Episode #25: Facing Death; Helping the Dying – Full Transcription

You can find the SHOW NOTES HERE.
Full Transcript:

Lisa: 00:00 Hello, you're listening to the Super Power U Podcast. This is episode 25.

VO: 00:11 Welcome to the Super Power U Podcast where we reveal the mental models and tactical skills needed to activate your inner super hero. And here's your host, Lisa Betts-LaCroix.

Lisa: 00:11 The mindset that dying is a problem, not a natural occurrence and regular part of life — influences much of the American fear of death and our reluctance to talk about it openly.  That’s a quote from Kate Sweeney, Today, we're going to talk about it.  Our guest is Sandy Buchman, a Canadian palliative home-care doctor whose Super Power is bringing Compassion in Action to his work supporting patients at the end of life. 

But first let do our Intermittent Fasting Experiment, a shout-out to our listeners and my podcast recommendation for this week.

I just finished my second week of the Intermittent Fasting Experiment and while the first full Month update won't happen until episode 27 on June 7th I will say that this past week I fasted for a minimum of 18 hours every day except for Friday when I broke my fast early at 16 hours.  My thinking was that I wasn't feeling great that day for some reason, maybe not enough water again, but I also wanted to remind myself that I can be gentle, even imperfect and then pick back up and keep on going.  On Sunday I did my usual 40 hour fast and it wasn't hard but in the morning I woke up feeling not great, which I'm committed to listening to.  So I'm considering reducing my long fast length to 36 hours for the next two weeks.  If you're new to the show, the Intermittent Fasting episode is #23.

This weeks shout out goes to Australia. For some reason the listenership from Down Under has picked up a lot lately so G'Day to you all and thanks for being here.  If you can think of a friend or a family member who might benefit from this episode, or any previous episode I would so much appreciate you sending them a link.  Most apps have a share option and you can find a url for any episode and email it.  The audio feed and show notes for every show are at lisabl.com/ episode number so this show is at lisabl.com/25.

What Lisa’s Listening to: Pearls from My Mom, the Podcast.  Jesse Kahat interviews people who have lost their mom about their memories and the legacies their mothers have left behind.  I got to be a guest on her show on Episode #17 in which I got to talk about and reflect on my mom.  Her recent episode is #20 and features pearls from her various guests and offer suggestions for tough holiday’s like Mothers Day.

Last week, Maya Lockwood took us through her own experience with a near-death experience and what she learned from it which she’s incorporated into her life…a deep commitment and focus on Love as the primary principle. 

New Speaker: 00:11 I met today's guest one month after my mother was diagnosed with metatastic stage 4 pancreatic cancer and she had decided that she wanted to die at home. For the next two months Sandy and his team supported us until Sept 9 at 9am when my mother took her last breath surrounded by my dad, her husband of 54 years, my sister, my mom's best friend Judy who flew in from northern Ontario to care for my mom until that last day.  I can honestly say it has been the most profound loss I've experienced

The sort of mindset that dying is a problem, not a natural occurrence and regular part of life — influences much of the American fear of death and our reluctance to talk about it openly. “Americans … are so obsessed with youth and triumphing over every challenge they face that they become afraid of aging and death, often seen as life’s ultimate defeat.” Kate Sweeney in a CNN article article called The American Fear of Dying. 

I get it.  I understand it.  I live with it.  Even my husband of 20 years has a ted talk in which he envisions a life free of death.  And of course, due to many dedicated people in medicine we’re living longer and often healthier lives as a result of medical advances But so far, living still involves dying. 

If you’re human, you will face it.  You’ll lose someone to it. And at some point, sooner or later you’ll face it yourself.

Lisa: 00:11 I met today's guest one month after my mother was diagnosed with metatastic stage 4 pancreatic cancer and she had decided that she wanted to die at home. For the next two months Sandy and his team supported us until Sept 9 at 9am when my mother took her last breath surrounded by my dad, her husband of 54 years, my sister, my mom's best friend Judy who flew in from northern Ontario to care for my mom until that last day.  I can honestly say it has been the most profound loss I've experienced

Lisa: 01:01 Dr. Sandy Buchman is an Associate Professor at the University of Toronto.  He provides home-based palliative and end of life care with the Temmy Latner Centre . He also serves as a palliative care physician through the Palliative Care and Education for the Homeless (PEACH) program out of Inner City Health Associates in Toronto.  He has a long history of service in the Canadian Medical system and in March was elected as the president elect nominee of the Canadian Medical Association. He currently serves as the Medical Lead for groups working to build two new residential hospices in Toronto, including a hospice for the homeless. Welcome Sandy. Thank you so much for joining me today. 

Sandy: 01:10 Thanks Lisa. Glad to be here. So our conversation today might be especially emotional for me since you were the hospice doc for my mother for the two months before she died at home in September 2016. So our conversation will be more personal for me than some. I want to take this moment to say thank you again for the gifts that you and your team were for my mom and for my family. It was profound.

Sandy: 01:34 It was kind of mutual. You gave me a gift and knowing your mom and your dad and yourselves, it was a quite incredible experience to get to know them. I kind of regret that I get to know people too late, you know? Your mom was a remarkable, remarkable woman.

