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Palliative Care with Dr. Edward Creagan

Dr. Edward Creagan spent four decades at the Mayo Clinic in Minnesota, working as a cancer specialist and then helping to develop the Mayo Clinic’s palliative care program. In his book and our conversation, Dr. Creagan shares his deep knowledge about how to navigate the medical system with refreshing honesty. He embodies a human-centered approach to medical care that focuses on quality of life and recognizes each person’s priorities and desires.


Sarah Cavanaugh: [00:00:00] Hi, I'm Sarah Cavanagh, 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. My guest today is Dr. Edward Cragen.

Sarah Cavanaugh: After a 40 plus year career at the Mayo Clinic in Minnesota, He wrote Farewell, Vital End of Life Questions with Candid Answers from a Leading Palliative Care and Hospice Physician. His book is a manual for navigating a complicated medical system. It's questions and answers that people are afraid to ask, or may not even know how to ask, or what to ask.

Sarah Cavanaugh: And you can open to the table of contents, pick a question, and dip right in. Dr. Cragen knows his stuff. He was one of the first formally trained cancer specialists in the [00:01:00] 1970s, and then he helped develop the Mayo Clinic's palliative care curriculum. His take on quality of life and human centered care is so refreshing and surprising coming from someone who worked in a hospital for four decades.

Sarah Cavanaugh: I think it's his own personal story, which you'll hear, and his perspective on life that's enabled him to hang on to his deep compassion and his respect for people. He's now retired from clinical practice, but is still doing a great deal of work to help people have these important end of life conversations.

Sarah Cavanaugh: Hello, Dr. Cregan. I'm so excited to talk to you today. Oh,

Dr. Edward Creagan: Sarah, great to connect.

Sarah Cavanaugh: I want to thank you so much for a book of questions because when my mother had cancer in 2001, Yes. I had no idea what questions to ask her or what questions even to consider. And so I just so appreciate the format of this book [00:02:00] being in the form of questions.

Dr. Edward Creagan: Thank you. Yes. This topic is a really big deal and nobody gets it. All this stuff is on Google, but to have a conversation is what people need. Hmm.

Sarah Cavanaugh: Agreed. Explain the difference between hospice and palliative care.

Dr. Edward Creagan: I am convinced this is one of those, um, existential paradoxes that nobody on the planet fully understands.

Dr. Edward Creagan: So let's back up a minute. I want to turn back the clock 72 years and I was seven years old and I had my first introduction to hospice and palliative care. I grew up in a rooming house in Newark, New Jersey and I was raised by my grandmother and there was a gentleman who lived on the second floor and he had cancer of the rectum.

Dr. Edward Creagan: Now the management of [00:03:00] that condition back at that time was brutal. Yeah, I would imagine. And he had a colostomy, a bag to collect his wastes. And my job was to come home from school and change that bag three times a day. And I knew that this would be my calling. So let's fast forward the tape now to 1969.

Dr. Edward Creagan: This is in London, and there was a physician named Dame Cicely Saunders, and like me, she was not satisfied with end of life care, and she focused on a facility to care for patients at end of life, and this was the start of the, the global hospice program. But now it gets complicated. By definition, hospice refers to a medical specialty for managing symptoms for patients and families, by [00:04:00] definition, with a life expectancy of six months.

Dr. Edward Creagan: Now, this is a Medicare related benefit, and we are not held to six months by the hour. But the question that is asked by regulators, does this patient have an anticipated survival? of six months or less if this disease runs its natural course. That's right. And the goal of hospice is quality of life and well being for patients and indirectly for families at end of life.

Dr. Edward Creagan: So we often think of hospice as a basketball, as a circle, as a sphere, and a sliver A sliver of that circle is palliative care. Palliative care is a board certified internal medicine specialty focusing on symptom management of patients at any [00:05:00] time in the trajectory of their illness. So let me explain what that means.

Dr. Edward Creagan: Let's suppose that a patient has advanced lung cancer. They've just been diagnosed and The chemotherapy people will be proceeding with chemotherapy and the patient is plagued with nausea and vomiting and shortness of breath. Rather than the cancer people becoming distracted managing these symptoms, in comes the palliative care people who are experts in treating the nausea, the vomiting, and the shortness of breath.

