EP 113: Designing a Good Death | Sunita Puri
On today's episode, we are going to talk about designing a good death.
Dr. Sunita Puri is the Program Director of the Hospice and Palliative Medicine fellowship at the University of Massachusetts, where she is also an Associate Professor of Clinical Medicine. She completed medical school and residency training in internal medicine at the University of California San Francisco followed by a fellowship in Hospice and Palliative Medicine at Stanford. She is the author of That Good Night: Life and Medicine in the Eleventh Hour, a critically acclaimed literary memoir examining her journey to the practice of palliative medicine, and her quest to help patients and families redefine what it means to live and die well in the face of serious illness. A graduate of Yale University and the recipient of a Rhodes Scholarship, her writing has appeared in the New York Times, the Los Angeles Times, Slate, JAMA, and, forthcoming, the New Yorker. She and her work have been featured in the Atlantic, People Magazine, PBS’ Christian Amanpour Show, NPR, the Guardian, BBC, India Today, and Literary Hub. She is passionate about the ways that the precise and compassionate use of language can empower patients and physicians to have the right conversations about living and dying.
Episode mentions and links:
That Good Night: Life and Medicine in the Eleventh Hour on Amazon
Why 'lost their battle' with serious illness is the wrong thing to say via NPR
We Must Learn to Look at Grief, Even When We Want to Run Away via NYT
Restaurants Sunita would take you to:
Worcester: Mare E Monti Trattoria
Follow Sunita: Twitter | Instagram
Episode Website: https://www.designlabpod.com/episodes/113
Episode Reflection
“And so in palliative care, I consider words to be my scalpel and my procedure is communication.” - Sunita Puri
Today I find myself pondering this statement from this week’s guest, Dr. Sunita Puri. This simple yet poignant phrase means so much. It’s a statement about the power of communication and healing words. The power of design is a part of this statement as well. For me, design has become my way of reconnecting with the humanity that I had lost in my own training and practice of medicine. In the language of design, human-centeredness, and empathy, I saw tools that when practiced would offer me an opportunity to serve the needs of those I set out to care for. Just as Sunita described the methods of palliative care as the antithesis to the dehumanized practice she had learned in medical school, health design is my break from the traditions of procedures and pills.
This isn’t our first episode of Design Lab focusing on death and dying. On episode 10 we had BJ Miller, a palliative care physician whose near-death experience led him to discover his mission to de-pathologize death. Another episode that offers a similar thread, while not directly being about death, was episode 19 with Maggie Breslin and Victor Montori and the idea of careful and kind care that we actually talked about just last week on episode 112 with Dominique Allwood. Each of these episodes are fantastic explorations into the subject of approaching care differently, challenging dogma, and rebelling against the dehumanized approach to healthcare that has become pervasive in the American system. To be completely honest, these are some of my favorite episodes because they help me to face my own mortality and hopefully leave me better prepared to help others do the same. Death tends to come up in a lot of our episodes because death is a part of life and this show is all about life! If something about this week’s topic resonates with you, drop us a line on social or in the reviews and let us know!
Written by Rob Pugliese
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Bon Ku: On today's episode, we are going to talk about designing a good death. I'm Bon Ku, the host of Design Lab. It's a podcast that explores the intersection of design and health.
Our guest today is Dr. Sunita Puri. She is the Program Director of the Hospice and Palliative Medicine Fellowship at the University of Massachusetts, where she is also an associate professor of clinical medicine. She completed medical school and residency training in internal medicine at the University of California, San Francisco.
Followed by a fellowship in hospice and palliative medicine at Stanford. She is the author of That Good Night: Life and Medicine in the 11th Hour. It's a critically acclaimed literary memoir examining her journey to the practice of palliative medicine.
And her quest to help patients and families redefine what it means to live and die well in the face of serious illness. She is a graduate of Yale University and the recipient of a Rhoad Scholarship. Sunita's writing has appeared in the New York Times, the Los Angeles Times, Slate, JAMA. Her work has been featured in The Atlantic, People Magazine, PBS, NPR, The Guardian, BBC, India Today and Literary Hub. She is passionate about the ways that precise and compassionate use of language can empower patients and physicians to have the right conversations about living and dying.