Lisa: 01:49 She was extremely fond of you, and I think when you came into the picture, during her illness, there was a certain kind of relaxation or calmness that came over her, I think because she felt that there was going to be some shepherding, and it was almost palpable. I want to just focus a little bit on you and your own personal life experience. You're @DocSandyB on Twitter and, there, in addition to your professional designations and your many accomplishments, you also describe yourself as a “husband, dad, granddad, brother, son, friend.” So I'm wondering if you might be willing to give a bit more insight into your journey. Maybe there's a story that comes to mind from your childhood, or from your early years, that might offer some insight for my listeners and for me into your life journey into what's laid the groundwork for your current life.

Sandy: 02:42 You know, I guess you could say my life has been lucky. My life has been privileged. You know, I was born here in Toronto. I've always been a kind of pro-Torontonian Canadian because it's a great country, a great place to be, but I've always been lucky.  I'm 63 years old and I still have wonderful parents. They're elderly, they're frail, but they're there and cognitively okay. I have fantastic siblings—one here in Toronto, another in California—who are mutually supportive and loving and great siblings-in-law, might I add. I have had the fortune of having had a roof over my head and good parenting and love. Grandparents, cousins, aunts, uncles, that kind of thing. I've had a country in which I live in with freedom. I've had the good fortune of an education though to university and beyond. I've always worked hard. That was a value that we've shared. But I think it's a life of good fortune and somehow there's a halo over my head and I practice gratitude every day. I didn't come from trauma. I didn't come from abuse, I came from a place of love, and caring, and stability, and have become convinced, over the years, given the number of people who haven't had those kinds of ingredients in their lives, that's something that I can share and spread out a little bit.

Lisa: 04:14 I really appreciate that, and I think that the word “privilege” has taken on a lot of layers of meaning, and I resonate with the idea that the most beautiful thing about privilege is that it allows us to come from a place where we can share and give and support other people. I've heard situations where the word “privilege” almost becomes sort of a derogatory word, and I guess that the difference between seeing privilege as being a negative thing and really not is when we can allow that kind of privilege you're talking about,  where we don't come from trauma and we have health and we have love as our base to make a difference in other people's lives, so thanks for giving voice to that.

Sandy: 05:00 Yeah, I do experience– because even in this day and age, you know, as a white male, I have privilege and it's often used negatively, to stereotype those of us that happened to be white and those of us that happened to be male. But one has to be aware of one's privilege and use it in a way to enable others. Not “empower;” I'm not saying that. I'm saying enable others to move ahead and stand up. You can create a more equitable society. I've always kind of based that as a principle of my life.

Lisa: 05:00 In my conversations with Sandy during his visits to check in on my mom and the rest of us I discovered that we share a great many values and one of those is a passion for learning as a lifestyle.

Sandy: 07:09 I do see myself as a lifelong learner. I went to medical school here in Ontario, McMaster Medical School. And as a physician you always have to learn. You have to keep up. What I learned in my medical education over 35 years ago has almost nothing to do with it today except the principles of caring, but the medical technology, and medications, and treatments, and investigations, and things like that are completely different. So unless you become a lifelong learner, and are open to new learnings all the time, you can't really be an effective clinician. What does stay with you, though, is the humanity part. Instead of just the science of medicine, the, shall I say, art. And that's all about relationship. And I always felt a kind of an obligation —I guess this is where I come from, and again, it comes back to privilege— I always felt an obligation to pay it forward, to kind of pay back.

Sandy: 07:56 I really, really believe, deep down, that, —particularly as physicians who are, again, such a privileged profession. We know are always employed. We don't run out of work. We're decently paid and the rest— I do think that I have an obligation to pay society back. I really believe we have a mandate, as physicians, and that I as an individual have a social responsibility and social accountability to improve lives, either one patient at a time, to improve the lives of the community, to facilitate improvements, and what I know best is the healthcare system at a system level, and education is part of that. I was given the opportunity of a great education, and if I can help others learn and progress and develop, I find that very rewarding. But it's also in another way allowing society as a whole and other people to be be helped in a similar way. So I see that as an important obligation  all the time.

Lisa: 08:57 When you were a child, did you imagine that you would be a doctor? And at what point did you evolve into that awareness that you wanted to give back in that way or be contributive?

Sandy: 09:07 Well, you know, I never really thought about being a physician. I didn't really think much about the future. I think those are pretty heady times. But the interesting thing was, I was a high school dropout.

Lisa: 09:17 Can you talk a bit about that? Because there are definitely a lot of independent learning people in my community and in my listener base.

Sandy: 09:23 Well, so that's kind of where I'm coming from. I was just bored at school. I was a pretty stable adolescent, but I was just bored. I didn't think I was learning much of any value or use, and kind of dropped out for a few months. And then, I don't know, I found my peers, also kind of wandering around the city, who were like me and wanted to do something. So we started our own school. It was called a free school, in the times, it's like 1970 or so, and we hooked up in a library. They gave us some free space, and we ran the school. We developed small classes. It was kind of a problem based learning approach. We had professors from the local universities, and high school teachers who were interested in alternative education. We used to sneak into high schools at night to do chemistry labs.  We had poets and artists and theater directors.

