a lot of dynamic honesty, and that takes effort. You need to dare to look at yourself, and that, to me, is sort of a big do. If you do that well, then the, the risk, like, like so much of what we've talked about today is it's not the problem of dying so much, but the difficulties of uncertainty is so much of what we're kind of guarding against or working with. Not so much death, but living with uncertainty, and that's a, that's something that we all do all the time. So my answer to all that is, is, you know, get real with yourself and be as honest as you can one moment to the next, and allow yourself to move and change with reality. That's a mouthful, but that's as close as I can come to a do.
- PAPeter Attia
Yeah.
- BMBJ Miller
Sorry. Does that [laughs] end-
- PAPeter Attia
No, that's, that-
- BMBJ Miller
... light up anything for you?
- PAPeter Attia
... that, that's actually really a, quite a profound one, because on the one hand, it seems so, um, easy is maybe not the right word, so self-evident, but on the other hand, it's so difficult.
- BMBJ Miller
It is.
- PAPeter Attia
And it's something that an- anybody with a modicum of introspection struggles with.
- BMBJ Miller
Mm-hmm. Yeah, and even when you think you got it, "Oh, I, now I know who I am," well, no, as relational beings, whatever's coming tomorrow might yank all sorts of other things out of you that you didn't know were there. So it is, this, this sense of self, this identity thing, is a biggie.
- PAPeter Attia
I guess this feels connected, but the word for me when I think about those, like, beautiful experiences or the ones where I walk away just feeling like, "Hmm, not bad," like, "I'd be okay with that," um, is about connection.
- 2:11:22 – 2:14:07
How psychedelics like psilocybin can unlock emotional breakthroughs and deepen connection for patients near the end of life
- PAPeter Attia
of you followed the, the sort of psilocybin work, the Roland Griffiths work, the end of life stuff? And, and, and what, what is your, what is your take on, um, again, notwithstanding the regulatory challenges of that, um, what is, what is your take on that literature and its, its efficacy?
- BSBridget Sumser
I think, I think anecdotally, I have seen psychedelic experiences be incredibly helpful to folks that have kind of run into a place in themselves where they don't have, you know, they've kind of just hit a wall in their own imagination, in their own mind as to what this experience is or what it can be. That there's just this kind of opening that can happen, um, sometimes incredibly subtly that allows for just some, you know, slightly different insight not generated by the brain that you know so well-
- PAPeter Attia
Yeah
- BSBridget Sumser
... or the parts of your brain that know so well, and I, I think it can be amazing.
- BMBJ Miller
Super helpful. I mean, I'm really, in my own experience-
- BSBridget Sumser
Oh
- BMBJ Miller
... and those of people I've worked with, you know, it, it's easy to start feeling evangelical. Like, just, we should just be putting psilocybin and other-
- BSBridget Sumser
[laughs]
- BMBJ Miller
... psychedelics in the water, you know? But the... And let's be careful. I mean, I think we are gonna wanna learn from reality as we s- begin to do more of this work and study, and let's be true to what we learn. But on the whole, these substances, these medicines, have been able to achieve, you know, in a s- in a session with a, a, a patient what, you know, months or years of talk therapy or other things haven't accomplished. And, you know, it's not necessarily about learning something in those experiences. It can be. But in my ex- in, in, f- from my time with it, it's more that I f- I get past my thoughts, and I get into this embodied felt thing. It's not a new, it's not an epiphany. It's just I f- feel the power of that epiphany or that idea in my-
- BSBridget Sumser
Mm-hmm
- BMBJ Miller
... bones, in my flesh. It's a kinda different kind of knowing, which then allows for a s- a super sense of connectivity. You can't be disconnected. That's just, you know, you're, you are connected, and you feel that and the therapy of that. Also, you get to see what a, what, how silly our minds can be.
- BSBridget Sumser
Mm-hmm.
- BMBJ Miller
And you just learn that very simple bumper sticker truth of, "Don't believe everything you think."