Visit our website at designlabpod.com. There you can find show notes from each week. Learn more about the guests that we have on the podcast. And get links to related content.
There, you can find a link to subscribe to our newsletter each week. Our producer, Rob Pugliese will send you show notes and links right to your email inbox. And he gives a reflection on each episode as well. Reach out to me on Twitter at B O n K U on Instagram at D R B O N K U. I love it when I hear from listeners. And rate us on Spotify and Apple Podcasts. Give us five stars. Leave us review. Tell someone about the podcast. That is how you support the show. Now my conversation with Dr. Sunita Puri.
Interview
Bon Ku: Sunita, welcome to Design Lab.
I'm thrilled that you're on the show.
Sunita Puri: Thank you so much for having me, Bon. This is a real honor.
Bon Ku: Well, I've been reading your memoir, which is entitled That Good Night: Life and Medicine in the 11th Hour. I highly, highly, highly recommended to all of our listeners, and when I've been reading your memoir, what jumped into my mind is that our user experience of death as a terrible one, both as a, both as a human, a caregiver, a.
Physician,
Sunita Puri: Yep.
Bon Ku: and I'm saying that lightly, but you know, is there a way that we could design our deaths to be better?
Sunita Puri: So first of all, I think that whole idea of the user experience of death is a really interesting way to think about it. And honestly, if we can't find levity, In how we talk about these things. Then the process of actually moving forward by metabolizing the gravity of what death it means and the ways we're falling short of making it a more compassionate experience.
I think without that levity, sometimes moving forward isn't possible. So I very much appreciate the kind of framing. So death is so far beyond a medical experience. Death is an emotional, spiritual existential experience because the process of dying, which is very hard for us to kind of really look at and embrace in our culture here, that process of dying is part of what also needs to be redesigned.
And the way we think about dying, the way we think about aging, the way we decouple how hard we fight to live with the body showing us its natural limit. All of these concepts which are deeply human and deeply spiritual. Those remaining uninterrogated are a big reason why I think dying and death have become so fraught.
So much to the point that it's much easier to just do something medically to somebody, for example, putting them on a ventilator than to stand back and ask what will doing this add to their life versus to their death?
Bon Ku: Hmm. And both you and I were taught in our medical training that a longer life is probably a better life.
Instead of the quality of life. You are a, palliative care physician, you
Sunita Puri: Yes.
Bon Ku: That's something that I don't think existed when I was a medical student way back in the day. Can you tell us about what palliative medicine is, what it's not, and this quantity versus quality of life.
Sunita Puri: So important. So palliative medicine, first of all, it's a term that just sounds confusing and hard to pronounce, and I think because of that, People get frightened or nervous. And what our field is, is we're a subspecialty of medicine that focuses on treating the physical, emotional and spiritual pain of somebody living with a serious illness.
And a serious illness is usually an illness that we can't cure. So, for example, stage four cancer or advanced heart failure, or even being in the I C U after a big car accident and having several organs failing with a lot of uncertainty about whether you'll ever wake up again. Right? And so we do two big things in our field.
We treat symptoms, so cancer pain, nausea from chemo, shortness of breath from C O P D, and then we also do something very important, which is to sit with patients and families in their medical team. To talk openly and honestly about what's going on with the disease, making sure that patients and families understand that. And then talking about how do we take care of you as a human being given what you're going through medically and what you want for your life.
Bon Ku: Hmm.
So
Sunita Puri: when people are living with limited time, for some people going through 13 rounds of chemo is not how they wanna spend their time, but we wouldn't know that unless we ask them. And so in palliative care, I consider words to be my scalpel and My procedure is communication. And you can have palliative care involved right alongside all your other medical therapies.