Sandy: 10:11 There's a place in Ontario here called Stratford Ontario, and based on Stratford-upon-Avon in England, where you have Shakespearian theater, right. And we would ride our bikes to Stratford and discuss King Lear around the campfire. It was very interesting times, but we knew we all wanted to go on in our education, so we were accredited by our Ministry of Education and eventually all of us went on to postgraduate training and learning. And, in fact, I feel that got me into medical school, because the medical school that I went into was focused on problem based learning: small group learning. And there's an interview. I remember they asked me, “what was a problem you had and how did you solve it?” And I told them that I had an education problem in high school, and we solved it by creating our own place of learning. We called it West Nohant. Nohant was a place in France where the author George Sand brought together the artists and intelligentsia of Europe to work together and play together and debate together. So we called ourselves West Nohant as a place of learning. So ever since my adolescence, I think, that concept of ongoing education, learning, creating a space of learning and improvement, is always something that has stuck with me. And I'm sure it got me into medical school.

Lisa: 11:26 That's amazing. And I think I did actually know that. I think at some point you told me something of that story. When you were involved in that, was it the students who initiated the process?

Sandy: 11:40 Oh yeah. The students did everything, yeah. There were no adults.

Lisa: 11:45 How many people?

Sandy: 11:46 I think there were about 27 kids, but the adults really didn't do anything. There was a scholastic admission test to get into university at the time, and I had to organize it, so I ordered the —it was all pen and paper, then, of course— I ordered the papers and the exams. And I remember they just delivered them to my home, because that's where they were. We had no principal, and I remember seeing that it was to the principal, and it had to be kept under lock and key, and I remember this kind of moment of–  I'll call it a moment of integrity, where I knew I could open them up and read those examinations, but I didn't, because I knew that was a moment of truth. If I would have opened this, I would never have known if I could really succeed in university, or succeed in the future on my own, because this was an experiment. And so I really wanted to prove a point, and really make it on the basis of my own ability. But we ran it; my high school diploma was signed by a fellow who sold used cars, because we needed somebody over 18 to be principal, and nobody was over 18. I still have it to this day.

Lisa: 12:42 That's amazing! Do you know what happened to that collective? Was it just your cohort and then it ended?

Sandy: 12:46 No, there were a few people on it. Again, I referred to my brother Lorne in California. He's the CEO and president of the ArtCenter in Pasadena. And I don't know if you know about the ArtCenter.

Lisa: 12:57 I do. One of my upcoming guests went there. 

New Speaker: 12:57 I just love how my conversations with my guests overlap and intersect.  My upcoming guest and dear friend Kendal Cronkhite-Shaindlin who is the Production Designer at Dreamworks on the Madagascar film, Trolls and more has spoken to me over the years and also details in our interview about the Art Center's profound impact on her life. So I love how my communities, my conversations and my guest's lives and stories intersect. 

Sandy: 13:05 So, yeah, Lorne was there, and he was younger than I, so there was a cohort that continued on. He ended up doing his PhD at Stanford, and then onto UC Berkeley, et cetera, and ultimately to the Art Center. So we had a cohort that mostly went on to things like that. And I think there were eight or something that became physicians, which is sort of a remarkable little trivia fact. But we went on to all these different things, because we were the sort of kids that were interested in furthering our education and our careers.

Lisa: 13:31 Amazing. That's so interesting. I remember very clearly the first day I met you, and you came to the house to meet all of us, and I remember one of us—it was probably me actually—said how nervous and scared I felt about what was coming, and how none of us really knew what to expect, and I certainly didn't. And I remember, at that time, you saying that it was okay, and that it was going to be your job to help us along the way and to accompany us, and that each step would happen in time, and how we didn't have to know everything in advance. And I said to you at that time, wow, it sounds a lot like the role my midwife played in my home births, and then you surprised me with your answer. Do you want to describe what you said to me when I–

Sandy: 13:31 You tell me I'm saying the same thing or not.

Lisa: 13:31 Yeah, I will tell you, I will tell you.

Sandy: 14:17 I guess I feel that home birthing and home dying are two sides of the same coin. I see– I'll go take it back a little bit. I was very involved in the whole home birthing movement early in my career.

Lisa: 14:30 Yes, this is the story.

Sandy: 14:33 And even my residency project, in my training, was on home birthing, and the safety and efficacy of home birthing. And I was at a comprehensive family physician, and that means we looked after people from cradle to grave. But even before, we were doing, yeah, some low risk obstetrics, and helping women through their pregnancies, but we would do a lot of intrapartum obstetrics: delivering babies. And I began to see the beauty of home birthing, and wanted to study the safety and efficacy of doing it in a place like Canada, in the middle of a cold winter.

Sandy: 15:03 So I was with a large group of mostly midwives; there were two physicians on there, but mostly midwives, who were trying to establish a freestanding birthing center here in Toronto. And I always looked after people at home. I always cared for people at home and seeing the natural place to these things. I guess I see birthing and dying, not so much as medical events, but as social events. They're cultural events. They're events for the family and events for the community, they're parts of our lives, and I think we've medicalized both birthing and dying too much. And when you get back into a home environment —and for some, they can't have it at home, so a hospice environment— then you're dealing with it more as a social, cultural, community, family experience. So I see, you know, birthing, you're kind of entering the world; dying, you're exiting, but as a physician healthcare provider, I can facilitate those events for people so that they are safe and comfortable. Did I say something like that?

