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Medicine in the Eleventh Hour with Sunita Puri

Sunita Puri is a palliative care doctor who chronicles her journey through medical school, fellowship and finding her specialty in her book, “That Good Night: Life and Medicine in the Eleventh Hour.” Sunita has an accomplished medical career and she’s also a brilliant writer. We talk about how her love of poetry and language directly serves her as a palliative care doctor, whose job it is to have hard, direct conversations with people at the end of their lives. If you or a loved one are navigating the medical system, this episode is for you. Her book is a must read if you’re considering medical school – Sunita’s candor and nuance about the grind of becoming a doctor and the opportunity to help people is refreshingly honest. 


You can find Sunita’s book and other work at https://sunitapuri.com/


Transcript:

[00:00:00] Sarah Cavanaugh: Hi, I'm Sarah Cavanaugh, and this is Peaceful Exit. Every episode, we explore death, dying, and grief through stories by authors familiar with the topic. Writers are our translators. They take what is inexpressible, impossible to explain, and they translate it into words on a page. 

[00:00:25] My guest today is Dr. Sunita Puri. She wrote a book about the role of medicine at the end of our lives based on her experience as a palliative care doctor. She questions our assumptions and pushes back on the barriers to compassionate human care in the medical system. She's asking herself and others what the responsibility of a doctor should be. 

[00:00:49] And she also explores the role spirituality plays in our lives and in our decision making. Yes, she has this incredible resume, but she's also a writer, a master with words. We talk about how her love of poetry and language directly serves her as a palliative care doctor. If you or a loved one are navigating the medical system, her book, That Good Night, Life and Medicine in the 11th Hour, is for you. 

[00:01:16] It's a must read for anyone considering becoming a doctor, even if palliative care is not on your radar. Sunita's candor, her nuance about the grind, it's real and it's invaluable to anyone considering a career in medicine. Sunita would be the first to tell you she doesn't have all the answers. And that's what makes her so good and full of insight. 

[00:01:44] Welcome to Peaceful Exit.  

[00:01:46] Sunita Puri: Thank you for having me.  

[00:01:48] Sarah Cavanaugh: So great to meet you at Mesa Refuge. And, um, I picked up your book this morning. And I just flipped to the back to the acknowledgments and I really read them and I don't know, it just brought me to tears this morning. Oh. The way you, um, expressed your gratitude. 

[00:02:05] Sunita Puri: Thank you.  

[00:02:06] Sarah Cavanaugh: You know, there are doctors and there are writers and you're both. In your book, That Good Night, Life and Medicine in the Eleventh Hour, you've given language to some really important experiences as a physician in training and in practice. How did you come up with the title?  

[00:02:25] Sunita Puri: So I remember sitting at a dinner table with a friend of mine who I also met at Mesa Refuge and we were trying to figure out the best title for the book and I took the line from the Do not go gentle into that good night. 

[00:02:42] by Dylan Thomas, because it has a life outside of the book, and because the idea of going gently was something that I was trying to communicate, that going gently is really the best case scenario and something we all deserve. And I also wanted to challenge the other lines or sentiments of the poem, which was to rage against the dying of the light. 

[00:03:10] And I think not going gently into that good night is why there is so much suffering when it comes to the idea of mortality. Because there's this concept that it is something to be resisted rather than something to be embraced because it is natural. So I wanted to turn the meaning of the poem kind of on its head. 

[00:03:33] And the subheading of life and medicine in the 11th hour was actually a contender for the entire title But the combination of the two Really kind of helped me to one push back against some of the ideas That we have in our culture and I think in many cultures now that western medicine has kind of infiltrated a lot of places That idea that we have to prevent ourselves from dying You When in fact, life and medicine in the 11th hour can actually be something quite beautiful and gentle. 

[00:04:07] Sarah Cavanaugh: I love that. Have you always loved poetry?  

[00:04:12] Sunita Puri: Yes. And I, I remember my 10th grade English teacher, Rod Flagler, who I studied with, still love very much who was in the acknowledgements of the book. Um, he would always talk about how the economy of language or saying something powerful in the fewest possible words is the real mark of an artist and poets do that so well. 

[00:04:36] So I think that studying poetry and enjoying it and really paying close attention to what's being communicated through images and very few words is part of, I think, how I try to refine my own work.  

[00:04:54] Sarah Cavanaugh: Yeah. Well, it's clear in your writing. It's really beautiful writing. And you write about the importance of language used in medicine, especially as a palliative care physician. 