Dr. Edward Creagan: Now, another way of thinking of this, every specialty has a toolbox. The surgeon has the scalpel, the neurologist has a reflex hammer, and the palliative care hospice people have the conversation with the patient and the family as part of their toolbox. And patients and [00:06:00] families need to understand that they have a right.

Dr. Edward Creagan: They have a right to ask for a palliative care consultation. They don't have to wait for the primary team to promote it. If grandma or grandpa has, let's say, end stage heart disease, and they have nausea and vomiting, the palliative care people have the skill set. to correct that problem. And in the hands of individuals who do this, about 90 percent or more will die with peace and dignity, relatively pain free.

Dr. Edward Creagan: But the families need to speak up and ask for it, because many people don't understand, and there's a perception that hospice is giving up. But I think patients need to understand hospice is a detour. We're sort of leaning into the curve [00:07:00] and almost every family comes to me after the patient dies and says, Dr.

Dr. Edward Creagan: Cregan, why didn't we do this sooner? Yeah. And in general, the average length of life of a patient on hospice is a week or two. Those patients should have been enrolled in hospice early in the course of their illness because that's when the hospice people make the most impact.

Sarah Cavanaugh: Is it true that people, once they accept their mortality, they accept that they are going to die, they tend to live longer with comfort care?

Dr. Edward Creagan: Absolutely. Many medical audiences don't buy into this, but there's a wonderful physician from Harvard. Her name is Dr. Kemmel, and she published a fascinating study in the New England Journal of Medicine. There was something like 100 patients with advanced lung cancer, common [00:08:00] problem. Everybody had access to state of the art traditional oncology management, whether it was chemotherapy, chemo plus drugs, those sorts of things.

Dr. Edward Creagan: And half of the patients were matched to receive only palliative medicine. In other words, everybody got traditional treatment, half had the palliative care people involved. Guess what? The palliative care people, less nausea, less vomiting, they gain weight and they lived on average two to three months longer than the people only getting the traditional chemotherapy.

Dr. Edward Creagan: So if you think about it, this makes sense. If you're nauseated, If you're vomiting, if you have no appetite, the last thing you're

going to do is rush for more chemotherapy. So when your symptoms are controlled, patients are [00:09:00] better able to participate in their management.

Sarah Cavanaugh: And so that led you to be a cancer specialist.

Sarah Cavanaugh: Yes. And then how did you get into palliative care from there? I

Dr. Edward Creagan: became the first Mayo physician board certified in hospice medicine and palliative care. That was in the early 90s. And the reason for that, I became overwhelmed with the soul shredding toxicity of chemotherapy. Because at that time in history, platinum became FDA approved to treat many kinds of cancers.

Dr. Edward Creagan: And this was a game changer. for controlling some cancers. And at that time, the focus was on cure. We never thought about symptoms. We never thought about quality of life because the patient would be cured. Well, those were two fallacies. Toxicities were horrific. Patients were not cured. And I [00:10:00] became very dissatisfied with what we were doing.

Dr. Edward Creagan: And in medicine, unless you're credentialed, you have no credibility. So I took the boards for hospice and palliative care and passed them in 1995, 1996. And then I started to go to hospice meetings. And they introduced me to the magic of steroids, primarily prednisone or dexamethasone or decadron. And these increase appetite, quality of life, they decrease pain, and all medical people know about the side effects.

Dr. Edward Creagan: This is not brain surgery, but if you only have a couple of months to live, there isn't too much concern about long term side effects. And this was dramatic. We never knew in the 90s. that morphine is magical. And at that time in history there was very [00:11:00] little legislative concern about addictive disorders and those sorts of things.

Dr. Edward Creagan: But a few drops of morphine under the tongue was transformative.

Sarah Cavanaugh: Well, my first thought when you were talking about the toxicity of chemo was my mother's. cancer was never diagnosed. She had an undifferentiated, one of those very unique cases where she was never diagnosed with a specific cancer. And so they hit her with the most toxic chemicals and made her very, very ill.

Sarah Cavanaugh: Um, she was fine before the chemo. She was not fine after the chemo. And so I really, um, what I'm hearing you say is that, you know, palliative care is really a doctor of compassion. You're actually treating that human being as a human being.

Dr. Edward Creagan: And in all honesty, we were one of the first specialties to ask a question to the patient.