Lisa: 16:03 You described it very similarly, in the sense that it really is about an alternative to medicalization of those experiences. And so because I had had two home births already, it really gave me a sense of, and a feeling of, relief, and I guess what I'd call recognition. It helped me see the process as having a deeper meaning, and it made sense, just as in my home births, where I certainly had fear, my midwives helped me to acknowledge, and process, and be in and through the fear and all the other emotions that came through it. And so I think that recognition really helped me understand, a little bit more deeply, what was involved in a possible home-hospice death. Yeah.

Lisa: 16:53 So actually on that, it seems to me that there is a fair degree of misunderstanding about palliative care. And, in fact, this morning I asked my Facebook friends what thoughts and feelings and images and questions came to mind when they heard the term palliative care, and the responses were definitely diverse. And so I'm wondering if you can describe, for people who may not understand palliative care, a little bit more about it. And, in particular, maybe talk about some of the distinct terms, and the difference between palliative care, and home care, and comfort care, and just some of the different ways that people might think about it, for those who might not completely understand what palliative care is.

Sandy: 17:40 Sure. So most people think palliative care is end of life care. So just really when someone's truly at the end of their life where they're actively dying. But palliative care is much more than that. That's end of life care. And we actually distinguish it as such. Palliative care is full medical care that addresses a concept of total pain or total suffering, and that includes physical pain, of course, physical symptoms such as shortness of breath or nausea and pain, but it also includes emotional or psychological pain, suffering and, for many people, spiritual or existential suffering. So it's the total suffering or total pain-picture, and palliative care addresses those within the context of a life limiting illness. So it doesn't depend to me on prognosis. It doesn't depend on whether you have six months to live or three months to live.

Sandy: 18:49 To me, it is an approach to that care that is comprehensive. Yeah, that's really what it is. It depends on a person's needs, and on their complexity, and less on their prognosis. So I've given palliative care for years to some people, and there are many illnesses that exist currently —a person with congestive heart failure, chronic obstructive lung disease, or end-stage kidney disease, or what have you— that requires a palliative approach to their care. It is about conversations. It's about the very person centered, very family centered, bringing that person's needs and their autonomy to the fore. It's about thinking about the future and tailoring it to their individual needs and values. What are their values, what's important to them, what is their essence or who they are? When we make healthcare decisions, we make them on the basis of our personal values.

Sandy: 19:43 What we believe is important might be about our dignity. It might be about our faith. It might be about our families and loved ones. But whatever our values are, we make them through that lens, and looking at the evidence behind any particular healthcare intervention. So it's about facilitating those kinds of difficult decisions for people near the end of life. Do they go back to hospital? Do they have resuscitation? You know, how much treatment do they want? Do they want more interventions or not? Doing it in the context of their personal values. Palliative care can be given in many locations, of course: in a hospital or a clinic and even emergency room, but it can be done in the home, and the services that I provide are really 24/7 with my team. I'm in the home. It is about interprofessional care. It is about working with, of course, doctors and nurses and coordinators and nurse practitioners and social workers and pharmacists and OTs and PTs, et cetera. So that the whole team collaborates together to support a person and their caregivers through the process.

Lisa: 20:41 So would it be fair to say that hospice is a subset of palliative care and that it specifically does deal with the end of a person's life or is that an accurate.

Sandy: 20:50 Well, you know, there's some confusion. You're right, there's confusion in the terminology. So in the U S it tends to be “hospice care” or “hospice palliative care.” In Canada we tend to use the word “palliative care” for kind of the act of care. Whereas “hospice” refers to a residential hospice, a place where people might go at the end of life. Where in the US, it's kind of bound up; “I'm doing hospice care” would be the same as I'd say in Canada “doing palliative care.” So there's a little bit of confusion on that. We tend to refer to residential hospice and I can refer to it that way so that I don't confuse listeners.

Lisa: 20:50 Right.

Sandy: 21:24 So yeah. So that's kinda how we use the terminology.

Lisa: 21:26 So what's your sense of the state of palliative care, or hospice, or end of life care, in terms of availability in either Canada or the US, if you're aware of the distinctions that exist here?

Sandy: 21:41 I mean, in a lot of healthcare outcomes, the US ranks pretty poorly. It spends the most amount of money per capita and has the worst outcomes. One of those exceptions is palliative care. They do it very, very well in almost all jurisdictions that I'm aware of. In the US, they have incredible centers of residential hospices, the hospitals, the cancer centers, they have some of the world's experts, some incredible palliative care, and so we see a lot of expertise going in the States. In Canada, where there is a quote unquote “universal healthcare system,” again, everybody is supposed to have access to full medical care, but in reality that's not taking place, and we don't have enough palliative care providers. Physicians, nurses, communities, don't necessarily have adequate training, even if they wanted to provide it. Some of our studies for the Canadian Hospice Palliative Care Association have shown that only up to about 30% of our population gets access to good palliative care.