So if you're getting chemotherapy, you can still get palliative alongside that to treat your symptoms. There's not a choice to be made between palliative care and other treatments. And in fact, we have a lot of evidence in medicine and studies that if you do the two together, people live longer and better. And so our field is a complicated one to explain, but when people tell me when they're sick that they want everything done, I often tell them part of doing everything for you is having a palliative care specialist involved.
Bon Ku: Is there some confusion or pushback sometimes when you come in that they think you're like doctor death coming in
Sunita Puri: Dr. Death, angel of Death, grim Reaper. I've been called a
lot of
Bon Ku: you've really I'm, I'm like joking. You've really been called
Sunita Puri: Oh yeah, I've had people say this stuff to me. The Black Dahlia is one I've gotten
Bon Ku: Oh my gosh.
Sunita Puri: Where that comes from, but I guess I've also been called a flower child by a few patients when I teach them some meditation work.
So maybe flower child Dahlia, not sure, but, certainly have been. Jokingly and sometimes not jokingly called those things. And I think what's, what's hard about that and the pushback is so much about the fundamental misunderstanding of what palliative care does and what it doesn't do. So we do not hasten death, we do not just refer everybody to hospice.
We do not encourage people to quote unquote give up. And asking for our help is not giving up on your patient. So there's a lot of this kind of black and white thinking about either you do palliative or you do other medical treatment. And you can see this even in the coverage about former President Carter going to hospice, where a lot of the verbiage is that he's decided to stop medical treatment and go to hospice.
Whereas hospice is a type of medical treatment.
Bon Ku: It's almost like the narrative is like he's failed and this is like he is giving up on
Sunita Puri: life.
Yep. And that's, I think that fundamental dichotomy in in medical culture of either doing everything or doing nothing. Being a fighter or being a quitter. palliative care gets ensnared in those very black and white, inaccurate, un nuanced ways that we think about life and death and illness and dying.
Bon Ku: what inspired you to write your memoir and can you take us through what the memoir is about.
Sunita Puri: Yes. So, I was always a writer before I came to medicine. I was, you know, an immigrant child. My dad wanted me to write a page every day on anything I wanted, cuz he just wanted me to be good at
Bon Ku: English
Wow. And your dad was an engineer,
Sunita Puri: right?
He's an engineer. Yes. and he thinks he's a doctor, but he's not.
Bon Ku: But your, your mom, your mom's a doctor, your
Sunita Puri: My mom is a doctor. Yep.
She's anesthesiologist and he would let me write anything I wanted, but I hated the assignment cuz I was like five years old and just wanted to watch Scooby-Doo. But I eventually found so much companionship on the page because my brother, my younger brother and I were typical latchkey kids where my parents worked a lot.
We would come home and let ourselves in. And so much of what I had to do was find ways to keep myself company, and I just began to love reading and writing because I felt like I had friends that understood me. Characters and novels became friends of mine. I started to write characters that I wanted to be my friends.
And so over the years, just thinking a tentative, very, being very intentional about language and storytelling was huge to me. And so when I went through my medical training, My journals were really my big companions. They were a witness to everything I was seeing that I just couldn't make sense of,
Bon Ku: you had time to document what you were experiencing during med school and residency? Cuz I wanted to do that, but I just didn't have, I felt like it. There was no time to do. I was too tired.
Sunita Puri: Oh yeah. No, and, and by documenting, I'm using that term very loosely sometimes it was just I had like receipts from Starbucks that I would just jot little things down on and then I would keep them in a shoebox. I did have actual, actual journal that I wrote into, but. by no means were these great literary essays.
They were really just like sketches of things that happened. Like I remember, coding somebody when I was in the I C U as an intern, and I just had this phrase come to mind that the distance between life and death was the span of my fingers. Because the distance between him and I was the span of my fingers.