[00:05:05] Um, I wonder if I could read a passage.  

[00:05:08] Sunita Puri: Yes, of course.  

[00:05:09] Sarah Cavanaugh: And just see what comes up for you.  

[00:05:13] If language reflects something about culture, then maybe my verbal fumbling made sense. The language of medicine reflected its biggest priorities, identifying and solving problems, saving and extending lives. It was about CT scans and laboratory tests and survival benefits. 

[00:05:32] Medical language atrophied when matters of suffering and mortality needed to be discussed, giving way to euphemism and avoidance. Lacking the language to discuss mortality is the ultimate way of erasing it.  

[00:05:47] Sunita Puri: Yes. Um, it's funny. I just did a book reading in Boston and my interlocutor pointed out that same passage. 

[00:05:57] It's something that I think about a lot, especially when I'm teaching people how to have these conversations because they're awkward and forced and often rushed and tentative because we don't feel comfortable inhabiting that space. Our culture doesn't really allow for it and the culture of medicine Also makes it very, very tough to sit down with somebody and to say, perhaps it's no longer about whether you can fight. 

[00:06:29] This is really an issue of whether your body can fight or whether we are coming up against a natural limit. And those concepts of what is natural. That is not something that we really stop to think about in medicine because there's always this idea that something more can be done to push back against a natural unfolding of a disease. 

[00:06:55] I'm from Los Angeles where the idea of aging is, you know, not something people like to believe in. So truly the idea of a natural arc of a life, the natural arc of a body, that's not something that is in most places accepted. And so when you try to have a conversation about what's natural, it becomes really challenging because you not only lack the culture and the language, some people, because of that, lack the willingness to go there. 

[00:07:29] Sarah Cavanaugh: Yeah. What's the weirdest euphemism you've ever heard for death?  

[00:07:34] Sunita Puri: Um, so on rounds, when I was a resident, people would say things like circling the drain.  

[00:07:40] Yes.  

[00:07:41] Or he's tanking. That was the other one. He's circling the drain, he's tanking. Those were the ones that could either indicate that we could still treat and maybe bring them back from the brink, but most of the time those terms were used when somebody was dying and saying you're dying or this patient is dying. 

[00:08:04] That felt very aggressive and almost like too much when I was in residency and it was only protecting me. I thought that it was my job to protect people from the truth in some ways, or the brutal truth, a truth made more brutal by using direct language. But, As I wrote about in one of my pieces for the New York Times, this idea of blunting language to spare people from feeling bad is almost the worst form of paternalism. 

[00:08:39] So instead of saying, you are dying, in the right context with the right setup, we say to each other, you're, this person is circling the drain or he's passed because we think that people can't handle what will come up for them. And it's almost like treating somebody like a child. The way we shield children from hard things because we think they're not quote unquote ready for it, but a full grown adult has had experiences and emotions that have been hard to handle their whole life. 

[00:09:14] So who's to say they can't handle it if I were to use the word dying or say the word death?  

[00:09:20] Sarah Cavanaugh: That's right. Do you think it's the chicken or the egg? Is it that our culture is ignoring it and avoiding it? Or is it that we don't use the language and therefore It's developed this sort of secrecy around it. 

[00:09:33] Sunita Puri: I think it's probably an interplay of both things, but I think that our avoidance in using the language is something that is probably the bigger culprit. And if we just start becoming more comfortable with saying these things and saying what we mean when we're saying these things, then I think we might have a tiny revolution in. 

[00:09:58] in cultural evolution around how we think about and be with suffering and dying.  

[00:10:04] Sarah Cavanaugh: That's my hope. That's my hope with all of these conversations. How do we all get fluent in this language of death?  

[00:10:13] Sunita Puri: Well, I think that the first step is just acknowledging that this is something that is coming for everybody. 

[00:10:22] That everything is that the only constant in life is change and the idea of impermanence. And so even if we step aside from the idea of becoming comfortable with our own deaths or the deaths of those around us or the dying or the suffering, just even acknowledging that everything around you will change, how do you cope with that? 

[00:10:46] What does it bring up for you that your dog is now five and once he was a puppy and in that same period of time he may no longer be here? What does that mean? What does it mean to sit with that? And I think that before we can become comfortable with those words and those concepts, we have to start small and think about what was it like when I lost something or someone that I didn't think I could survive losing? 

