The In-Between with Hadley Vlahos

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The EG.5 Covid subvariant achieves dominance as we near the fall. Alice K. Lattis, author of The G-Spot, which unlocked a revolution in women's sexual awareness, passes at 102. The F.D.A. approves the first ever pill for postpartum depression.

This is America dissected. I'm your host, Dr. Abdul, I'll say it.

How many of you, if given a chance, would save a life? I'm sure you said yes, because you're a good, upstanding person who cares about others. It'd also be super weird if you said no, but let's be honest, we can't actually save a life.

None of us can. We're all facing the same fate. You're going to die, and I am too. We all will now. I hate to be a downer, but I promise there's an upside here.

But let me walk through the valley of the shadow of death for just a little while longer. If you're young, you probably haven't thought much about death, you haven't had to. We usually think about death as the reserve for folks who've lived a lot longer. And God, I wish everyone got that chance.

But young people die, too. In fact, it happens way more often here in the good ol U.s of A than in any other high-income country in the world. Why, you ask?

Because we're the only folks who can't seem to figure out that. Letting people carry super deadly weapons anywhere and everywhere is a really stupid idea. But I digress, despite the absolute fact of death. The conceit of living in a high-income, relatively privileged society is that you don't see it all that often. And when it happens, it usually happens after a long life. My dad, who grew up in 1960s Egypt, for example, had already experienced two deaths by the time he was five.

The fact that we don't experience death as often also means that we don't talk about it as often either. And because we don't talk about it, we don't talk about it. It's kind of one of those taboos. No one wants to be the punk who brings up death at brunch or a cocktail party or on a weekly podcast, but perhaps we should.

The fact that the most normal thing in the world remains, well abnormal, means that we just don't do it as well as we should. Too often. Dying in America means dying in a hospital connected to all kinds of gadgets and tubes. While some medical team pumps your body full of meds on a last-ditch Hail Mary effort to delay the inevitable. It's a big reason why we spend disproportionate amounts of our health care spending at the end of life. In fact, about 13 of all medical expenses are spent in the last single year. Think about that.

That's $3 trillion to raise national life expectancy by a year now. Look, that was a lot about death, so here's the upside. I promised to get us to. Even though the fact of death is inevitable, we can actually die better, and that's where hospice comes in.

Hospice is about dignifying the end of life, it's about recognizing that at the end of a life. You can either play for time or play for quality. And here's the thing about it. On average, patients on hospice live 20 days longer than patients who are not. So when you play for quality, you also get time.

But there are two big barriers to hospice. The first is financial. hospitals make a lot more money, throwing medical hail Marys $3 trillion after all, but the second is cultural. We need to do a lot better about having end-of-life conversations, and those conversations simply shouldn't start at the end of a life.

At least that's the argument that our guest today is making. Hadley Vlahos is a hospice nurse, and she's written a fantastic New York Times bestselling new book about the end of Life. The In-between. She joined me to talk about Hospice end of life and why we're so reluctant to talk about it. Here's my conversation with Hadley Vlahos. We are recording.

Okay, can you introduce yourself with the tape?

That's both really exciting, but it's also somewhat surprising because you wrote about one of those topics that nobody wants to talk about. But it turns out a lot of people want to read about.

First, I want to step back because your book is about death and dying, and it's about your experiences. As a hospice nurse, literally somebody who specializes in taking care of people who are dying. Why did you want to become a hospice nurse?

That is what I want to be doing. So I took a job in hospice. It's been six years ever since, and my life has completely transformed in ways I didn't even expect when I took the job.

I've taken people to the beach for the last time and that is very different than any other type of medicine.

What informed the writing of this book? What was it, obviously you wanted to write? but why this book?

And I think other people need to hear about these experiences as well.

And we will bring in nurses and physicians and aides, and we're on call 24-7.

So instead of having to go to the hospital, you call us. And the criteria to be on hospice is having a terminal illness and you're not seeking any curative treatment. And then doctors say that you have six months or less left to live. But that is not an exact science, it's just best guesses, basically.

And whenever you're at that point, and if you don't want to keep pursuing what they call curative treatment, you can call in hospice.

The aides who come and give baths, you're not getting all of that, so it's a scaled down version of hospice while you're still pursuing things such as chemotherapy.

And almost, to make a point, tongue in cheek. But also because it's true, I remind them that actually, all of you will fail, nobody saves lives, everybody dies. The question you have to ask yourself is, What are you aiming for? Do you want to extend the length of life?

Do you want to improve the quality of life? do you want to make access to a long, high-quality life more equitable? Do you want to reduce the costs of doing all these things? These are all a number of objectives you can have and actually can achieve. But the idea of truly saving a life, the notion that somebody does not die because of your intervention, actually at some point will fail.