Sandy: 22:34 We know that the cost of it keeps people out of hospital; so most people want it, but we don't have enough yet providers. And it's about the culture aspects. People are afraid to deal with it. They're afraid to talk about end of life. They don't want to go there, so they keep on doing aggressive interventions. They don't have the conversations that I was referring to earlier. They end up in ICU intubated maybe with brain damage, et cetera. Receiving medical interventions, investigations that are not proved to be any benefit, and might actually be harmful to them. So we're continuing to promote the idea, what we– We have something called a Choose Wisely campaign about investigations and treatments. It started out in the US and now adopted in Canada. Trying to get people to have more of these conversations so they don't get treatment that can be harmful, or prolong their lives and their suffering unnecessarily.

Lisa: 23:22 One of the reasons I wanted to talk with you on the podcast is because it does seem very much like the idea of aging and death, and how we face it and the options available to us, are not spoken about enough. There seems to be, like I said, a lot of misunderstanding and lack of knowledge. So I'm curious to know how that begins to shift in our culture and I know we talked about the Atul Gawan– help me out here with the book?

New Speaker: 23:22 Atul Gawande. ‘Being Mortal.'

New Speaker: 23:54 ‘Being Mortal.' Yeah. A friend of mine, who had lost her mother the year before my mother became ill, recommended that book to me, and I read it right around the time that I met you. And it really hit me how deeply our culture does avoid the topics of aging and death, and that's your field, right? That's what you do. So I'm wondering; what insight do you have for a general audience?

Sandy: 24:15 Sadly it's not just about aging, though. Again, it's more seniors, and we do live longer in our society, but it's with young people too. We do pediatric palliative care, for example. We've had children in adolescence and then lots of young people who are taken from us far too soon. I guess what we try to do, and what the palliative care movement does, is make people comfortable in talking about death and dying. And making death and dying and celebrate it as much as we do birthing. And we talk about “is a good death achievable?” And “what does that mean?” And I think a good death is achievable, but we have to start practicing it, and opening to what the realities are of life, and realizing, whether it's a young person or a senior, how we value each and every life, and how we really can help people come to grips with the reality.

Sandy: 25:04 Palliative care is about accepting the limitations that happen to us as we age, and recognize that we're not immortal, and that we can get a lot of meaning as we age. We can get a meaning for many people out of suffering. Well, we hope people come to often reconcile dysfunctional relationships or other things at the end of life. For example, I work with the homeless population here in Toronto, providing palliative care, and we have the Good Wishes Project. And sometimes that's a material thing, like a dinner at a restaurant or getting a cell phone for the first time, but for other people and for many of them, it's reconciling relationships with family members and loved ones who were estranged or they haven't seen for many years. People often will have those goals. They'll talk about their legacy, and the impact that they'll have on others. We help them prepare legacy projects so we can make the dying process something that's really meaningful for that individual and for their family. I guess we help them come to accept as well, you know, what's happening to them.

Lisa: 26:07 The thing that comes to mind as you're speaking is the fact that part of having a good death doesn't necessarily mean there isn't sadness and pain, and my own personal experience is that you were very with us in that. When I think back on it, I was quite struck by the fact that you shared with us in the pain and the sadness, and that seems in some ways quite different from some fields of medicine. And I don't know if that is part of the process or just your own personal approach to it, but I'm wondering if you can talk a bit about the role that sadness and shared emotions occurs in your day to day work, and how that impacts you. I'm sure there are many people who think, “wow, how can you do this work? It must be so hard and so sad. ”

Sandy: 26:57 Yes. And I'm sort of going to answer your question in a roundabout way, but just starting with that, “it must be so sad.” It is sad and it's tragic, but the rewards are great here. I've had a relationship with your family since your mom's passing. Even this conversation right now is a reflection of that ongoing relationship. And to me that's an incredible reward. Your dad was phenomenal. You know, we continue to honor the relationship. He held a fundraiser for hospice that I'm establishing in Toronto: a jazz night, as an incredible photographer and a jazz lover. He established that beautiful thing, in memory of your mom, but really as a fundraiser for ourselves as well as other charities. So the rewards that we get, you know, that I get, personally from the people that I associate with and care for, are really beyond description. You can't put a price on that.

Sandy: 27:48 You used the word earlier in the interview about accompanying you, and that's really what it is, it's a witness and accompaniment, as I am trying to alleviate parts of the pain, for example, that your mom suffered. And the patient is not just the patient herself, but it's the whole family. So that comes from a place of compassion. This is all about compassion. It's about compassion for the individual patient and what they're going through. It is about their family and what they're going through and it's about creating a compassionate community around them and in our own society. So compassion is really the core of all of this. Of what I do, and I guess how I see myself and I guess I found it in palliative care. I've found it in lots of areas of medicine, when I was doing more comprehensive care, but the focus on palliative end of life care helped me really express that compassion.

Lisa: 28:42 You've mentioned it already, but I'm wondering, and I think you've answered this question implicitly, but I'm wondering if explicitly you could share: how would you define a good death?

