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Timothy Ihrig: What we can do to die well

September 8, 2013

The healthcare industry in America is so focused on pathology, surgery and pharmacology -- on what doctors "do" to patients -- that it often overlooks the values of the human beings it's supposed to care for. Palliative care physician Timothy Ihrig explains the benefits of a different approach, one that fosters a patient's overall quality of life and navigates serious illness from diagnosis to death with dignity and compassion.

Timothy Ihrig - Palliative care physician
Timothy Ihrig advocates for an approach to healthcare that prioritizes a patient's personal values. Full bio

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Double-click the English subtitles below to play the video.
I am a palliative care physician
00:13
and I would like to talk to you
today about health care.
00:14
I'd like to talk to you
about the health and care
00:18
of the most vulnerable
population in our country --
00:22
those people dealing with the most
complex serious health issues.
00:25
I'd like to talk to you
about economics as well.
00:32
And the intersection of these two
should scare the hell out of you --
00:34
it scares the hell out of me.
00:39
I'd also like to talk to you
about palliative medicine:
00:42
a paradigm of care for this population,
grounded in what they value.
00:45
Patient-centric care based on their values
00:52
that helps this population
live better and longer.
00:55
It's a care model that tells the truth
01:00
and engages one-on-one
01:03
and meets people where they're at.
01:04
I'd like to start by telling the story
of my very first patient.
01:09
It was my first day as a physician,
01:13
with the long white coat ...
01:15
I stumbled into the hospital
01:17
and right away there's a gentleman,
Harold, 68 years old,
01:18
came to the emergency department.
01:21
He had had headaches for about six weeks
01:23
that got worse and worse
and worse and worse.
01:25
Evaluation revealed he had cancer
that had spread to his brain.
01:28
The attending physician directed me
to go share with Harold and his family
01:32
the diagnosis, the prognosis
and options of care.
01:39
Five hours into my new career,
01:43
I did the only thing I knew how.
01:46
I walked in,
01:49
sat down,
01:51
took Harold's hand,
01:53
took his wife's hand
01:55
and just breathed.
01:57
He said, "It's not good
news is it, sonny?"
02:00
I said, "No."
02:02
And so we talked
and we listened and we shared.
02:04
And after a while I said,
02:08
"Harold, what is it
that has meaning to you?
02:09
What is it that you hold sacred?"
02:13
And he said,
02:14
"My family."
02:16
I said, "What do you want to do?"
02:18
He slapped me on the knee
and said, "I want to go fishing."
02:20
I said, "That, I know how to do."
02:23
Harold went fishing the next day.
02:26
He died a week later.
02:29
As I've gone through
my training in my career,
02:32
I think back to Harold.
02:34
And I think that this is a conversation
02:36
that happens far too infrequently.
02:40
And it's a conversation
that had led us to crisis,
02:43
to the biggest threat
to the American way of life today,
02:47
which is health care expenditures.
02:50
So what do we know?
02:53
We know that
this population, the most ill,
02:54
takes up 15 percent
of the gross domestic product --
02:57
nearly 2.3 trillion dollars.
03:00
So the sickest 15 percent
take up 15 percent of the GDP.
03:04
If we extrapolate this out
over the next two decades
03:07
with the growth of baby boomers,
03:11
at this rate it is 60 percent of the GDP.
03:14
Sixty percent of the gross
domestic product
03:19
of the United States of America --
03:22
it has very little to do
with health care at that point.
03:23
It has to do with a gallon of milk,
03:26
with college tuition.
03:29
It has to do with
every thing that we value
03:31
and every thing that we know presently.
03:33
It has at stake the free-market
economy and capitalism
03:38
of the United States of America.
03:42
Let's forget all the statistics
for a minute, forget the numbers.
03:46
Let's talk about the value we get
for all these dollars we spend.
03:49
Well, the Dartmouth Atlas,
about six years ago,
03:54
looked at every dollar
spent by Medicare --
03:57
generally this population.
04:00
We found that those patients who have
the highest per capita expenditures
04:01
had the highest suffering,
pain, depression.
04:07
And, more often than not, they die sooner.
04:12
How can this be?
04:15
We live in the United States,
04:17
it has the greatest health care
system on the planet.
04:19
We spend 10 times more on these patients
04:21
than the second-leading
country in the world.
04:24
That doesn't make sense.
04:27
But what we know is,
04:29
out of the top 50 countries on the planet
04:30
with organized health care systems,
04:34
we rank 37th.
04:37
Former Eastern Bloc countries
and sub-Saharan African countries
04:41
rank higher than us
as far as quality and value.
04:46
Something I experience
every day in my practice,
04:52
and I'm sure, something many of you
on your own journeys have experienced:
04:54
more is not more.
04:59
Those individuals who had more tests,
05:04
more bells, more whistles,
05:06
more chemotherapy,
more surgery, more whatever --
05:07
the more that we do to someone,
05:09
it decreases the quality of their life.
05:13
And it shortens it, most often.
05:17
So what are we going to do about this?
05:21
What are we doing about this?
05:23
And why is this so?
05:25
The grim reality, ladies and gentlemen,
05:26
is that we, the health care industry --
long white-coat physicians --
05:28
are stealing from you.
05:32
Stealing from you the opportunity
05:34
to choose how you want to live your lives
05:37
in the context of whatever disease it is.
05:40
We focus on disease
and pathology and surgery
05:42
and pharmacology.
05:45
We miss the human being.
05:49
How can we treat this
05:53
without understanding this?
05:54
We do things to this;
05:58
we need to do things for this.
06:02