Dr. Edward Creagan: Tell me, Mr. Jones, what are you most concerned about? Mrs. Smith, what one issue, if we could fix, would [00:12:00] that make you a happy camper? And those answers were the kind of things we never thought about. One of them is, I want to live to see my daughter released from prison. I want to see my son graduate from whatever.

Dr. Edward Creagan: I want to see my husband be sober for one year. The other thing that patients would talk about are their pets. Yeah. And what I learned, you will have a friend for life if you ask a patient about their pets. They smile and then out comes the cell

Sarah Cavanaugh: phone. I was going to say, they're going to show you all the photos.

Dr. Edward Creagan: Oh, and my first experience with this was a gentleman for advanced lung cancer, and this was in the winter of about 1990. And here we live in Siberia, it's very, very cold. And he was basically left in the [00:13:00] emergency room at one of our hospitals, and we didn't think he would make it through the night. But through the magic of Mayo Medicine, he did make it.

Dr. Edward Creagan: And he said, I need to get home. to be with Rex. And we thought Rex was a son, daughter, partner, wife. No, Rex was a 90 pound German Shepherd Cross. And that's all that mattered. I want to get home and see Rex. And Rex was the catalyst to mobilize his intrinsic immune system to get home. So when we slow down and listen to the stories and the drama, It puts the joy back in medicine, but that joy is being somewhat siphoned off by myriad issues over which we, we have very little control.

Sarah Cavanaugh: I'm very grateful for what you decided to do in your life. And well, thank you. And you're an amazing storyteller, and I'd love to kind of be in your [00:14:00] shoes in the, in the white lab coat, you know, with that patient, kind of, um, what's it like for you to give someone some difficult news?

Dr. Edward Creagan: The way we get that right is to ask the patient one question up front.

Dr. Edward Creagan: What have your healthcare team shared with you about the situation? Find out where that patient is because many patients are clueless about the term metastatic disease, clueless about stage four, whatever. So I need to know where that patient is. What planet are their feet in? So they may say, gee, Dr.

Dr. Edward Creagan: Smith told, well, let me give you a real life example. Patient had the resection of a colon cancer. Cancer was removed, it was about the size of a fist, and 20 lymph nodes were removed. But [00:15:00] of those 20 lymph nodes, half harbored cancer. So what the patient heard was the surgeon saying, we removed that primary cancer and we removed the lymph nodes.

Dr. Edward Creagan: We got it all. So the patient thinks, well, why are you here, famous cancer doctor, if the surgeon got it all? And I'm thinking, well, we have a problem with communication. Because the surgeon was correct, he did get it all, but what was removed harbored cancer. So, we have to say, what do you understand about the problem?

Dr. Edward Creagan: Once you know what they've heard, then we can proceed with a more meaningful discussion. The other issue is, I have to make certain whom does the patient want involved in that room, in that space. There are data when the boom is dropped, [00:16:00] so to speak, not to be casual about this, patient's retention, in my view, is essentially zero.

Dr. Edward Creagan: Zero. Once they hear the word cancer, Once they hear the word chemotherapy, once they hear the word hospice, boom, the party's over. Nobody remembers anything. So I think the provider needs to say, tell me what you've learned. And then how much information do you want? Every patient is different, but the caveat has to be we have options, we have alternatives, we have interventions, and never, it's anathema to say, go home and get your affairs in order.

Dr. Edward Creagan: We don't know that. Right. And everybody knows someone who was given a dreadful prognosis and they outlived their doctors. Yeah. And I think we just need to recognize That we don't have all [00:17:00] the answers, and that some people do far better than others for reasons that we don't understand except for one thing.

Dr. Edward Creagan: The people who outlive the averages always have meaning, purpose, and engagement. Yeah. And that always involves a living,

breathing human being. Even a parakeet, a cat, a dog, a fish. Another living being. Yes. And my veterinarian colleagues all tell me, Grandma and Grandpa have been married 100 years. They even look like each other.

Dr. Edward Creagan: They finish each other's sentences. So, Grandpa dies and Grandma's left with a, um, pitbull that nobody wants. But the pitbull is her anchor to reality. The pitbull needs pitbull food. The pitbull has to see the pitbull vet. And when the vet Finds that the dog has died, guaranteed [00:18:00] grandma will pass on within a very short period of time, called conjugal bereavement.

Sarah Cavanaugh: Wow. One of the things that struck me about when you were talking about people not remembering, they hear a word and then they just sort of, their brain shuts down? Yes. I would imagine that many of your patients are elderly. Yes. And that they have, they may have some memory issues, but on top of that is this sort of inability to absorb.