And so I would write these things down as they came to me and the thing that really kept me up at night was, you know, I'm doing these things to somebody. I have a man with metastatic cancer in the ICU with a bad infection. Every organ system is failing. I could put in a dialysis line, but that just instinctively feels wrong to do because all I'm doing is prolonging the inevitable. But I didn't have a way to really think through that or give voice to that or help my patients give voice to what they wanted, cuz I I wasn't trained to. And so in the book, what I really sought to do was to lay side by side my experiences growing up, being a writer, being a child of immigrants, who taught me that death is inevitable and all things are temporary, and then going into a field of inquiry or profession where.
Those things were just taboo. And as you said, our hardwire to privilege the extension of life at all costs, including the cost of suffering. So I wrote the book in part because these were stories that were really pushing against my bones for a very long time, and in part because I wanted to write a book that I felt.
I would've benefited from reading when I was going through things, and I wanted it to be just a really honest, vulnerable book. And so at various parts of the book. There's very personal things I talk about, including a very serious eating disorder that I had for some time, and my relationship to my body, my relationship to my background, to my parents, to language, because I think I could only bring readers along if I was my unvarnished self. And so part of what it meant to write this was to push myself as a writer as well as a doctor to the truest points of honesty which is ultimately where we are trying to get our patients.
Bon Ku: Yeah. I really appreciate the honesty and it's so cathartic for me because I feel with the dehumanization that goes on with medical training, you know, I've had to really detach myself from these really hard things that we experience and, and I think that spills over just into other aspects of life and so your book's very humanizing and I really, really appreciate that cause I think, in medicine. I don't know. I just feel like as doctors and we're both in teaching facilities, that it's not encouraged, I think, to be that vulnerable and honest. So I really, really app appreciate that.
Sunita Puri: And yet when we can be vulnerable and honest, those exchanges I think make us better doctors. Because it allows us to return to who we really are, beyond the white coat, beyond the degree and the profession to people just trying to make their way in the world, in a world that's confusing and demanding.
And you add on to that, the confusion and demands of medical practice, and how wonderful is it when we can be safely vulnerable with each other.
Bon Ku: I heard you speak on empathy, and I love the way that you, define empathy and the role that it plays in, in your life. Can you tell us about your understanding of empathy?
Sunita Puri: Yes. So, you know, I think empathy and compassion are obviously very, very aligned. And I think of empathy as in my own personal definition, and this may not be the technical definition, but I just think it is the willingness to step into an experience that is both shared and different because, when I'm with a patient and they're talking about their tremendous fear about the end of their lives, we've all known in different situations tremendous fear, and I think what it means to empathize is to be willing to go into your own space of tremendous fear and use it in some way to ask questions to more deeply understand the pain of the person in front of you. So it's both a journey within. To connect to the journey of somebody else's with it.
Bon Ku: Hmm.
Sunita Puri: And if we can connect on that basic level of humanity, it is truly transformational when what people will be willing to say and do. And I think empathy is kind of a state of being. None of us are empathic all the time towards ourselves or to anybody else, but if we can access that willingness to understand the shared human vulnerability between us patient, then I think that is the basis for empathic communication and empathic way of being.
Bon Ku: Hmm. Wow. I was not taught that in medical school or residency. And it sounds scary, this type of empathy that you're describing. Like sounds scary for me and I, I've been taught just to detach myself as much as possible and I guess it's a little bit scary cuz does that type of empathy lead to burnout of, because you know, we experience such pain, um, that we see and that it goes on in the hospitals and the lives of our patients, the lives of caregivers.
Sunita Puri: Yep.
Bon Ku: It's scary to me.
Sunita Puri: It's no, and I, you know, a hundred percent, and I think the distinction or the, the caveat or footnote that I will make is that there's a way to be with someone in their suffering and not to take it on. And I think that is a learned skill. So something I tell my trainees is that when I'm with the patient, I often envision like a clear glass pain between me and the person I'm talking to so that I can be with them and I can see them, but I'm not taking on the energy coming towards me. And in that way I can be with somebody almost like in a meditative way or the way a surgeon is with a patient in the OR where all their concentration is on what they're doing. But then you leave the, OR you leave the family meeting and you have to not take on what's just happened. And I think that is a way to be with somebody, somebody empathically, but also to preserve your sense of who you are and to have a boundary between your patient and yourself. Cause I think boundaries is, the other thing we're not often taught in medical training is we have this very idealized vision of being empathically or compassionately with our patient. And you need to think about them and invest all this time, but you also need to be detached and that's healthy too.