In the long swath of time, our lives are but little blips, right? So what's the difference between 85 years and 35 years, right when you think about it in cosmic senses? Of course, for the person living that life, it's a huge difference. And I don't want anybody listening here to be like, Wow, that guy doesn't even care about longer lives. Of course, it's the end purpose of both of our work. But the point that I'm making here is to say that we have this odd relationship with death because we treat it like a disease, and diseases can be cured.

Death can't be cured. And so how do you think about that, vis-a-vis a lot of the rest of medicine? Because oftentimes, the work that you all do is sort of seen as giving up on, and that carries a lot of weight. Can you speak to that?

And he said, Well, you're just you don't do anything, you're not going to do that, you're not going to call 9-1-1. That is not what she wants, and I said, You want me to do nothing, nothing.

You want me to do nothing, and he said, You're not doing nothing. Making sure that she is happy and comfortable, and in her home, making her a sandwich, whatever it is she wants is doing something, even if society does not always realize that. And I didn't even understand how much it had been ingrained in me. That you always have to be doing something, and nursing school really teaches you this.

Because they say, whenever you document a problem, you have to say immediately after what you're doing, even if it's not fixing it, it's you say, Oh, they had this lab result. I told the doctor you always have to do something. And so for me, doing what I consider to be nothing was very different for me and I had to really retrain myself.

Now we need chemo here, dialysis there. And they were not having any quality of life at that point.

And everyone around you, almost being blind to the possibility that these are your last days alive on Earth.

And that is often the counterfactual between saying, you know, on the other side of this gamble of we could beat it, we could win, and I want to put a little asterisk on that, beat it and win. Argument is, these are my last days on Earth, and I want to spend those last days on earth doing things that are extremely meaningful to me and to the people I love. And we don't appreciate. That time is fixed and your space, your ability to actually be present in that time that you have can often be dulled by the medications that you may be taking. On the hail, Mary, attempt to quote Save your life.

And that choice about how you spend those last days, whether they're in a CCU, being pumped full of medications, or they're with your friends or your family. With other loved ones, potentially at home, that that that could make all the difference about how you spend those last days. And the problem is is we all bet on a hail Mary Pass to win, rather than bet on the joy and the meaning of those last several days. And what I love about your book is that you write really eloquently about that time. So, as someone who's been a witness to death and people in those last days, what does that look and feel like? To them? And to you as someone who has that really honored position of being with them and helping to steward those last precious moments that they have?

Family members will come and go. If I can give people a heads up, I think it might be within the week. They'll come and they'll go, and you'll see grandkids running around. And a dog's always on the bed. And they sometimes will have their favorite drink, or they'll smoke a cigarette if they're not on oxygen. And it's just, it's just peaceful.

Almost programmed to feel like they've given up on a loved one. If they're choosing, you know, or choosing hospice, or they're not trying to convince their loved one out of hospice, how do you have that conversation with them?

And I really learned over the years that sometimes they just want someone to talk to. They understand that I can't fix anything, I can't give them those moments back. I can't cure terminal illness, but they just want someone to hear them and what they're going through. So I always try to just really listen.

And.

It's something about, I think, our culture. Where one of the privileges of living in a society where you're not exposed to death very often is. It can be far away for you. But one of the costs of that is that it is imminent, and we can delay and push away what is inevitable only for so long. And that tricks us into thinking that we don't actually have to prepare. And why do you think it is that in our particular culture, in this particular time and space, which is not good at talking about death, we don't like to talk about it?

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I'm sure that the process of of of becoming a hospice nurse, the work that you do, the book that you wrote, has changed the way that you show up in your private life. Can you? Can you talk a little bit about that? How have you tried to have those conversations in your own life?

So people were saying what they wanted and how they would want to spend their last days. And one friend, in particular, said that he would want a sort of living funeral where he gets together with all of his friends. And I remember that, and that friend unexpectedly died two days later, just out of nowhere. And I went and talked to his mom, who we're close to, and I was able to tell her. We had these conversations about death. And he did not want to be on the ventilator, which she had chosen to take him off of it.

And he got what he wanted, which is getting together with his friends one last time. And I think that that's brought her a lot of peace.

Is that you don't think about your mortality because you don't realize that it actually could happen, right? That this really could be your last day on earth? And obviously even saying that people are like, Oh, don't say that, you hear that all the time. I can imagine everyone listening be like, don't say that, that you're just bringing upon foreboding. But in our tradition, one of the things that we do quite a bit is we're taught to ponder death.