The triple aim of healthcare:
06:07
one, improve patient experience.
06:09
Two, improve the population health.
06:12
Three, decrease per capita expenditure
across a continuum.
06:17
Our group, palliative care,
06:23
in 2012, working with
the sickest of the sick --
06:25
cancer,
06:30
heart disease, lung disease,
06:31
renal disease,
06:33
dementia --
06:35
how did we improve patient experience?
06:37
"I want to be at home, Doc."
06:40
"OK, we'll bring the care to you."
06:42
Quality of life, enhanced.
06:44
Think about the human being.
06:47
Two: population health.
06:48
How did we look
at this population differently,
06:50
and engage with them
at a different level, a deeper level,
06:53
and connect to a broader sense
of the human condition than my own?
06:56
How do we manage this group,
07:00
so that of our outpatient population,
07:04
94 percent, in 2012,
never had to go to the hospital?
07:06
Not because they couldn't.
07:11
But they didn't have to.
07:15
We brought the care to them.
07:16
We maintained their value, their quality.
07:19
Number three: per capita expenditures.
07:25
For this population,
07:28
that today is 2.3 trillion dollars
and in 20 years is 60 percent of the GDP,
07:29
we reduced health care expenditures
by nearly 70 percent.
07:35
They got more of what they wanted
based on their values,
07:40
lived better and are living longer,
07:44
for two-thirds less money.
07:47
While Harold's time was limited,
07:54
palliative care's is not.
07:57
Palliative care is a paradigm
from diagnosis through the end of life.
08:00
The hours,
08:06
weeks, months, years,
08:08
across a continuum --
08:11
with treatment, without treatment.
08:12
Meet Christine.
08:14
Stage III cervical cancer,
08:17
so, metastatic cancer
that started in her cervix,
08:18
spread throughout her body.
08:22
She's in her 50s and she is living.
08:24
This is not about end of life,
08:28
this is about life.
08:30
This is not just about the elderly,
08:33
this is about people.
08:34
This is Richard.
08:37
End-stage lung disease.
08:39
"Richard, what is it
that you hold sacred?"
08:42
"My kids, my wife and my Harley."
08:45
(Laughter)
08:48
"Alright!
08:49
I can't drive you around on it
because I can barely pedal a bicycle,
08:52
but let's see what we can do."
08:55
Richard came to me,
08:58
and he was in rough shape.
09:00
He had this little voice telling him
09:04
that maybe his time was weeks to months.
09:06
And then we just talked.
09:09
And I listened and tried to hear --
09:10
big difference.
09:14
Use these in proportion to this.
09:16
I said, "Alright, let's take it
one day at a time,"
09:20
like we do in every
other chapter of our life.
09:22
And we have met Richard
where Richard's at day-to-day.
09:26
And it's a phone call or two a week,
09:30
but he's thriving in the context
of end-stage lung disease.
09:34
Now, palliative medicine is not
just for the elderly,
09:42
it is not just for the middle-aged.
09:45
It is for everyone.
09:49
Meet my friend Jonathan.
09:50
We have the honor and pleasure
09:53
of Jonathan and his father
joining us here today.
09:55
Jonathan is in his 20s,
and I met him several years ago.
09:57
He was dealing with
metastatic testicular cancer,
10:00
spread to his brain.
10:04
He had a stroke,
10:06
he had brain surgery,
10:08
radiation, chemotherapy.
10:09
Upon meeting him and his family,
10:13
he was a couple of weeks away
from a bone marrow transplant,
10:15
and in listening and engaging,
10:18
they said, "Help us
understand -- what is cancer?"
10:20
How did we get this far
10:27
without understanding
what we're dealing with?
10:30
How did we get this far
without empowering somebody
10:33
to know what it is they're dealing with,
10:35
and then taking the next step and engaging
in who they are as human beings
10:37
to know if that is what we should do?
10:41
Lord knows we can do
any kind of thing to you.
10:43
But should we?
10:48
And don't take my word for it.
10:53
All the evidence that is related
to palliative care these days
10:55
demonstrates with absolute certainty
people live better and live longer.
10:59
There was a seminal article
out of the New England Journal of Medicine
11:04
in 2010.
11:07
A study done at Harvard
by friends of mine, colleagues.
11:09
End-stage lung cancer:
11:12
one group with palliative care,
11:13
a similar group without.
11:16
The group with palliative care
reported less pain,
11:19
less depression.
11:23
They needed fewer hospitalizations.
11:25
And, ladies and gentlemen,
11:28
they lived three to six months longer.
11:30
If palliative care were a cancer drug,
11:35
every cancer doctor on the planet
would write a prescription for it.
11:39
Why don't they?
11:44
Again, because we goofy,
long white-coat physicians
11:47
are trained and of the mantra
of dealing with this,
11:50
not with this.
11:56
This is a space that we will
all come to at some point.
12:02
But this conversation today
is not about dying,
12:07
it is about living.
12:10
Living based on our values,
12:12
what we find sacred
12:13
and how we want to write
the chapters of our lives,
12:14
whether it's the last
12:17
or the last five.
12:19
What we know,
12:22
what we have proven,
12:24
is that this conversation
needs to happen today --
12:26
not next week, not next year.
12:29
What is at stake is our lives today
12:31
and the lives of us as we get older
12:34
and the lives of our children
and our grandchildren.
12:36
Not just in that hospital room
12:40
or on the couch at home,
12:42
but everywhere we go
and everything we see.
12:43
Palliative medicine is the answer
to engage with human beings,
12:48
to change the journey
that we will all face,
12:53
and change it for the better.
12:58
To my colleagues,
13:01
to my patients,
13:04
to my government,
13:06
to all human beings,
13:08
I ask that we stand and we
shout and we demand
13:10
the best care possible,
13:14
so that we can live better today
13:17
and ensure a better life tomorrow.
13:19
We need to shift today
13:21
so that we can live tomorrow.
13:24
Thank you very much.
13:28
(Applause)
13:29