So I think the way I've come to balance it all is to do that is to say, I'm gonna be with you as a surgeon with their in the OR but I'm not gonna take every aspect of this with me because that's the only way I can come back tomorrow and do this work again.
Bon Ku: I wish I was your medical student or resident. I, was never taught this. Is this being taught in medical schools your approach? And if not, Why don't we teach this to, why doesn't every doctor have this basic training?
Sunita Puri: So I think there's certainly more attention to palliative care and its concepts and how to have difficult conversations in medical school, but I think the nuance of how do you be empathic and protect yourself. How do you balance engagement and detachment? These are not things that are being taught and I think it's, a tragedy because these are the sorts of things that burn us out.
These are the sorts of things that aren't modeled for us, that aren't talked about openly. And I try very hard to be open and transparent with my trainees because to be honest, Bon, I wish someone had been that for me. And so a lot of my style with the trainees has to do with A, what they tell me they need. B, also having a little bit of intuitiveness about what they seem to need and asking them if I'm on the mark and answering them in whatever ways I need to, but also being very Bold about my own experience and what I wish I had, and nine times outta 10 people respond well to that because no one is asking them this.
No one is telling them that it's okay for me to admit my human mistakes because you are gonna need a model for that. You're gonna need someone who's gonna be there with you and say, it's okay to tell me that this patient is totally burning you out, or that you think about something so much that it's becoming obsessive and we need to help you find a boundary around it.
Bon Ku: What advice do you have for patients, caregivers on how we can design a better death.
Sunita Puri: So I think that part of designing a better experience of death involves two things. One, being willing to actually acknowledge one's own mortality.
Bon Ku: Yeah.
Sunita Puri: And two, understanding that no matter how much we prepare, what ultimately happens at the end may be totally out of our control.
So there's the balance between those two things and to kind of talk about the first aspect of really kind of interrogating one's mortality.
Bon Ku: it's crazy, right? Like we talk about our retirement plans, we talk about our RA accounts, and like very few people talk about death and flash news we're all gonna die. , and, but it's such a taboo subject. and it sounds like your parents instill this type of interrogation in you from an early age.
Sunita Puri: Yes. So when I was like five years old. And this is in the preface, uh, or the author's note my book, but my mom was on call a ton, and so my dad would like take me to like long John Silvers for fish sticks and things like that, which I don't even know if long John Silvers is like still a thing.
But I remember those nights where we would go get hush puppies and like hershey's chocolate bars, and my mom of course never found out about any of this cause she would've had my dad's head. But one night we were eating and I was looking at the sunset in the sky and I was just telling my dad, why can't the sky always look like this?
And he said, because all of life is like the sky, it will change and you can never pin anything down and keep it the way it's. And I just, I remember just being so unable to wrap my mind around that concept, but knowing that my dad was telling me something that I would keep with me the rest of my life.
Bon Ku: Mm. was that too depressing for you? Cause I think there's an argument there of like, oh, we shouldn't talk to kids about this. It's too depressing.
Sunita Puri: I found it fascinating.
and I think it was because we were talking about something within nature and nature. You know, in Hinduism and Buddhism, in a lot of the mystical traditions, nature is the great teacher about what existence and non-existence mean. And so even just outside my window, you know, at home here, I had a tree that was beautifully green when I moved here in the summer, and then it turned, the leaves turned, brittle, and were shot through with Burgundy, and then they fell to the ground and now the branches are all bare and they're kind of extending themselves to the heavens almost in supplication. Once you have this example in front of you of the fact that absolutely nothing will stay the same, including our bodies, which are also products of nature.