So we're taught to go, you know, we have a very open funeral culture, so in the Islamic tradition, the funeral is a prayer. And it is, you know, it's a. It's actually really quite poetic. So a lot of folks know about the Muslim. Call to prayer When you're born, your father will call the prayer in your ear. On one side. And then after the call to prayer, there's a second call to stand up to pray.

Right, it's like the first call is like, come to the prayer, the second one is stand up, it's time to pray, and they'll call that one on your left ear.

And that is the call to prayer, to your funeral, prayer. And so you think about the notion, even at birth, that this is the call to prayer, to the funeral prayer of this person. Right? As a father, when my daughters were born, I called the prayer to their funeral, prayer.

That's that's how we're taught to think about it. And so when you go to a funeral, prayer, it'll be an open thing. Obviously the family and the loved ones and everyone will be there. But everyone's encouraged to come and then you're encouraged to go to the burial. Right to support one another. But also as a function of remembering that at the end of the day, this is where you're headed. And I find that the pondering of death helps you live a little bit clearer, because you remember that this day could be the last day.

So how do I want to live this day? Do I want to maintain this beef that I have with this person? Do I want to treat this person a certain way? Do I want to go to bed with anger in my heart to whomever and I, I wonder, you know, as you think about, you told that story.

How has being a hospice nurse and seeing death, experiencing the death of a close friend at a young age? How has that changed the way that, that, that you live?

And every single morning, that is exactly what I think to myself and I try to set that intention for the day. And I have learned that through taking care of so many patients and hearing what they regret at the end of life. Such as I had a patient in the book, Who. She spent too much of her life on the treadmill and she died pretty young. And she said she wished she would have eaten the cake and spent more time with her friends. And stopped caring so much about what other people thought of her. And she was such an incredible, amazing woman who changed my life and many other people's lives, too.

There's been multiple Eat the cake tattoos that I've seen so far. And she had no one with her whenever she died.

And he said, yes, so I worked overtime for that Thunderbird, I wanted it, and I got it, but I worked so many overtime hours. And I actually missed my daughter, who was his primary caregiver's dance recital for that car because I was working overtime. And I said, OK, and he said, I can't stop thinking about that car is probably rusty parts only now.

And my heart is missing that memory as I sit here with my daughter reliving memories and going through photos. We were looking at photos of dance recitals and I, I wasn't there.

You know, it's easy to get lost in whatever it is that you're doing, whatever it is, you're chasing. And you know, as I've been making some life decisions, a lot of folks are like, Oh, but you know, they're young, they're not going to remember. I think sometimes we forget to like, Yeah, but I will, I will remember. And there's something about remembering that. It's like your function is not just about what you were there for for someone else.

It's also something about the kind of life that you lived and the kinds of experiences that you had. And that's like a really poignant reminder of that.

If, if we as a society could change one thing about the experience of death and dying, what do you think that should be?

It's a lot, some people are giving medications every two hours for months, that's insane, and whenever they need help. You either have to be extremely poor so that you're on Medicaid, or extremely rich. To where you can pay for paid caregivers. Which can be upwards of thirty dollars an hour, with a minimum of six hours per day. Or put people into a nursing home, which not everyone's comfortable with that. So for people who cannot afford thirty dollars an hour, don't want to put their loved one in a nursing home, they don't have any options.

And that is a huge issue, and I think it's what causes a lot of people to not choose hospice care.

When I was in med school, I was working at a hospital and I just built a new ICU. And they had a really, really talented end of life care doctor who ended up getting transferred out of that hospital because she was too good at having end of life conversation. So what happened was patients who would have ended up in the ICU and would have been billed at ICO rates were now choosing hospice. Because she was having these very effective end of life conversations, and she was losing the hospital money. Can you talk a little bit about the structural incentives against hospice care and the way that we set up our health care system?

And you're right, things, especially like chemotherapy, surgeries, you don't do that anymore whenever you come on to hospice. So those are huge things that are billed to Medicare. And of course, as we know, Medicare is one of the biggest payers in our country, and most hospice patients are Medicare eligible. Because they're over 65..

So yes, you're right, it is. There's no incentive to send people to us. They're basically having to do it out of the kindness of their heart, essentially.

And one of the craziest statistics in health care is that upwards of a third of health care expenditures, on average, are spent in the last three months of life. So you got to imagine a lot of that money was not spent effectively because most of it was curative care and it didn't work by definition, right? That person passed. And hospice care is way less expensive.

You're not doing that surgery, you're not getting that extra CT. I mean, a lot of these patients. When you're talking about extreme illness, you're getting major diagnostics literally every day. You are taking medications that at times can be experimental, you're getting surgeries.