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Timothy Ihrig - Palliative care physician
Timothy Ihrig advocates for an approach to healthcare that prioritizes a patient's personal values.

Why you should listen

Dr. Timothy Ihrig, MD practices palliative medicine, caring for the most vulnerable and sickest people, and helps other providers improve the quality and value of the care they provide to this population. His work has shown how patient-centered care improves quality and length of life, and that it has significant economic benefits to patients, healthcare systems and the economy.

Ihrig is nationally recognized for his expertise in continuum population health and community-based palliative care. He holds appointments as content expert to the Accountable Care Learning Collaborative, an industry-leading healthcare innovation collaborative co-chaired by former Health and Human Services Secretary and Utah Governor Mike Leavitt and former Food and Drug Administration Commissioner Dr. Mark McClellan. Ihrig is a member of the Advisory Council of the Iowa Healthcare Collaborative, a think-tank for strategies in health care quality, safety and value for the state of Iowa. He also serves as an Iowa Alternate-Delegate to the American Medical Association.

Ihrig has been an expert source for palliative care development for the Brookings Institution, and he was the sole practicing physician assisting the Iowa General Assembly in raising minimum standard requirements for Iowa physicians with respect to end-of-life care and oversight of prescriptive narcotics. He also acted as an expert clinician in support of Iowa Physician Orders for Life-Sustaining Treatment bill. He holds appointments as Clinical Adjunct Professor in the Department of Medicine at the University of Iowa Carver School of Medicine and acts as Palliative Care clinical instructor. He is on the board of the Hospice and Palliative Care Association of Iowa, is the former chair of the Advocacy Committee and sits on the Palliative Care Advisory Committee.

Ihrig's other interests include sexuality at the end of life and global health. He served as the Medical Chair of the Health Services Committee for Empower Tanzania Incorporated, whose mission is the development of sustainable healthcare solutions in sub-Saharan Africa for individuals suffering with HIV/AIDS, cancer and other life-limited illnesses.

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