[00:11:15] What did I do? And how did that experience transform me? Is there a way that contemplating our certain end may also be a process of transformation? So it's not just about saying the words or getting comfortable with it. It's about opening yourself to the transformative power of living amid loss.  

[00:11:43] Sarah Cavanaugh: I love that. 

[00:11:44] Part of the first things we do in our Peaceful Exit course is talk about what each individual story is around death. What are the losses you've had? How have they impacted your life? How are you taught to grieve? A lot of people, uh, including myself, Our family's never talked about grief and that's, it's really profound in your book when you write about your parents, how they taught you that suffering, aging, getting sick and dying, we're all parts of life of being human. 

[00:12:15] Sunita Puri: So I grew up the daughter of very spiritual Indian immigrants Sikhism and Buddhism. So this idea that, um, Life is full of suffering and it's only made worse if you try to resist it. I was also kind of exposed to this idea that science and spirituality can kind of be bedfellows and not these binary opposites. 

[00:12:44] Because my mom, who was an anesthesiologist, would pray with her patients. She would ask them, would you like to pray? Before she would take them to the operating room. And so Those were the things that I was kind of exposed to that made it so that I understood suffering is inescapable and normal. And obviously you can know it intellectually when you're younger, like, you know, a teenager, but you have to really grow into embracing that understanding. 

[00:13:14] So when I was in medicine, I, to be honest, none of that, especially medical school, It was all about getting the right answers and getting into a residency and making sure you knew facts. And I was very still humanistic and kind with my patients, but I was very much in the mode of, okay, this person has this problem. 

[00:13:37] We need to fix it. And it was really in palliative that I started to kind of open to the idea that there's a lot that you can do that doesn't mean the suffering will go away. It doesn't mean that people's suffering goes away, even if you've cured a disease. Because there's so many elements to suffering when you're sick and when you're not sick that go beyond the physical. 

[00:14:03] So the emotional residue of having gone through a curative liver transplant, That's something significant. Your whole life has changed because of that. You may be cured and you may never be able to go back to the job that you had if you're on a bunch of immunosuppressants. So the kind of experience of illness and the uncertainty and the fear and everything that comes with it doesn't end when your job is done, when you've cured a disease or not. 

[00:14:35] And so it was really kind of in my fellowship, in my early years of being a doctor, being a palliative care doctor, that I really kind of had to learn that for myself. And also that just, What people really want is to be seen and heard. And sometimes that has nothing to do with what you're doctoring them for, but just taking the time to really make an effort to see them beyond their physical suffering and to let them be and not do things like tell them Don't cry or it's going to be okay, because how do we know it's going to be okay? 

[00:15:16] What does okay mean? You know, it means just stepping back from that compulsion to quote unquote make it all better. Which is what we try to do as doctors. And that's something I actually tell my patients is you are more than this sick body, this sick body has nothing to do with your magnificence. And it's amazing how often that is reassuring to them. 

[00:15:47] And it doesn't necessarily come from their own tradition, but at some level, don't we all know that we're more than a body?  

[00:15:57] Sarah Cavanaugh: I love the metaphor, uh, that you used in the recent New Yorker piece and explained the balance between patient autonomy and the doctor's responsibility to inform patient decisions. 

[00:16:08] It's like going to a mechanic and being asked to decide without any guidance how he should fix my car. Yes. Can you talk a little bit about, you need some information about options, then you can make that decision about your treatment.  

[00:16:20] Sunita Puri: So I think that part of what I have noticed in my career is that we lay out options as if this is Burger King and it's a have it your way sort of situation. 

[00:16:36] And that's actually how I, the, one of the analogies I drew about CPR in that piece, where we offer people options in the absence of the context in which we're asking them to make those decisions. So asking somebody, laying out chemotherapy options and saying which one, like what, what would you want to do, I think is an abdication of responsibility. 

[00:17:00] And I actually feel very strongly about this, that in order to help somebody make a decision, you have to be able to be very honest and clear about what situation they're actually in. That means stepping back from words like your cancer is treatable because treatable to most people translates to curable. 

[00:17:20] When I've heard people say treatable, it's a euphemism because you're not saying what you mean. If somebody's living, for example, with stage four cancer, you say these are possible treatments. But they will not cure your cancer and you need to understand that in order to make the best decisions for you. 