- PAPeter Attia
[laughs]
- BMBJ Miller
And you then, you come out of there-
- BSBridget Sumser
Mm
- BMBJ Miller
... with a new relationship to how you hold your thoughts.
- BSBridget Sumser
And people get to that by other means, right? Through meditation-
- BMBJ Miller
Sure, yeah
- BSBridget Sumser
... through prayer, through deep, transcendent communal experiences, right? So it's, it's accessible by way of other avenues.
- 2:14:07 – 2:28:41
Lessons from the dying on how to live well
- PAPeter Attia
You've obviously spent a lot of time with people in, um-
- BSBridget Sumser
Mm-hmm
- PAPeter Attia
... by definition, the final stage of their life. What, what have you learned? What have you learned that changes the way you live your life or the way you wanna live your life?
- BMBJ Miller
Well, I, I could say something. Uh, you know, there's, again, huge, beautiful questions you asked, Peter, me. But one is, and maybe this is some relief for your audience, um- I think we all would love to, you know, I think many of us would say we'd love to be fearless and love to go into our death unafraid or, um, live a s- a life so conscious that we have no regrets. Uh, I like to kind of just... And my patients have taught me to kind of undo those strangleholds a little bit. It's more the truth that I've learned from folks at the end is, is, is more like have, have a, change your relationship to fear, your relationship to regret. Uh, the mark of living with no regrets, yeah, there might be an in- there may be something for you in that, but I, I'm not sure how, if you're being really honest with yourself, how possible that is. So it's not necessarily... It's, it-- The lesson has something to do with coming around to accepting everything that's in you, including the gnarly stuff like regret and fear and even suffering.
- BSBridget Sumser
Are there certain regrets that people have shared with you more, more often than others?
- BMBJ Miller
Well, invariably, or I don't know about invariably, but they all, uh, the, the common thread, d- depending on sort of whether it's I regret working too much, or I regret, you know, didn't spend as, I didn't say, tell my kids I love them, the sort of the standard-
- BSBridget Sumser
Yeah
- BMBJ Miller
... uh, regret menu, what they all seem to have in common is they regret not letting themselves feel or not letting themselves be true to the, what they actually felt. Something got in there, shame or something else, g- uh, wedged in themselves and separated themselves from themselves or separated themselves from other people they love. And the regret has something to do about artificially or accidentally putting a wedge between you and anything. Um, you know, like it could be, spend a lifetime running from fear. But if, I've watched a lot of people come around to when they finally got the cue that fear was just a natural part of being in a body, like they became okay with fear. They took away that sort of secondary shaming of fear, and then, then fear became this, it was sort of right sized to them, and it was defanged. You know, I've seen that play out a lot.
- BSBridget Sumser
Sure.
- BMBJ Miller
Uh, and the same with regret, you know? So it's, it's-- I just think the, the commonality, back to your question, has something to do with not being quite true to themselves or not allowing a f- trying to keep something out of their experience and all the work they did. And when they g- come to realize that it's all gotta go anyway, you kind of welcome even pain. So just to get to feel anything is kind of wild and magical.
- BSBridget Sumser
Do people need to be really close to the end to typically come to that near inevitable realization?
- BMBJ Miller
No.
- BSBridget Sumser
Or is that something people are realizing six months out where they can do something about it, where they still have all their faculties and they can still, you know, mend a bridge or, um, mend a relationship?
- BMBJ Miller
Yeah, absolutely. That can happen anytime. Kids, back to kids are doing, you know, they're not gumming their own works up. They can do that pretty... And to, so yes, we can do this. We can learn to do this. This is another reason why we would invite this subject into our daily lives. If you look out your window, death and life are happening all the time. You see it on your windshield. You see, it's like this is, it's all over the place. If you can sort of really be aware or let, let these messages in, then you can let the lessons in too towards reconciliation. Or why hold a grudge? Why, beyond any, why would you ever cause suffering in another person knowingly and yourself included, et cetera? So yeah. And Buddhism was, is sort of lo- sort of founded around this question and to give you a life of practice around meditation to how do you hold your mind so that you don't suffer unnecessarily, so that you can be okay with the fact of your death. So yeah, there are bod- there are scholarship bodies of thought and just your own personal experience of living daily life.