Sandy: 28:53 I think death has all the elements of the things we were talking about in palliative care. First of all, that—and different people want different things—but overall I think a good death means physical comfort. That pain and shortness of breath and other physical symptoms are relieved. A good death may be that a person can be in the place of their choosing, his own, an environment where they feel loved and supported and comforted. A good death can be surrounded by the people they love. Maybe there are issues of faith and things that couldn't be addressed for them. A good death needs to be dignified. It needs to respect that person's dignity and their values. However they define dignity. I think dignity is kind of subjective and knowing that everything is happening and it's according to their wishes, to the best of the helpers ability and the families of acknowledge what they want. A good death may involve for some the reconciliation with these relationships about doing legacy projects for say you have a child or grandchild and you know there's gonna be future messages and things that you want to leave. For them, it's about a reflection of your life and the impact and the contribution you've made to the world. So I think it involves all those aspects and as a palliative care team, we strive to provide that to our patients and families.

Lisa: 30:14 Great. So at the risk of opening a big Pandora's box, I'm wondering if you can talk a little bit about the article, “The Doctor Who Took on Death” that MacLean's did on you, and about the complex issue of medical assistance in dying, as I believe it's called in Canada. Can you talk a little bit about that issue and the current policies as relates to MAID and maybe something about your own values. It seems like a really complex issue and I'm wondering if yo

u can just give us an overview.

Sandy: 30:45 Yeah, it's a very complex issue and it's a very divisive issue. Just to give your listeners a little background, “medical assistance in dying” is euthanasia. It's been practiced in the Netherlands and Belgium and other countries for many, many years, maybe 30 years or more, and eventually became legal in Canada in June of 2016 and it's right across the country, whereas it's legal in certain states in the US in a slightly different way. For example, in California. And really I struggled personally and professionally with the ideas of whether I would become a provider of MAID; Medical Assistance in Dying. I struggled because my training and background was everything to extend and save life at all costs.

Lisa: 30:45 The Hippocratic Oath, kind of thing.

Sandy: 31:34 Yeah, the Hippocratic Oath kind of thing. Well, the Hippocratic Oath holds the position that you would never perform or facilitate an abortion. And so I think, the suffering of people, that kind of became the core for me. And again, with a compassionate lens as to the suffering that people have, where lives were being extended and the suffering was immense. I had many, many, many patients over time express a wish to hasten their death. They were getting good palliative care, but the issues that maybe medicine and even palliative care couldn't address: issues of control over the process of life for people who often were used to being in control, or existential spiritual suffering was so great that despite even the best of palliative care, they still wanted it. And it's become, again, a very divisive process. So we had certain challenges to our Supreme Court that prevent– you know, it was part of the criminal code against assisting people who wanted to have a suicide.

Sandy: 32:29 So the law actually changed to enable physicians to help people assist their dying. And there's very, very strict legislation about it, processes of eligibility assessments. There is a lot of concern for vulnerable people and the possibility of coercion. And so there's a very strong law about assessing all of that and ensuring that none of that happens. But ultimately I came to grips with the fact that addressing suffering was the key to what I do and a compassionate approach would be to provide the ultimate relief of suffering to people. Even this afternoon, and not even an hour before you called, I was on the phone with a 51 year old woman with metastatic ovarian cancer who has it all through her bones, and even with the best, she's still in pain. And so we're going to perform a procedure for her next Tuesday. She's had all the things and she's just begging for it.

Sandy: 33:29 And so relieved the fact that she doesn't have to go on with her suffering for months on end because we're able to facilitate a dignified end to it, surrounded by her family at a time of her choosing, and so that's probably a good death. The actual deaths that I've seen and been involved with, with this, have been all beautiful. In their arms or their loved ones in a peaceful way within minutes. So it is not inconsistent with who I am as a physician, even though I have many, many respected friends and colleagues who absolutely disagree. What we're coming to and I hope we continue, is that we can respect each other, because this, particularly in palliative care, this is a very divisive area, but just that we begin to see the humanity and respect. I base everything on the principle of autonomy. I respect my patient's autonomy to make a decision for him or herself.

Sandy: 34:20 I'd like people to respect my autonomy to be your provider. And people who are what we call a conscientious objectors who feel they can't be involved in this would feel complicit in hastening someone's death, I respect their autonomy as well. Our Catholic institutions, for example, of which there are many in many hospitals, would not have anything to do with this as an example. And we have to respect that and work around those issues so that we here in Canada can provide a legal, ethical and funded procedure like any medical intervention that they're eligible for.

Lisa: 34:54 Wow. Yeah. I can imagine it must be so emotionally complex.

Sandy: 35:12 And to be honest, a lot of palliative care providers, and I agree with this, say that not people get access to care, right? And so maybe when they choose MAID because they don't have good palliative care so I'm a strong believer in improving access and delivery of palliative care. We know that if we explore their suffering and address it through palliative care, or whatever it is that it takes to address their suffering, we know about 80% of people will choose alternative treatment and will accept those treatments, those palliative treatments. There's always a core that will go on to want medical assistance in dying, but we can actually reduce its frequency by providing excellent palliative care. It's really important to note that.

Lisa: 35:46 Yeah, I think we really experienced that with you. I can remember at least a couple of points along the way with my mom that she asked you if you would help her if she decided that she was done and was really relieved when you said that you would. And I remember at least a couple of times along the way where she said, “I think I am done. I think I can't continue.” And you asked her that exact question and said, “if I could relieve your symptoms, would you feel the same way?” And a couple of times along the way where you were able to do that. And I think having the option was a huge relief for her.

