The In-Between with Hadley Vlahos | Crooked Media
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August 15, 2023
America Dissected
The In-Between with Hadley Vlahos

In This Episode

Dying … is not a topic most of us like to talk about. But we probably should, considering that all of us are going to do it someday. But how do we have those conversations — and why don’t we when it matters most? Abdul reflects on our odd relationship with the one thing all of us will do. Then he speaks to Nurse Hadley Vlahos, a hospice nurse, and author of the new book “The In-Between.”




[AD BREAK] [music break]


Dr. Abdul El-Sayed, narrating: The EG-5 COVID sub variant achieves dominance as we near the fall. Alice K. Ladas, author of the G-spot, which unlocked a revolution in women’s sexual awareness, passes at 102. The FDA approves the first ever pill for postpartum depression. This is America Dissected, I’m your host, Doctor Abdul El-Sayed. [music break] 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. And also it’d 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. God, I wish everyone got that chance. But young people die, too. In fact, it happens way more often here in the good ole 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 dollars to raise national life expectancy by a year. Now, look, that was a lot about death. So here’s the upside I promise 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 Mary’s, $3 trillion dollars 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. 


Dr. Abdul El-Sayed: We are recording. Okay. Can you introduce yourself for the tape? 


Hadley Vlahos: I am Hadley Vlahos.


Dr. Abdul El-Sayed: Hadley, you wrote a really uh great book that is now two months on the New York Times bestseller list um as of literally now. And uh that’s both really exciting, but it’s also um somewhat surprising because you wrote about one of those topics that nobody wants to talk about. Uh. But it turns out a lot of people want to read about. So 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. Um. Why did you want to become a hospice nurse? 


Hadley Vlahos: So I wanted to be a writer growing up. And then I went to Florida State University, and life took me on a little bit of a different path. I ended up becoming a very young, single mother and went into nursing to provide for us. And after feeling extremely burned out in every specialty that I was in, I saw while working in a nursing home, hospice nurses get to be one on one with their patients. And I said, what kind of nursing is that? That is what I want to be doing. So I took a job in hospice and 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. 


Dr. Abdul El-Sayed: Hmm. And tell me what it is about that experience of caring for someone, by definition, at the end of life that’s so different from caring for them at other stages? 


Hadley Vlahos: In hospice, we really focus on comfort. We’re not just focusing on trying to fix people like medicine usually does, any other type of medicine I’d ever worked in the goal is always to heal what people would say is broken. And whenever you’re in hospice care, we’re just focusing on quality of life instead, if you want. I’ve taken people to the beach for the last time, and that is very different than any other type of medicine. 


Dr. Abdul El-Sayed: So you ended up being a both a nurse and a writer. Uh. Congratulations on that. Um. What what informed the writing of this book? What what was it obviously you wanted to write, but why this book? 


Hadley Vlahos: I got started on social media about three years ago sharing stories from the bedside of my patients. I had been collecting these stories for many years before I got on social media, and at one point I really felt like I was being selfish, just keeping all of the this amazing advice they were telling me and all these amazing stories. And I remember sitting in my driveway because I would always have to take a moment between work and transitioning into home and having a really amazing experience with a patient before he died, where he saw a deceased loved one and saying, I don’t fear death anymore and I used to. And I think other people need to hear about these experiences as well. 


Dr. Abdul El-Sayed: Hmm. You share them so beautifully. Um. I want to step back for a second before we talk a little bit more about some of those experiences. What is hospice? Because I think it’s it’s one of those things that folks have a lot of misconceptions about. So what makes hospice hospice? 


Hadley Vlahos: Yes, a lot of people think it’s a place and it’s not. It’s a service. So we will come to you wherever you are. Usually that’s people’s homes where they’re being cared for by a primary caregiver such as a spouse or a child. 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. 


Dr. Abdul El-Sayed: And what’s the difference between that and palliative care? 


Hadley Vlahos: So palliative care is going to be for anyone with any terminal illness, but they can still get treatment. And that is such a common misconception where people don’t understand the difference. But on palliative care, since you are still getting treatment, you’re not getting as many services as hospice. So you don’t get a nurse manager who comes and sees you. You’re just seeing the doctor, 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. 


Dr. Abdul El-Sayed: Got it. So what makes hospice hospice is that you have in in some senses decided not to continue to pursue curative care. 


Hadley Vlahos: Yes. 


Dr. Abdul El-Sayed: Palliative care can be adjuvant to to to curative care, but it is about trying to make you feel more comfortable. Hospice is is saying that we are shifting the overall priority of your care to your comfort rather than to extending uh life. 


Hadley Vlahos: Correct. 