Sarah Cavanaugh: Once you have that sort of physiological response to news, you know. You probably have to repeat yourself, I would imagine.

Dr. Edward Creagan: Yes, and that's why this is not something you want to do five o'clock on a Friday. And that's why when I anticipate it's going to be a heavy lifting conversation, I gently insist that the patient have someone with them.

Dr. Edward Creagan: Because we've given the worst news in their life to that patient and then [00:19:00] we expect them to drive home. Are you kidding? Right. Now on occasion, we'll have a Zoom or a Microsoft Teams approach. It's not ideal, but families are complicated. And I've also learned painfully, no one. has a will that's valid. No one has advanced directives that are valid.

Dr. Edward Creagan: And upon their death, this is a financial Armageddon. Mm, agreed. And if you google famous people who didn't have a will Elvis, Jimi Hendrix, Janis Joplin, Chief Justice Blackmun, Supreme Court person, he was Mayo Clinic's chief counsel, dies without a will. Frank Sinatra had a very sloppily constructed will, uh, when he passed away.

Dr. Edward Creagan: So families are complicated, [00:20:00] and if there are assets, combines, farm futures, if there are trademarked copyrights. And if the appropriate legal channels are not navigated, it's a disaster that's, that's left behind. Do you have a will? Oh, absolutely. It's a will which we revise every three years. Fabulous. And one of the codicils in our will is that if I'm

hospitalized and I'm not improving by day 30, by day 30, supportive care is stopped.

Dr. Edward Creagan: Yes. Because in your neighborhood and in ours, we can be maintained in a vegetative state basically forever. We also have crystal clear advanced directives which are unambiguous. Because any one of us in a heartbeat could be in a situation where we may not improve and we cannot speak for ourselves. [00:21:00] And if we haven't spelled out our advocate, our representative, then nobody kind of knows what we're supposed to do.

Dr. Edward Creagan: I'm

Sarah Cavanaugh: really curious, you write that you wouldn't Follow an aggressive road of treatment, and what factors into your decision about personally not taking that road?

Dr. Edward Creagan: By virtue of what I do, I know the facts, I know the figures, I know the trajectory of an illness. If I had a primary brain tumor, I know that Mayo Clinic operates on and sees about 10 percent of the brain tumors in the world.

Dr. Edward Creagan: So I'm living in the epicenter of brain tumor patients. And in general, from the time the biopsy is positive until you die, it's about 10 to 12 months. You may get a [00:22:00] few more months, you may get less, but that's the ballpark figure. And I'll give you a true story. One of our physicians, he was a cardiologist, He developed a brain tumor.

Dr. Edward Creagan: And if you're a prominent professional, you may get more aggressive treatment than is appropriate. So this prominent physician, and I knew the people who cared for him, were bombarded with recommendations, do this, do that. And he lived 11 months. And I was familiar socially with his wife. And I would see her in a big box store and she was bitter, she was angry.

Dr. Edward Creagan: We should have stopped this last year, we should not have prolonged this because I knew, my husband knew, and the team knew where this was heading. So, if I had certain kinds of advanced cancer, I would be [00:23:00] very hesitant to participate in some of these treatments. I would think very seriously about the potential risks of a phase one study.

Dr. Edward Creagan: The phase one study is also called an investigational program of a chemical of a drug which had been screened in a petri dish or in an animal tumor model. So by definition, a phase one drug has not been proven in

humans and the design of the study. is to determine what dose creates toxicities. Right. So it's not tumor specific.

Dr. Edward Creagan: Now some patients because of altruism or some other motivations may elect to do that. I have no quarrel with that by any means, but I think we have to step back and ask. What am I buying from this particular [00:24:00] management?

Sarah Cavanaugh: I think in my mother's case, she did a phase one trial at the end of her life and no one really explored what the motivation was for that.

Sarah Cavanaugh: And I think your question is on point because Had anyone really sat down with her and said, is this something you want to do yourself for science? Or would you rather be home in your garden with your grandchildren for the last week of your life? And I think there's no question in my mind, what the answer would have been, had she been asked.