And I think kids are much smarter than we give them credit for, and they're very observant. And I think a lot of kids, when I've taken care of young patients that have young children, they know quite a lot. And so in keeping things from them or in not saying things to them in a way that's emotionally safe and digestible for their developmental age, we are kind of also blocking them from having a human experience of loss.
And I think this is part of the tragedy of not having a better dialogue about mortality is. Suffering and mortality and dignity. All of this is a part of the human experience, and if we wanna cut ourselves off from something that profound, are we really living fully? Has always been my question. And so I think there is a way to engage with mortality that is safe and that is honestly just intellectual.
Forget spiritual, just acknowledging and embracing each one of us will die one day is a good starting point. And then when we face resistance, like why am I reluctant to go here? I think the question we should ask ourselves is, where is that resistance coming from? Because resistance to what is in Buddhism is the source of so much suffering.
And the embrace of what is, is I think a portal to freedom.
Bon Ku: I'm just taking that all in right there. That's, do some countries or cultures approach death? Better than the US. I saw this quality of death index that was done maybe about eight years ago, and it ranked the countries of UK, Australia, New Zealand as being like the top three in terms of like quality of death, and have you seen that report and what did they do differently than what we do in the US.
Sunita Puri: So I have actually not seen that report. But it's news to me. But I think that. You know, in other countries, for example, the UK. That's where the birth of hospice and palliative care really was.
And so this orientation, yeah, so Dame Cecily Saunders, who was a British nurse who became a physician and was also a social worker, she was basically one palliative, one woman palliative care team.
She founded St. Christopher's Hospice, which she started because she observed that the needs of people dying from cancer were really not being met. So St. Christopher's Hospice was really the first facility that focused on treating what we call total pain, the physical, emotional, and spiritual aspects of suffering that comprise the life experience of somebody with a serious illness.
So in England this is where so much began in terms of hospice and palliative care. And I just think in general, If you look even at Canada, a lot of hospitals have hospices attached to them.
Bon Ku: Oh,
Sunita Puri: . Structurally in these health systems, there is a literal space for people who need hospice and palliative care in a way that there is not nearly enough of
Bon Ku: Wow. So they're, they're literally designing the spaces differently
Sunita Puri: exactly.
Bon Ku: hospital systems.
Sunita Puri: Exactly, and so I think that's one big difference when we think about quality of death is if you're living in a country where acknowledgement of death is as bold as we have a hospice wing attached to every ho most hospitals, then that normalizes something very profoundly. It normalizes the fact that medicine's mission is not to help people become immortal.
Medicine cannot cure mortality. That is a condition of human existence that is beyond medicine. And so if you have those physical reminders that there is a place for cure and there's a place for caring for people that we can't cure, that in and of itself gives other places a leg up on us. And so, and I think places that are also just philosophically
oriented differently. So for example, in India, this is not true for everywhere, but there is, especially in some of the rural areas, death is everywhere. People die younger because they have less access to the sort of medical care in the big cities. They're doing hard labor, which makes them more prone to accidents and you see death and dying as part of your everyday existence. Here in the US death and dying have really been cordoned off into hospitals and ICUs and you know, places that are not the home and the hearth. And so the more medicine or the more dying became the domain of inpatient settings, the more people became less and less familiar with it.
And I think when it's a part of your everyday existence, it's very hard to say, this is never gonna happen to me. So in countries or in parts of countries where you really, you don't have acute care I C U beds around the corner, you understand and you almost have to embrace mortality in a way that, you know, you and I have the potential luxury to avoid.
So I think there's that element of it too in different parts of the world that make it very different from the experience in the us.
Bon Ku: Yeah, we have outsourced the dying experience. I, I heard a very funny line that you said, or phrase in the interview you said in hospitals, there's like this customer service approach to death and I thought that that just resonated with me. What
Sunita Puri: talk about, did I talk about the Burger King codes?