- BSBridget Sumser
Hmm.
- BMBJ Miller
If you let it in, you can gain these lessons anytime along the way of life.
- BSBridget Sumser
Yeah. I mean, I th- I don't... You know, if I think about my own learning, like you, it, you can't, I don't think, really hang out in this space a lot and not really wrestle with the reality that we don't know when we're going to die, which means that this is my life. I mean, I think that's, I've got two young kids, so regular I'm kind of like, "Okay, this is my life, this is my life," just as like a management strategy. But I think there's also like a s- a, a tether to the reality that like, this moment is what I have, right? It, it is not, it, it may start to sound trite, but it is not, tomorrow is not promised to me, 10 years is not promised to me, and if that is true, can I use that as this reminder that like this moment, the way that I speak to you, being tender when I do things out of my value system, right? Staying really connected to now, right, is the invitation that comes from or comes next to or has come for me in being so aware of mortality, right? And that you do not have to be sick, you do not have to be facing the end of your life. No one in your life has to be dying right now to be really, to just take pause and be like, "This is my life, this moment, and then the next." Do I remember that all the time? Absolutely not. But it is a very available reminder.
- BMBJ Miller
And practice.
- BSBridget Sumser
Yeah. I stay, I intentionally stay connected to it. I intentionally make it something my kids can be connected to because it's inarguable.
- BMBJ Miller
Mm-hmm.
- BSBridget Sumser
Right? We can, we can have three different takes on everything that we've said today, but it is inarguable that we are always living in the reality that we don't know when we're going to die.
- BMBJ Miller
I just want... Yeah. Amen, sister. And I think there's, that's what gets back to sort of the do's and don'ts. Do have a relationship with all, with mystery, with not knowing.
- BSBridget Sumser
Yeah.
- BMBJ Miller
You know? Do have a relationship with the present moment, you know? Those are some pretty good-
- BSBridget Sumser
Yeah
- BMBJ Miller
... do's.
- BSBridget Sumser
I don't want to-- What I'm saying is not like light or easy. It doesn't-
- BMBJ Miller
Mm-hmm
- BSBridget Sumser
... make me not afraid. [chuckles] It doesn't make me, you know, not... I, I feel very aware of how much I want to be alive and how long I hope my life is, and also
- BSBridget Sumser
humbled by the fact that, like, what I have influence over and control over really inarguably is right now
- 2:28:41 – 2:34:59
The physical process of active dying, and the emotional and practical considerations for loved ones
- BMBJ Miller
today.
- PAPeter Attia
Well, let's talk about that, that final thing. What is, what is that, what does that last 24 to 48 hours look like?
- BMBJ Miller
So the phrase we use is active dying-
- PAPeter Attia
Yep
- BMBJ Miller
... to, to distinguish it from the rest of living, dying thing.
- BSBridget Sumser
[laughs]
- PAPeter Attia
Yep.