Dr. Edward Creagan: I am convinced that if a patient enrolls in a phase one or early clinical trial. And if you read the consent form, no human being can make sense of it. Sure, sure. And I am convinced that many of these patients do not understand that the design of a phase one trial is to determine toxicity. before it can be offered in a [00:25:00] phase two trial, and by definition, all patients in a phase two trial have the same sort of cancer.

Dr. Edward Creagan: But I think there is this magical thinking that I'm different. The miracle cure. Miracle cure. And, and these do happen. I have an operative report. from a patient that I saw 50 years ago that was indeed a miracle. So these things do happen. Every provider has them, but I think one needs to be realistic.

Dr. Edward Creagan: Yeah.

Sarah Cavanaugh: Yeah. Well, I would love to talk about grief. Um, at the end of your book, you have these distinctions. You really look to who is left behind and these distinctions of chronic grief, delayed, masked, exaggerated. I really appreciate it. Uh, last night I was at a gathering where a friend of mine's wife just lost her mother and there was a prolonged illness and [00:26:00] she was the primary caregiver.

Sarah Cavanaugh: So he was telling me it was like she ran a marathon and when her mother died she was elected the executor and now after running a marathon and collapsing she has to get up. lift five pound weights in her hands

and run five more miles to figure out all the logistics. And it, and it reminded me of this, this concept of, when do we grieve?

Sarah Cavanaugh: If we're so wrapped up in all of the tasks at hand.

Dr. Edward Creagan: Our society doesn't allow mourning, grief, and bereavement. And in the corporate world, you've lost your life partner, you've lost your soulmate, and maybe you'd be given 96 hours and then you're expected to be back doing what you normally do. And what I appreciate, no one is prepared when that moment comes.

Dr. Edward Creagan: That's right. And I'll give you an example. My [00:27:00] parents, uh, were chronic alcoholics. No AA, no treatment. They were always drunk. And my mother was going downhill from alcoholism, breast cancer, and some other issues. And she was back in New Jersey. And it was obvious. Every time I would see her, every couple of months, she was losing ground, and anyone could have anticipated her death.

Dr. Edward Creagan: So I had come in from a run on a bitterly cold morning, and I remember this as if it were yesterday, and our son, Ed, who was in high school, met me in the garage, and he said, Grandma died. And here I am. staff, Mayo Clinic, professor, blah, blah, blah. And it's as if I was shot in the stomach with a bazooka.

Dr. Edward Creagan: Felt totally incompetent. I remember slumping over the dryer in what we call the mudroom. [00:28:00] I felt incapable of making phone calls. I felt incapable of making airline reservations. I felt uncomfortable about contacting the funeral director. And here I am, rock star, Taylor Swift, doing this stuff every day for 20 years and BAM!

Dr. Edward Creagan: What happened next? You know, I must admit it was a fog. And it was a fog because of complex family dynamics. My mother, uh, was married to a gentleman who also was an alcoholic. He owned a bar and two liquor stores in Newark, New Jersey, which is a blue collar, hardscrabble community. And no will, no estate planning.

Dr. Edward Creagan: I was his legal son. I inherited a bar and two liquor [00:29:00] stores, which I needed like a root canal, halfway across the world. There was a seven figure piggy bank that nobody paid taxes on. So if a beer was a buck, they rang up 90 cents. So not only was I dealing with the death of my mother's life, but a financial, legal, liquor, nightmare, where I was totally in over my head.

Dr. Edward Creagan: So I had to deal with the tax people, the IRS people, lawyers, uh, and I also had to deal with the person who introduced herself as my stepsister, whom I had met years ago. So you can imagine the conundrum, death of a mother, legal, financial stuff, and then a woman whom I vaguely remembered. who was indeed my biological sister.

Dr. Edward Creagan: Now, fortunately, It all worked out okay, but you can imagine [00:30:00] what a nightmare this could have been because there were substantial assets. There's a vulnerability that nobody can see.

Sarah Cavanaugh: Do you think there's something particular about losing your mother?

Dr. Edward Creagan: Yes, because that's our link to the world. There's something theatrical about that.

Dr. Edward Creagan: This person gave you life.

Sarah Cavanaugh: I really appreciate. your integrity and the way you address dignity in your book and the way you consider the patient and their concerns. Well, thank you. So what are your end of life plans and, uh, have they changed over time?

Dr. Edward Creagan: Oh, absolutely. And one of the things that has changed is my reality compass.