Bon Ku: Oh no. What is that? Tell me about
that
Sunita Puri: where, you know, I think that we have become, so reluctant as doctors to say, here are the things we can do, and here are the things that make no sense. That we just present patients and families with a menu of options without guiding them. And it has become like, In order to protect ourselves from liability or to feel like we're really honoring autonomy in a problematic way, that we just give people options regardless of whether there are options that meet their actual goals.
And then we hoist all this responsibility on their shoulders to say, you make the choice in the absence of optimal guidance.
Bon Ku: Can you give an example of how that plays out?
Sunita Puri: certainly. So I think, you know, the example of C P R is a good one where we say to people, and this is not an approach I endorse, but you know, I hear it all the time where people will say, you know, if your heart stops, would you want us to press on your chest to revive you? And if you stop breathing, would you want us to put you on a breathing tube to save your life?
And there's just so many parts of that script that are deeply flawed because we're asking people to make a choice in a vacuum. We haven't said, you know, you are somebody who is dying from end stage cancer, and if your heart were to stop and you were to die, it would be from causes related to the cancer that we can't treat. And if we don't say that, then we are not actually empowering people to make an informed choice. And so when we go into the customer service model of, do you want us to do this or that, we are almo, it's almost like me going to a mechanic and I know nothing about my car and something's wrong with the car.
And the mechanic asks me, would you like me to do A or B? And I'm gonna probably say, well sir, I know nothing about cars Like, I need more context. I need you to help me make this decision. And that's just a car. But in medicine, when we want to almost put all the responsibility on the patient and family to protect ourselves, often from liability, are we really doing our job? And the phrase Burger King codes comes from me having seen things like people asking to, you know, they don't want to be intubated, but they want cpr.
Knowing, and we know full well that if you suffer a cardiac arrest, you're probably gonna, you're gonna need to be intubated cuz you can't protect your airway.
But that's an example of people, of us being okay with people choosing components of a medical procedure instead of us saying, actually all of this goes together.
Bon Ku: Yeah.
Sunita Puri: For example, asking people, do you want us to do this chemotherapy or this immunotherapy? And we give some context, but definitely not enough for someone to make a really informed decision and that customer service model, nine times outta 10.
When I've been involved in situations like that, it just ends up causing more pain and suffering for the patient and family and even for the medical team cuz at some level Bon we know when we offer things in that sort of customer service model, we are secretly wishing for a patient not to choose some options.
teach the residents when you feel like you're offering a choice A and B, and you're telling yourself, please don't choose A, please don't choose A. I teach them. You need to listen to that because that is something within you saying, I don't think this is a good thing to be offering.
Bon Ku: Yeah.
Sunita Puri: So,
Bon Ku: Do you advise patients and family members to have these conversations earlier, even though, you know, death may not be imminent, like in months or days or even years, because it's hard when a patient sees me and I ask 'em that question, I've literally have approached it that way of like, chest compressions and breathing tube in. It's too late. I can't have like a long conversation with you, like I'm, I'm gonna ask it without context, and it's like, it's almost too late when I ask you that question in the
Sunita Puri: Yes.
Bon Ku: someone's coding,
Sunita Puri: Well, that's, I mean, in the ER all bets are off. Right? And that's, and you, I bet you've, I'm gonna go out on a limb here where you've intubated or done CPR and people that you're wondering why, how did it get to the point where this is happening?
Bon Ku: all the time, all the.
Sunita Puri: And so I think context is so important, and I have so much compassion for my colleagues in the ER especially when we went through Covid and so much was falling to you that should not have been falling to you.
And yet it's again, a design flaw in the whole system where we doctors are equally to blame because we don't wanna admit that a patient could be dying or we don't know the right time to bring up a conversation because we don't, quote unquote, wanna take away people's hope, or we don't wanna make people give up or give them the impression that we're giving up if we ask about CPR, just as an example.
But in truth, when we can't have the conversation upstream, What people think is that this then isn't a conversation that matters. Cuz if it matters, my doctor will bring it up and we think if it matters to them, they'll bring it up because it's a topic of great sensitivity. And so it becomes this strange cycle of like, who's gonna blink first?