[00:17:41] Because, you know, for example, if you're offering somebody an option that could devastate their day to day life, they need to know that that devastation is something they're undergoing. for a specific potential outcome. And I think we're so bad in medicine at being with uncertainty that when we're explaining these options, we're not good at saying, here is what I can offer you in terms of guidance, but I cannot assure you of anything in particular, because I don't know how your body is going to respond to this particular treatment. 

[00:18:20] And I think it also Saying, tell me what you're hoping for. Tell me what's important to you in your life. Tell me, is there an event you're trying to get to? Because you need to understand the life context that that person is bringing into that conversation. And you also need to be explicit about the medical context in which somebody's making decisions. 

[00:18:44] So it's not, do you want us to do CPR? Would you want CPR? It's, Tell me what you know about your condition. If they don't know what's really going on, you correct it and say, I want you to understand that you are living with a cancer that will at some point take your life. It is not a curable disease. 

[00:19:07] Therefore, if your heart were to stop from complications of something we can't cure, here's my recommendation about what a natural death would look like, for example. But we don't do that. We don't talk about what's reversible and what isn't. We're too afraid to say here's my recommendation because we're so afraid of being paternalistic that we've forgotten how to do our jobs. 

[00:19:34] We're so afraid that someone's going to sue us. If we say, here are all the things we can do, but this set of things are not on the table for these reasons, we're so afraid that we're going to get in trouble or be sued that we can't be honest with people. And then I show up sometimes at the 11th hour, and I have to be the one who's honest. 

[00:19:59] And that is a gift in a lot of ways, and I'm blessed to do it, but it is also a burden. Because it comes down on me because everything before has failed.  

[00:20:14] Sarah Cavanaugh: Do you often find patients really surprised by your honesty?  

[00:20:19] Sunita Puri: Yes, I do. And it makes me really sad because some of the things that I'm saying, had they been said months before, the decisions some people would make would, would have been different. 

[00:20:35] And this isn't, I also just want to make it clear. I'm not saying that all of my colleagues in medicine don't know how to do this. Some do this very well, but the times when. I'm telling somebody something in a way they can understand really deeply for the first time and it's very late in their disease course. 

[00:20:53] That's what makes me really sick. Because it didn't have to be that way. But it sometimes is.  

[00:21:02] Yeah,  

[00:21:03] yeah.  

[00:21:05] Sarah Cavanaugh: Do you determine quality of life, or how do you ask a patient about what quality of life they wish for? In my conversations, it's always different what people determine is their own quality of life.  

[00:21:18] Sunita Puri: Yes, and I think it's a moving target. 

[00:21:21] So when I'm meeting somebody early on, let's say around the time they first get a diagnosis, I will ask them something like, tell me what a good day is for you. What do you do on a good day? Great question. What's a bad day for you? What makes a bad day bad? Like really simple stuff and it's open ended enough that people can answer in whatever way they want. 

[00:21:46] So in a way, it's like a Rorschach test of what's going to come to mind when I ask you what a good day is. Is it that you could get up and walk around and only take two doses of your pain medicine? Or is a good day a day when You know, you go to work and you don't think twice about the fact that you have heart failure or is a good day, you know, a day where your spouse isn't fighting with you. 

[00:22:14] And all of those things are different windows into what's important to somebody. And so, on a bad day, similarly, if somebody says a bad day is when I can't get out of bed, then we can tailor our treatment to what will help you get out of bed. What's missing from those days that I can help support you in doing? 

[00:22:34] And that, to me, when I'm doing pain management for somebody, it's all about function. What does your pain prevent you from doing? And how can we come up with a combination of medications or physical therapy or acupuncture or other treatments to help you do the things that you want to do? End. I also tell people if I'm able to meet them early in their disease course that how you define quality of life is going to change. 

[00:23:04] You know, eight months into this, if you're getting sicker, a good day might just be being able to sleep and not be woken up by pain. That might be your new target. And we just adjust how we support you based on your new targets.  

[00:23:21] Sarah Cavanaugh: Something you said struck me, um, how early should a patient? Seek out a consult with a palliative care doc. 

[00:23:30] Sunita Puri: So the American Society of Clinical Oncology and the American Heart Association amongst other professional organizations now recommend a palliative care consult at the time of a serious diagnosis. So if, for example, that's, Stage four cancer. Ideally, we should be seeing somebody from the get go. Um, and the get go doesn't have to be day one. 