Sandy: 36:25 Just knowing. Yeah. And we find that over and over. So even if they don't take advantage of that, just knowing that it's a possibility that their suffering may end, and that kind of hope and that they have a clinician who is willing to support them and explore that and rather than handing them off to someone else, really alleviate a lot of significant suffering in and of itself.

Speaker 5: 36:47 Hmm.

Lisa: 36:49 Yeah. Well, it's such important and deep work that you do with people. And there's a couple more things I want to touch on. You touched already on the work that you're doing with the homeless, but I'm wondering if you can talk about the specifics and the particular situations that that population faces and the challenges that you– or the opportunities or the needs that you face with the homeless.

Sandy: 37:15 Yeah. So homeless people are really very, very vulnerable. Part of the population are marginalized in society. Many have very serious mental health and addiction problems and ultimately have struggled in society. The patients I see are living in shelters. They are on the street, even, or they're in precarious housing, subsidized housing situations that most of us wouldn't consider up to standards. You know, they're broken down and cockroaches and bed bugs and rodents and all sorts of things we see, but this is their home or their place. They want to stay there. They lack trust in the healthcare system that stigmatizes them, they have a mortality that's usually 25 to 30 years before the average person, the average Canadian in our case, so they die much, much younger. Poverty is poverty, should be listed on death certificates, the social determinants of health, meaning the most important determinants of your health or your income, your education, your social supports. And most of these individuals have none of this. And we're even in a system where they have accessible healthcare, etc. And yet we still find they have all these challenges. So providing, say, morphine drugs to an addict who's injecting heroin or fentanyl or other things that we have an opioid crisis on our hand, both in Canada, United States, you know, it was a challenge to relieve their pain while you're trying to do will they divert the drugs you're giving them, will they overuse the drugs are giving you, what could you contribute, how do you gain their trust in a system that has stigmatized them. And so that's sort of the challenge of working with this population. So how do you address these kinds of issues in this population? And again, we have to develop the kind of social services support team based care all given through this kind of feeling of compassion towards their suffering to be able to help them get access to palliative care as well.

Sandy: 39:25 Our whole healthcare system here is based on having a home and an address, and when you're on the street facing these issues, that's a lot more difficult. It's a very low threshold, very hard to get people. We often go wandering around the streets trying to find them and so it's not something that's, shall I say, economically good for the practitioners or providers, but it's very cost effective for a system to provide the kind of care and relief that it keeps people out of emergency rooms in hospitals. It provides them with as close as we get to a good death given the limited circumstances that they have. With that in mind, for example, we're opening up to the hospice. Actually May 1st is it's opening date a few days away. There's only one other one similar to that in Canada where we're going to provide care in a supportive environment for these individuals.

Lisa: 40:16 So you mentioned to me before we started recording that you're involved with two hospice projects. Do you want to tell us a little bit about both and how they differ?

Sandy: 40:28 Absolutely. So we call this Journey Home Hospice, it's a hospice for the homeless, but about three or four years ago, I was approached by people who wanted to establish another residential hospice. And a residential hospice is a place. In this case it will have 10 beds where people can come to at the end of life. Many people don't want to be in their homes, necessarily, or their homes aren't, say, conducive to providing good palliative care. They don't have the social supports. Maybe they have an elderly spouse or no family at all that can provide round the clock care that they need. At that stage you saw yourself how important it was to have family available, that you provided for your mom. It's impossible without that and there are many, many people that don't have those kinds of social supports, so a hospice or a residential hospice is a place where they're going to get expert medical attention, nursing care, personal support workers, comfortable environment, you know, meals, prepared medications, etc.  And done in a culture of support that addresses their total needs, emotional, psychological and spiritual needs.

Sandy: 41:26 So I was approached a few years ago to see if I would take on the medical leadership of that. Got me at the right time. It was just a kind of a place in a time where I thought, yeah, this is something that I think always wanted to do. And Toronto in particular as a big city has a lack of hospices. There just hadn't been the attention. 70 percent of our population dies in hospital. We have something called palliative care units, which are inpatient facilities in hospitals or longterm care institutions and that kind of thing, but we have no residential home hospice environment, so I'm establishing a hospice. We call it Neshama, which is a Hebrew word that means “soul,” but the way we're using it is more about essence. It's like when I talked earlier, I think, about getting to who that person is and that individual, about their individual values in their personhood. I'm getting at the essence of who they are and so we're calling it that in order to sort of demonstrate that this is a philosophy of care and approach that each and every individual and their families who come into that environment have that kind of personal care.

Lisa: 42:30 Great. Beautiful. If any listeners are moved to support the work you're doing with the homeless or the hospice, is there a place we can point people to? I'll include the information in my show notes.

Sandy: 42:44 We are just in the process of establishing a website. There is also a website if somebody wants to do an aid called CanadaHelps. We are a registered charity in Canada, so that is one option, or you can share my emails and I can direct it, because we're just getting started. So that's for the Neshama Hospice. For the Journey Home Hospice for the homeess, there is now a website that's also been set up.

Lisa: 43:10 Okay. I'll put that in the show notes.

Sandy: 43:11 Yeah, you put that in the show notes that you can share my email as well. Happy to respond personally to people.

Lisa: 43:16 Okay. Thank you. So it would not be the Super Power U Podcast if we didn't talk about your superpower.