Dr. Edward Creagan: None of my colleagues can walk to the bedside and camouflage or morph or [00:31:00] massage the problem and what the possibilities are. Because there's no free lunch. There's no easy street to the big dance. And whatever they would suggest would have side effects. So what I would probably say, okay, got a bad thing here.

Dr. Edward Creagan: Let's try some standard treatment. One cycle, maybe two. If you hit a home run and this thing has disappeared, I'll include you in the will. If I'm sick, you're out of it, baby. You ain't gonna get nothing. So, so there is a macabre sense of humor to all of this, but for my wife Peggy and I, we're active, we're physical, uh, and, and that, that's crucial.

Dr. Edward Creagan: And I would want to know how my quality of life would be impacted upon whatever you're telling me. And I'll give you one final story. We have a god daughter in Guatemala. And we had been there for many years. We were due to go to Guatemala [00:32:00] and my wife noticed a lump over my spine between the shoulder blades.

Dr. Edward Creagan: And most of us have these things on our back. This is a sebaceous cyst. You're a little bit uncomfortable, no big deal. She said, you know, before we go to Guatemala, you better have that taken off. So I went to see the dermatologist at Mayo Clinic, wonderful woman. She said, gee, this is a sebaceous cyst. No problem.

Dr. Edward Creagan: Go to South and Central America. I said, well, if I do that, my wife will shoot me. Okay, we'll take it off. So she takes it off surgically. And what should have been a 15 minute procedure took an hour, took an hour. And I thought, This doesn't feel real good. And we stopped talking about the twins and the vikings and the football and that kind of stuff.

Dr. Edward Creagan: She said, you go home, I'll call you. So a week later, she calls me and she says, you better come in. We found something. Okay. [00:33:00] Well, what she found was a one in a million cancer, call it eccrine sweat gland carcinoma. So then the eccrine cancer specialist at my own clinic comes in and he says, you know, this cancer has an uncertain biological significance, meaning we kind of don't know what this is going to do.

Dr. Edward Creagan: So what we can do, do a big excision about the size of Bolivia. We can remove the lymph nodes under your arm and see what happens. Now, I grew up. In racetracks, odds, percentages, probabilities were the way people made a living. I says, you know, this doesn't sound so good to me. I'm willing to roll the dice.

Dr. Edward Creagan: Well, that was 20 years ago. The doctor's dead and I'm still here. Now, was I lucky? Was I stupid? I don't know. But I think we have to insert treatment options into our [00:34:00] lifestyle.

Sarah Cavanaugh: Thank you so much. I have, I have my one last question that I ask all of my interviewees. The reason we are called Peaceful Exit is really about what we all wish for as a peaceful exit. Right? Yes. And that's what creating these legal documents is about and these letters of intent and talking to our families.

Sarah Cavanaugh: What does a peaceful exit mean to you?

Dr. Edward Creagan: I'm smiling because it can mean a number of different things. What you see in the obituary ain't reality. This is the boilerplate. So and so died peacefully at home after a valiant battle with, put in the condition, yadda yadda yadda, surrounded by his loving spouse, adorable children, all of whom won the Nobel Prize, yadda yadda yadda.

Dr. Edward Creagan: In general, Maybe we wish for that, but it's not realistic. I think a peaceful exit for me would [00:35:00] be with peace and dignity, to have my bowels and bladder intact, and be surrounded by the people that love and care for me. And it's interesting, in the hospice, look on the nightstands and see what people value.

Dr. Edward Creagan: It's not an award. It's not a letter from their corporation. It's not a 403B or a 401K. These are religious articles that have significance. Look at the pictures. It's faith, family and friends. So we need to be thinking what that will look like. Otherwise, this becomes a runaway locomotive and may not be consistent with our values.

Sarah Cavanaugh: So well said. It was such a pleasure to meet you and talk to you today. Likewise.

Dr. Edward Creagan: Thank you.

Sarah Cavanaugh: Thank you for listening to Peaceful Exit. You can learn more about this podcast and my online course at my website, peacefulexit. net. If you enjoyed this episode, please let us know. You can rate and [00:36:00] review this show on Spotify and Apple Podcasts. This episode was produced by Large Media. You can find them at larjmedia.

Sarah Cavanaugh: com. Special thanks to Ricardo Russell for the original music throughout this podcast. More of his music can be found on Bandcamp. As always, thanks for listening. I'm Sarah Cavanagh, and this is Peaceful Exit


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