[00:23:55] I actually think the oncologist needs some time to suss out the situation to meet with the patient a few times and then have us see the person. But the advantage of that is we get to know somebody early on and we can help control their symptoms and keep these conversations about what's important to them going as things change. 

[00:24:18] And as things change, their symptom burden will change, their feelings about what's important and not important will change. And so you help support them making the decisions that fit best for the life they want as that life progresses. And so that's kind of the gold standard. In reality, I think I still meet the vast majority of people towards the end of their life, um, meaning the last few months, sometimes the last few hours or days in the hospital. 

[00:24:54] And for them and their families, that's It's a pity because a lot of what I will hear is that somebody's been suffering from symptoms that could have been better controlled or decision making that ended in a lot of emotional familial gridlock that may have been a softer process if they had the support of a palliative care team. 

[00:25:16] But a lot of people still think it's a choice between palliative care and other medical care, not realizing you can get both together. that being seen by a palliative care service doesn't mean you give up access to chemotherapy or dialysis or whatever your other treatments are.  

[00:25:35] Sarah Cavanaugh: Yeah, there's some confusion between palliative care and hospice, I think. 

[00:25:39] Sunita Puri: Yes, certainly.  

[00:25:42] Sarah Cavanaugh: Yeah. What's it like for you when one of your patients dies?  

[00:25:49] Sunita Puri: Um, it really depends on the circumstances. So if I've known somebody for a while, and they die. To me, what determines my reaction to it is what the process has been like for them. Sometimes the process has been very challenging for me. 

[00:26:09] Let's say it's a very challenging patient with challenging circumstances. But my biggest question is, did they suffer? Did I do a good enough job in minimizing the suffering and the things that were under my control? Because there's so much that isn't. But the majority of times for my patients, when they die, I feel a relief. 

[00:26:39] And gratitude that I could be part of their journey, even if it was for hours, sometimes minutes. But I also, I very much don't feel that they are gone, because I don't think that Things end when our bodies die. So I don't feel an immense sadness or a heavy grief. I really feel that they have been liberated from this particular world of suffering and that, and that I hope something better awaits them. 

[00:27:14] Sarah Cavanaugh: I love that. How do you talk to God? Or an afterlife with your patients, or if your patients bring it up.  

[00:27:22] Sunita Puri: So if people bring it up, I'm always looking at it with curiosity. And I ask every one of my patients, are you a person of faith or is there a spiritual tradition or practice that speaks to you? And when people say, yes, I just simply say, would you like to share more with me? 

[00:27:43] You know, this is an important part of living and of being sick. And I'd love to hear more about the place of spirituality in your life. And people talk about any number of things. Some of them talk about the miracles that they've seen God perform for other people that they know. Some of them talk about how they used to be very religious, but now they don't know what to believe. 

[00:28:11] Some of them say that no matter what happens, You know, God was there for me when times were good and God's here for me now. It doesn't matter what my circumstances are. He's always there. And you really kind of get a window into who they are when they're talking about having faith. in whatever it might be. 

[00:28:39] And for some people just being in nature is their faith because it's a reminder that all things come and go and that there's something beyond us orchestrating it, something that unites us. And so I personally find some of the most rewarding conversations with patients to be about that. And I try when I have to address hard subjects to use that language with them. 

[00:29:07] So for example, when the heart stops, some people consider that God's call. Is that how you think about it? Because it's a much different way than to talk about what do you want the end of your life to look like versus What do you want it to feel like when God calls you? 

[00:29:31] Sarah Cavanaugh: I'm finding myself wishing you're my doctor.  

[00:29:36] Sunita Puri: Whatever you need girlfriend. 

[00:29:42] Like in seventh grade, will you be my girlfriend?  

[00:29:44] Sarah Cavanaugh: Yes, I'm, I'm passing you a note right now in class.  

[00:29:48] Sunita Puri: Yes, please. 

[00:29:53] Sarah Cavanaugh: Did COVID change your practice at all?  

[00:29:55] Sunita Puri: Yes.  

[00:29:56] Sarah Cavanaugh: The, the fact that people could not be with their loved ones. when they were dying. It certainly happened, I think, post when your book was published. And so what, what kinds of things have you learned since this was published through the pandemic? 

[00:30:13] Sunita Puri: It became more intense because people were often alone and we were trying to figure out how to make sure that their families had a way of saying goodbye. 