Sandy: 43:16 Of course.

Lisa: 43:16 Thoughts?

Sandy: 43:27 Yeah. I guess, you know, I never thought of this kind of thing before, but I think the core of how I lead my life with my patients, my profession with my family and you know, I say I'm a son and I'm a dad and a brother and I'm a husband and I've got wonderful grandkids. I think it's all about compassion, that's continuing education that's paying it forward to others. That's basically in my professional medical career. You know, you have to understand their suffering. That's kind of cognitive, but then it's followed by an emotional response in empathic response. Are there concerns for the suffering of others? So in palliative care, in a MAID situation, but in anyone who's suffering for the homeless on the street and then it leads to an action to alleviate their suffering that's meaningful for them. So I can do that for the individual. And this is where I kind of bring in my accountability to patients, but to society.

Sandy: 44:25 I advocate, I push, I demonstrate compassion to that individual, the community. If I'm helping a patient, I sort of see that as that kind of the micro level of advocacy, demonstrate my advocacy and the action through a compassionate act of helping their suffering. If my community needs a hospice, I need a compassionate community to come together and support a hospice, so when people come together to donate, when people come together to volunteer at a hospice because that's the basis it becomes part of the community and it leads to a better world. I'm meeting the needs of the community, establishing a hospice because we're so short here. And we develop a compassionate community around it. We're neighbors and people come together to support seeing death and dying as a transition, much like a birthing center in a way.

Sandy: 45:13 It's a place where you have hospices here in Canada where people can have gazebos and people get married and they celebrate life too. And then there's the compassion that can be demonstrated on a system level. So I've had a lot of leadership in medicine and I see my type of leadership as really compassionate leadership. It's role modeling and supporting a compassionate culture. One of the things I'll take over in Canada is universal access to medications. We call it pharmacare that's happening here in Canada that every Canadian will have access to medication and treatment irrespective of their income. We don't have that 10 percent of Canadians won't get their pills because they can't afford it. Then another 10 percent sacrifice on housing and food in order to pay for their medications. So we know it's good. We can say billions a year in Canada. We know this by getting universal pharma care. So I see that as a compassionate act and affecting the system level as opposed to just the individual, the community. So I think my superpower is about compassion. It's about therefore establishing positive relationships between me and others of course and within the community.

Lisa: 46:25 And it sounds like it's compassion in action, specifically.

Sandy: 46:30 Compassion in action. That's a good way to put it. Yeah. Operationalize it. How do you implement your passion. I think that's probably what I'm good at and that I seek to achieve. And it has all these great implants. We know, for example, when you lead compassionate healthcare organizations, you see innovation, you see people just wanting to participate in feeling valued and coming up with such incredible innovative ideas that really improves things, technology and everything just when you lead organizations and groups that have compassionate their core. So that's kinda what I believe in, something that I continue to live throughout my life in all areas of my life.

Lisa: 47:08 That's illustrative of a super power: that it shows up everywhere. And that's beautiful. Thank you so much. I want to thank you for taking the time to talk with me today and also want to express my deep gratitude for all that you do in your professional life, and in your work and in changing attitudes and supporting people and bringing compassion in action to people facing death. I'm very, very grateful.

Sandy: 47:37 Thank you, Lisa. I really appreciate the opportunity to share this with you and to maybe spread a little bit of it around, you know, if we can start hearing about compassion and about palliative care and we sort of say “palliative care is everybody's business.” And if so there's listeners out there who appreciate this kind of approach and method and combination of bringing compassion into their lives and there's so many ways to do that, then obviously that'll have another impact like ripples when a stone falls in the water; it can spread out and create a better world.

Lisa: 47:37 I hope my conversation with Dr Sandy Buchman has done a small part especially for those people like many of my facebook friends for whom the phrase palliative care surfaced only images of lonliness, passivity, abandonment, choking, and many other negative thoughts and feelings.  The variation in the responses from my friends on this topic was striking.  It seemed to me that those who had had direct experience with hospice and/or palliative care had much more positive associations reflecting many of the point Sandy and I discussed.  Those people tended to share comments like: “It's a beautiful thing to have such care” and “making the most of the time left. Making amends. Setting things right. Doing what gives you pleasure. Living pain-free and accepting death”, “time to think through what we wanted to do before she left us, and the time to do a lot of those things”, “being surrounded by loved ones. Receiving respectful compassionate care. Maintaining dignity”, “nurturing, quality time with family and love ones, the right to die on your own terms without horrible interventions.”

Before meeting the Dr Buchman I couldn't imagine how I could possibly survive the loss I knew was coming.  My hope is that this episode do some small part in raising our awareness of the importance of palliative care in treating life-threatening illness and the potential beauty, closure and support residential or home-hospice end-of-life care can provide.  It's doesn't stop the grief from losing a loved one but there's definitely comfort in knowing their needs are being addressed and being supported in the physically, mentally, emotionally, preparation for the life passage that is about to happen. My family and I will always be grateful for the support we had and for our ability to keep my mom home and surrounded by love.  I would like to see the same gift made possible for more people.

Speaker 1: 48:32 Thank you for listening to the Super Power U Podcast. Please subscribe to the show on iTunes and get more information at lisabl.com.