- BMBJ Miller
And the body is, you know, is actively shutting down. So system by system, uh, you know, you'll stop, your kidneys will stop, shut down. You're not making as much urine, in part because you stopped drinking probably a few days becau- uh, days ago 'cause your body couldn't handle the fluids. So, and thanks to kidney shutting down, you get a bu- a buildup of, uh, toxic metabolites and, and get a little intoxicated, a little dreamy, a little... That may be the course, that may be the, the mechanism of your delirium. Um, so you're not eating, you're not drinking as a general rule. You're probably a little fuzzy if, and, or entirely asleep. Um, breathing, so the, some of the two biggies, those can happen anywhere along the way, but the ones that tell you you're really close are when you have mottling of the skin, a sort of lacy bluish experience where your body's just not moving blood effectively, and you'll see skin changes, especially at the extremities. And breathing patterns, um, change. Um, oftentimes you get apneic, so long periods with no breath at all. Um, you often hear something that's, sort of it's like a frightful phrase, but the death rattle, um, so which often is sort of a, a, um, a gurgling sound with breathing. That's just because your, your oral pharynx is no longer... The reflexes are dying out, so you're no longer moving fluids as they pool in the back of your throat, which is an important note there. If your, if your reflexes are no longer functioning, you're not likely feeling it. So a death rattle sounds pretty gnarly. It's, but it's generally probably harder for the audience than the person dying. But those are the things that you, that are typically experienced in a body that's actively dying.
- PAPeter Attia
And that's only gonna last a matter of days.
- BMBJ Miller
At most. Hours to, to a day or two.
- BSBridget Sumser
I think the other thing that's happening is the experience for the people around that person.
- BMBJ Miller
Mm-hmm.
- BSBridget Sumser
Right? And, um, there's so much to say in that space, but I do think having, you know, counseled a lot of people, there is, there's a feeling of preciousness, right? We don't know when that last breath is going to come. We, we, you know, maybe we really want to be there, maybe we feel like we can't. But, um, often for someone watching and waiting, um, it can be really hard to stay connected to our own experience. So, like, people won't get up and go to the bathroom because they don't wanna miss that moment.
- BMBJ Miller
Mm-hmm.
- BSBridget Sumser
They won't eat. They don't eat. Maybe their appetite is low anyways, which, you know, is fine, but it is a time to be thinking about really basic needs and basic comforts for everyone in the space, um, because that influences the space and the environment for, for all. And most people feel like this is the dying person's experience. This is, like, all the focus is there. We're watching every respiration. We're even matching their breathing. We're creating anxiety in our own bodies because of that. And if we can invite attention to everyone's experience and give permission to, like, "You need to take a walk, go take a walk," it may mean that they die when you're not in the room, and maybe that's okay. Um, maybe they die in the one minute you're going to the bathroom for the first time in six hours. Like, it may just be that way.
- BMBJ Miller
That's a really, really important point. Sort of like once you understand delirium and so you can contextualize what you're hearing from a loved one, that point Bridget so is pointing to is such an important one. A lot of loving families keep these vigils and don't sleep, don't do anything so that they can be there for the death thinking that that's the most, that's the highest high and it's-
- BSBridget Sumser
That's what it means to be there when someone dies-
- BMBJ Miller
Yes
- BSBridget Sumser
... is in that exact moment when they take their last breath.
- BMBJ Miller
And so to Bridget's point, this is a lived experience for everyone, so you gotta keep doing... You have to sleep. You have to, you know... Yes, and, um, it just, I, I don't think any of us could tell you why this is, but it is just a thing. You talk to anyone who worked in hospice for a while, it seems to be that a lot of people need to be alone for the final, their final moments on the planet to really let go. And so it's almost-
- PAPeter Attia
Wow
- BMBJ Miller
... it's, I c- I can't tell you why.
- PAPeter Attia
Yeah.
- BMBJ Miller
But, but it is a thing. So you going to the bathroom or taking a walk or stepping out of the room-
- BSBridget Sumser
May be the thing
- BMBJ Miller
... may be exactly the thing that that person needs to finally let go. So, and the message is, "Don't leave," and therefore the person will never let go.
- BSBridget Sumser
[laughs]
- BMBJ Miller
You just potentially can make it harder and harder for that person to actually finally let go. So go to the bathroom, take a walk, kiss the person goodbye-
- BSBridget Sumser
Drink some water
- BMBJ Miller
... and, or drink some water, and know that not only they may, they may be gone when you come back, but that may be exactly what they needed to finally let go. It's a hard one-
Episode duration: 2:34:59
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