And when you're trying to throw hail Mary and it's costing hundreds of thousands of dollars, right? You got to ask who benefits from that? And the only entity that benefits are the hospitals, and oftentimes, unfortunately, the physicians. And how do you think we should be thinking about policy relative to end of life care? What would be an approach to try? And at least make sure folks understood the options on the table for themselves or their loved ones?

They just don't know, they don't understand. So I think it is important to have someone in the hospitals where they do know what's going on and what options are. So that they can run it by you. And I think they should be a patient advocate, but you know, that's hard to do within hospitals whenever they're the one paying their bills.

It's it's difficult. But studies do show that patients live longer on hospice, about 20 days longer. And I think educating the public is the best we can do for now.

One of the pushbacks when you have a conversation about end of life is that you're bordering on ageism. That you just. You just kind of want to let you know. People die and you don't want to spend so much money on them and you'd rather focus on. You've heard all these arguments, how do you counteract that in terms of what you've seen at the bedside?

From there, the registered nurses have to go through and meet criteria for whatever disease the person has. And then we have to run it by our physician who's trained in it. It is the Medicare regulates us. And if they feel like we admitted someone too soon, they'll pull all the money back for the entire state. So we don't want to risk admitting someone when we shouldn't.

So it is pretty rare to do what we call a live discharge, which is where someone has to come off. Because they've lived longer than six months and we think they're going to keep living for many, many years. So I always say it, if you're eligible for hospice, it usually means you can, you can be there, you should be there.

You know, people that we don't want to think about dying ever. How do we facilitate the conversations that really we ought to have before what is imminent becomes obvious?

They never have the conversation and then people will die and they have no idea what they wanted. I have sat at the bedside of hospice patients who are on hospice for months, who had cancer for years. Where they say, I don't know if they want to be buried or cremated. And this was not a surprise to anyone, but no one wanted to bring up that conversation and actually discuss death. And to me, that's that is something we need to change.

My brother's a doctor, I'm a doctor. So these are conversations that were a little bit closer to having and have been trained on having, but they're still uncomfortable. I mean, there are still several loved ones with whom I have not had that conversation because I don't know that they take it the right way.

And usually the way I put it on myself is like, Hey, I'm somebody who's going to turn to me and ask, What does? What do you want? And I want to make sure that I am, I'm adequately capturing what you want. So that's the only reason I'm asking. But it still would be super uncomfortable.

Do you have a couple of ways in to have that conversation with someone you love? Without without them feeling like you're beckoning it, or just turning the mood sour?

And I was thinking, maybe while we're here.

It looked like he was in the hospital the last couple of days of his life. Is that what you would want if you had ALS? I think good ways that it's like, not so obvious, it's like, Hey, happy Sunday. What do you want me to do with you when you die?

Well, I really appreciate you bringing some context and some levity, some honesty and some courage to a really important conversation that all of us need to be having. Our guest today was Hadley Vlahos. She is a hospice nurse and she's the author of a of a great New New York Times bestselling book, The Inbetween, Hadley. Thank you so much for joining us today and sharing your wisdom.

Two, is it more serious and three, is it more immune evasive? And as of now, the answer appears to be a big no to all three. That's great news. That said, as vaccine manufacturers hustle to formulate the fall 23 version of the COVID-19 vaccine booster. They're likely working to assure that it has reactivity against this subvariant, given that it's poised to lead the fall bump, should such a thing exist?

And on that front, we should be hearing more any day now. Dr. Alice K. Lattis passed away this week at 102 years old. She was a pioneer in women's sexual health with the publication of her coauthored 1982 book, The G-Spot, which went on to sell over a million copies.

At the time of publication, the book fell under intense scrutiny from the medical and psychological establishments over whether or not such a spot actually exists. And yet, since it's credited with having unlocked a sexual awakening for women around the world, women's sexual health remains, for all intents and purposes, as we've discussed so many times on the show, a taboo. And yet, good sex is predictive of good physical and mental health. And the fact that, for most of human history, women in particular, were robbed of it is in keeping with a general distrust, disregard and disinterest in women's health issues more generally.

And by the way, the scientific consensus is that there is a such thing called a G-spot. Though, like so many things when it comes to human physiology and sexuality, it likely comes in different positions and sizes, in different people, in other neglected issues in women's health,....

And until recently, treatment for postpartum depression has been limited to intravenous therapies. This drug is oral and it's taken for only 14 days, with improvements starting as early as 3 days, prompting comparisons to the Z-Pak, the extremely common oral antibiotic. In terms of speed of action, so this, this is good news, that's it for today. On your way out, don't forget to rate and review.

It really does go a long way.

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