[00:30:25] And those, that kind of ebbed and flowed as restrictions ebbed and flowed during the pandemic. I also don't know that the pandemic really changed people's willingness to have some of these conversations. I think it's popularly thought that it did. But even though words like ventilator were out in the, uh, in the ether in a way they previously weren't. 

[00:30:52] I don't know that the understanding of what a ventilator is and what it's meant for, I don't know that that understanding for example has evolved and stayed evolved. So for example, somebody saying that they would never want to be on a ventilator because they were thinking of what happened in COVID, it may actually be that they could have something reversible that a ventilator, a short term support might actually bridge them back to the quality of life they're telling me they want. 

[00:31:22] And in other instances, people could say, well, my dad had COVID and he was on a vent and he got better, so I want a vent, but you have stage four cancer. So, um, I think that the pandemic did a lot to demonstrate death is inescapable. How people metabolized that is really variable. I will be honest that I, well before the pandemic, have had people who've died alone, whose families couldn't make it in time, or couldn't make it in at all. 

[00:31:53] The circumstances of the pandemic made it a specific type of tragedy that they have may have been right outside the hospital but couldn't be let in. And that inability to be there at the bedside when you were two floors away, that is a pain that was overwhelming to witness. If anything, it just has made me remind people that it is a gift to be at people's bedside because had this happened years before, it may not have been the case. 

[00:32:24] So when people waver, I say, you know, what would you regret more? Would you regret not being here? Would you regret being here? Because you may not want this to be your last memory. But I also, you know, very much try to support them in whatever their decision is, and to remind them that if you're on the fence, but you had a bad experience during COVID, think about how you might want to make a decision differently now. 

[00:32:51] Sarah Cavanaugh: That makes sense. That makes a lot of sense. The other thing that really came up for me in your book is about death being the great equalizer and how a good death at home seems like it might be the ideal for everyone. But, you know, culturally speaking, that's not the case, which I really found interesting. 

[00:33:10] Sunita Puri: Yeah. I mean, I think that we really have this gauzy overblown image of dying at home in your own bed, surrounded by everybody you love. And if you can achieve that and plan for it and have the resources. to achieve that. That's a wonderful blessing, if that's what you're hoping for. But when I did hospice work, and this is what I wrote about in the book, in South Los Angeles, I took care of a lot of people whose children were working multiple jobs just to stay afloat and keep a roof over their heads. 

[00:33:44] And they didn't always have a caregiver at home, which can be a dangerous circumstance for hospice, because if we came in and nobody was there and somebody, for example, was screaming in pain but couldn't get to their pain meds, that's not safe in a lot of circumstances. It's also not a good example of hospice working. 

[00:34:04] And hospice works really well when you have the things that hospice cannot give you at your disposal, like money, like living in a neighborhood where your pharmacy has opiates because it's not an unsafe neighborhood, like having kids who can take time off from their job, for example. None of those things are things that hospice can give you. 

[00:34:32] And if you have been really sick and doctors and nurses have taken care of you the entirety of your illness, for us to just hand that off to a scared family that doesn't know how to dose morphine, or is worried that they will give a dose of morphine and then their mother will die, and they'll wonder if they were the ones that took her life. 

[00:34:56] It's a really big burden to bear, and for all of those reasons, a lot of my patients, especially at that time, wanted their loved ones to die in the hospital, because for them, that wasn't a bad death. For them, that was a great death because their loved one wasn't suffering and was under the care of experts. 

[00:35:17] And I remember having to advocate hard for some of my patients on hospice to get admitted to the hospital and discharged from hospice when they were dying. Because I knew that the suffering for everybody involved trying to keep that person at home would be overwhelming. And I also knew I would not have to live with that overwhelm, but this family that I knew really well would. 

[00:35:45] And I think that's part of being a good palliative care doctor is recognizing when something, a plan for a death at home is a gauzy sentimental hope. That's not rooted in someone's reality. And that's part of what it means to see somebody, to really see them and their circumstances is to know dying at home is maybe not for them. 

[00:36:08] And that's not a bad thing.  

[00:36:11] Sarah Cavanaugh: It strikes me too, that it's a matter of dignity because if they don't have the strength or the resources, even to keep clean, for example,  

[00:36:21] Sunita Puri: It's huge. I mean, most of my patients don't want anybody wiping their ass. I hope I'm allowed to say that word on this podcast, but that is a phrase that so many people use. 