And then you end up in the er. With you, a fabulous doctor trying to do his job, but also not really having a choice to offer people because death is imminent and you've gotta intubate them and leave the conversation for later. So I think that since we're talking about design, so much of health systems redesign really has to be a looking at early palliative care as the best possible care for people and for health systems because it's all about reducing suffering and the earlier on when somebody gets sick or when somebody's aging or when somebody has a family history of early cardiac arrest.
The earlier we are plant the seed in a kind and supportive way. In a primary care office or a cardiology office or wherever that as your doctor, I wanna help you plan for the hardest scenarios you might face. And this is one of them, and I'm bringing this up for X, Y, and Z reasons.
That I think is a huge part of redesigning things.
Bon Ku: And right now, is it okay if you know, my mom were in the hospital and it was something serious that I go to the medical team, it's like, Hey, can we get a palliative care consult? Like , how does it happen? Like I, as a family member can ask that to the medical
Sunita Puri: Mm-hmm. . Yep. And every hospital is different. That's part of the issue with palliative care, is that we're so heterogeneous. So at one medical center, you might just have one nurse practitioner, and that's the palliative team. Yes. And at another center like here, we have a full compliment. We have physicians, advanced practice practitioners, social workers, we have spiritual care folks we work with.
We have a music therapist on our team as well. So very different than a place where there might be one NP. So institutional culture matters a lot and that determines the shape of a palliative team. But it centers with a palliative team, if you ask. Usually you're gonna be able to see somebody unless there's additional hoops to jump through, and I always recommend that people advocate for that and explain why.
Because you might be dealing with a medical team that thinks palliative is just giving up
Bon Ku: Yeah, because it's not, always gonna be offered
as a
Sunita Puri: it's not always gonna be offered. And so I've actually encountered this quite a lot where somebody is suffering greatly and they're, their daughter is pushing the team, please call palliative.
And it's actually really heartening for me to see this because it shows me that our culture is changing and that people lay, people are recognizing that we are not Dr. Death that we are actually doctor life
Bon Ku: yeah,
Sunita Puri: many
Bon Ku: yeah. I love that. you have extremely busy schedule. You're in the hospital taking this, so I really appreciate that. One question I'd like to ask our guest is if a listener were to visit you, where would you take them out to eat?
Sunita Puri: Oh my gosh. So as I mentioned, I have moved very recently from Los Angeles, so if you came to visit me in LA I mean, there's such a bevy of options that my first question would be, what sort of food do you like? And if you were like, take me wherever you love, I would take you to El Condor, which is a Mexican place in Silver Lake.
It was steps away from where I used to live. It is fantastic. Or I would take you to Mommed, which is a Mediterranean restaurant in Atwater Village, which is not far from Silver Lake. Fabulous Mediterranean food and also just a beautiful outdoor patio with really lovely like wicker seats and lights and all of the hipster sort of LA stuff.
And if you came to visit me here in Worcester, I would probably take you to a place called Mare Monti, which is an Italian place. And they have very, very good food and they have the kind of red brick inside with little twinkling lights. And so it's a place you can go with friends. It's a place you can go on dates.
The staff are really lovely and it's family owned, so that's probably where I would take you if you come visit me in Worcester.
Bon Ku: Awesome. Well, I think I am gonna go to Worcester later this year, so let's go there.
Sunita Puri: Yes, I would be so happy to introduce you to Mara Monti. It would make my day, so that must for my quality of life. Let's make that part of your trip.
Bon Ku: All right. Thank you for coming on the show.
Sunita Puri: Thank you so much.
Bon Ku: I hope you enjoy my conversation with Sunita. You can follow her on Twitter and Instagram. Her handle is S U N I T a p U R I M D. Design Lab is produced by Rob Pugliese editing by Fernando Queiroz. Our theme music was created by Emmanuel Houston and the cover design by Eden Lew. See you next week.