[00:36:35] I don't want anyone wiping my ass, which is a great colloquial way of saying, I want to remain clean and dry and dignified. I don't want to feel like an infant again. That sort of helplessness, that sort of grimy feeling, and I want to be able to tend to my own needs. And I think that that is something that people cannot always give their loved ones at home, even turning their loved ones or helping them out of bed. 

[00:37:04] What we ask of these caregivers is so immense. They're the unsung heroes. We do not give them the support that they need. Even getting them to take FMLA if it's unpaid or that's the best they can get, that's not really seeing them or seeing their needs because their needs at a certain point are inextricable from the patient's needs. 

[00:37:32] And who wouldn't then say, if a nurse in the hospital can keep my loved one dignified, why wouldn't I want him to die there?  

[00:37:42] Sarah Cavanaugh: Yeah. It's especially complicated with families. If it's the child taking care of the parent, for example.  

[00:37:48] Sunita Puri: Yes.  

[00:37:49] Sarah Cavanaugh: And I'm sure you've seen that quite a bit.  

[00:37:52] Sunita Puri: Often.  

[00:37:53] Sarah Cavanaugh: Yeah, you probably often see as well without dementia, an elder patient feeling like they don't want to be a burden. 

[00:38:01] Sunita Puri: I see that a lot.  

[00:38:02] Yeah.  

[00:38:03] And when people say that, sometimes if they say it to me, I really try to be curious and not assume what that means. Because people might feel like a burden physically, They might feel like a burden emotionally or financially. And so I just ask, you know, tell me where that's coming from. 

[00:38:24] What worries you? In what ways do you feel like you might be a burden? And just see what they say. Sometimes it comes out in family meetings. And I will ask them to say what they mean, but sometimes we'll also turn to whoever they think they're a burden on and say, you know, I'm sure this is not easy for your mom to say, but what's your response to her concern? 

[00:38:48] And nine times out of 10, it's like, are you crazy, mom? Of course you're not a burden. So sometimes, like, that's the thing about family meetings that can be really interesting, is unless there's some performative aspect going on to the, to the dynamic, they can be forums for truth. that people can't say to each other unless it's a mediated situation. 

[00:39:13] And those are the times where you really know that you're kind of helping a family in even a small way to heal by just telling each other what's true.  

[00:39:24] Sarah Cavanaugh: It truly is healing what you're doing. And you're healing the ones that are left behind, you know, the loved ones that are left behind. By hosting those family meetings. 

[00:39:33] Sunita Puri: I hope so. You know, it's, you never really know. And this is something that I think has become a growth point for me is you don't really know what happens when you leave the room, you don't really know. If what you've done is complicated the situation or eased it because there's so much, you don't know about that family. 

[00:39:57] And there's so much you don't know about what goes on even, for example, in a marriage. So I'll give you an example. Not long ago, I had taken care of a really lovely man who'd been married to his wife for 50 years. And in these meetings, a lot of times, you know, people will marvel at that. And the trainees sometimes, or people, other people in the room will say, wow, you know, I wish I could have had that. 

[00:40:24] Or, you know, that's amazing. And, um, I have become, I don't know if it's becoming more skeptical or more mature, but just living in the space of, I don't know, is it a good marriage? Or is it just a long marriage? Is someone there because they want to be or because they couldn't leave? And I think the more I've seen in this job, the more I realize how little I really know about what's going on in someone's life versus what they're sharing with me because the hard stuff is embarrassing or shameful or something like that. 

[00:41:05] And it's not to step away from the true goodness and of what I get to see in people's lives and relationships. But I try to encourage the trainees in particular to think about what they're projecting versus what is, because it will influence how you interact and what you expect and the questions you ask or don't ask. 

[00:41:28] And so it's something, I think this is where my writerly self has really kind of stepped forward into my work, because a good novel or a good memoir will not give you anything easy. And a good writer will not give you anything easy, because people and life are not easy. There's no such thing as an uncomplicated narrator. 

[00:41:53] We're an uncomplicated character, but if you hold up the marriage of 50 years in a gauzy way, gauzy is like my word of the day apparently, but in this kind of way suffused with light, then what you're doing is making the crevices and the edges, the interesting stuff, you're blotting them out. And so that's where I think there's been an interesting new intersection of my writerly and doctorly selves. 

[00:42:22] Sarah Cavanaugh: Beautifully said, and I hope you remain skeptical and not become cynical.  

[00:42:27] Sunita Puri: This is something I'm trying hard not to do. I don't know that I'm, I've gotten too cynical yet, but certainly skeptical and thinking about like, what does that mean to become more skeptical?  

[00:42:42] Sarah Cavanaugh: Yeah. Well, you pause. Yes. You don't run into things as if you have the answer. 

[00:42:48] Sunita Puri: Exactly. Exactly.  

[00:42:51] Sarah Cavanaugh: Yeah. I just want to pause for a second. And just another thing I came across this morning beyond the acknowledgements, which which really opened my heart, was this part at the end about death. And it's not in the last chapter. And interestingly, I spoke with Michael Wiegers recently. He talked about poetry and how, as an editor of poetry, he doesn't look for the last line being the aha or the ah moment. 

[00:43:17] He looks for the moment of recognition or Somewhere in the middle, and you haven't put it in the last chapter for me. You've put it in the third to last chapter, like a poem, and I appreciate that. And I wonder if I could read it for you.  

[00:43:33] Sunita Puri: Yes, of course.  

[00:43:36] Sarah Cavanaugh: What had I learned about death and doing this work? 

[00:43:39] I'd seen that no amount of considering or preparing for it made it easy. Talking about it to prepare frightened loved ones, saying or writing goodbyes, if one was lucky and lucid enough to do so, and trying to make peace with a higher power might soothe us and help us. We feared it and sought to control every aspect of it, even considering physician assisted suicide to give us a sense of agency over an unconquerable, aspect of human existence. 

[00:44:10] But if death was not only a medical fact, but also a spiritual and sacred passage, then it would always have a certain mystery that would perhaps be worth accepting rather than attempting to control. Because we can't control it. We can't always anticipate or prepare for it. What we define as a good death may not be in the cards for us, but maybe we can use the inevitability of death to live differently. 

[00:44:36] Maybe we need the promise of death to guard against taking life for granted. Love that. Thank you. I  

[00:44:44] just love  

[00:44:44] that.  

[00:44:45] Sunita Puri: And it is something I think about a lot more. Like I, I really, the kind of idea, there's a line in the Bhagavad Gita, which I also quote, it's one of the epic Hindu poems, but I see it now, this world is swiftly passing. 

[00:45:02] Yeah.  

[00:45:03] And it's such a simple line, but every time I say it, something really hits me because it's so correct, right? I see it now. This world is swiftly passing.  

[00:45:16] Yeah.  

[00:45:17] And when I remember that, I think to myself, like, what are the things you're putting off that you shouldn't put off? Even if you make arrangements, there's no guarantee it will happen. 

[00:45:31] What are the things you're worrying about? What other people think of you? What they say behind your back? Who are these people? Who cares what they say? I see it now. This world is swiftly passing.  

[00:45:47] Sarah Cavanaugh: Yeah. Yeah. So I'll ask you the question I ask all of my guests. What does a peaceful exit mean to you?  

[00:45:56] Sunita Puri: To me, a peaceful exit means letting go and letting The mystery, wash in. 

[00:46:10] A line I often tell my patients, and I'm going to try not to get emotional when I say this, because it does evoke, the image evokes a lot of emotion with me, but I will walk you to the riverbank. And that to me is really a peaceful exit. To be walked to the shore.  

[00:46:31] Sarah Cavanaugh: All just walking each other home. 

[00:46:37] It's been such a pleasure to have you. Thank you so much for joining us on Peaceful Exit.  

[00:46:43] Sunita Puri: Thank you for having me. This has been fantastic.  

[00:46:46] Sarah Cavanaugh: I hope we bump into each other again at a writer's retreat.  

[00:46:49] Sunita Puri: Yes, ASAP.  

[00:46:51] Sarah Cavanaugh: Thank you for listening to Peaceful Exit. I'm your host, Sarah Cavanaugh. You can learn more about this podcast at PeacefulExit.net and you can find me on LinkedIn, Facebook, and Instagram @APeacefulExit. If you enjoyed this episode, please let us know. You can rate and review this show on Spotify and Apple Podcasts. This episode was produced by the amazing team at Larj Media. You can find them at larjmedia.com. The Peaceful Exit team includes my producer, Katy Klein, and editor, Corine Kuehlthau. 

[00:47:28] Our sound engineer is Shawn Simmons. Tina Nole is our senior producer, and Syd Gladu provides additional production and social media support. Special thanks to Ricardo Russell for the original music throughout this podcast. As always, thanks for listening. I'm Sarah Cavanaugh, and this is Peaceful Exit. 

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