Dr. Abdul El-Sayed: Now, for a lot of folks, particularly in medicine, this is almost antithetical to the way that you you’re taught to think about disease. So, you know, I do a bit of teaching and one of the the things that I do in a lot of my classes is I will walk into the room first day of class and ask, how many of you here want to save a life? And every hand goes up. Everybody’s there to save lives. 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 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 uh about about about longer lives. Of course, it’s the the end purpose of both both 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. So how do you think about that vis-à-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? 


Hadley Vlahos: It is and first of all, I wish someone would have told me in nursing school what you tell your students because I did not get that talk. And the first time I got that talk was from a physician while I was working in hospice already. And I remember calling him and saying, what what am I supposed to do? Like, we we need a hospital. She needs a hospital because we are so programmed to fix, fix, fix. 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 911. 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 considered to be nothing was very different for me. And I had to really retrain myself. 


Dr. Abdul El-Sayed: Hmm. One of the one of the ways of appreciating all that you are doing in hospice is to paint the picture of the counterfactual. So you have somebody with terminal illness and you are continuing to pursue curative care. What does that look like for them? 


Hadley Vlahos: That is extremely difficult. And we see the tail end. We see the results of people who try everything they possibly can. And for these patients who I then come into their home and they don’t have to go to these appointments anymore, when they talk to me, they tell me that they felt like they were cattle being herded from this place to the next, go get this lab result. Go to this surgery now. We need chemo here, a dialysis there. And they were not having any quality of life at that point. 


Dr. Abdul El-Sayed: And at the very extreme, oftentimes you’re talking about living inside a critical care unit, being pumped full of many, many different, extremely painful therapies with very, very noxious side effects. 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. Right? 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, right 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 as someone who has that you know really honored position of being with them and helping to steward those last precious moments that they have? 


Hadley Vlahos: It is compared to the hospital which I have taken care of hospice patients in the hospital as well. But especially when they are at home and we’ve been having a relationship for a couple of months and I really know them. Those last few days of their life are peaceful, is the best way I could describe it. They will sleep a lot. Usually a lot of the time they will watch their favorite TV shows. Many times 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. 


Dr. Abdul El-Sayed: One of the hard parts about end of life care. And I got to see this up close when I was in med school is we always assume that we have more time with the people we love. And I say that as as as being on the other side of that that bed. And you see a lot of the guilt that people have about not having spent that time, about not having had those conversations, about not having said, I love you, about not having been present in a in a moment play out because they’re trying to chase that moment again and realizing they don’t have time. And then the way that that sometimes plays out in the conversation is, no, I can’t give up on them. As if to try and atone for that moment missed. How do you have conversations with loved ones who, 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? 


Hadley Vlahos: I, depending on how the family is, if they need to hear it, I will tell them, you’re not giving up. You are just getting, you’re just having choices. You know, really, we have the choice. Just like you were talking about, where we can choose how we die and not guilt tripping your loved one and saying that they’re giving up or using any sort of terminology that’s similar can be extremely liberating for them. But a lot of times with those really tough conversations I’ve learned, at first I really wanted to fix things for them and give them the best advice possible. 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. 


Dr. Abdul El-Sayed: Hmm. And a lot of these dynamics, they play out because we don’t have conversations about death before death is imminent. And so there’s a lot of miscommunication that happens. You hear all the time it’s what he would have wanted or it’s what she would have wanted. It’s it’s it’s who they were as a person. They were a fighter. 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, uh in this particular time and space, we’re just not good at talking about death, we don’t like to talk about it. 


Hadley Vlahos: I think that in our culture, I do think it’s shifting. I have seen a noticeable shift in the last couple of years, but before what I’ve seen recently, I think that it’s just uncomfortable. And for a lot of people their gut reaction is to just avoid something that’s not comfortable to them. They would prefer to just look the other way. And I think that we see that in a lot of society for a lot of different issues, and I hope society’s changing for a lot of those, but I think that’s one of them. [music break] 




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


Hadley Vlahos: I don’t shy away from having those conversations. And interestingly enough, um kind of a side story. But once the book came out, we threw a party to celebrate it and we invited all of our friends to stay at a house with us for the weekend and basically all of our bridesmaids and groomsmen. And we had a great weekend together. And much of that weekend was talking about death because of my book. 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– 


Dr. Abdul El-Sayed: Wow. 


Hadley Vlahos: –went and talked to his mom, um 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 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. 


Dr. Abdul El-Sayed: Wow, what a powerful story. I think that the thing about about being young 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. Um. And obviously, even saying that people are like, oh, don’t say that. You hear that all the time. I can I can imagine everyone listening being like, don’t say that. That that you’re just you’re just bringing upon foreboding. But you know 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 um open funeral culture. So in the Islamic tradition, uh the funeral is a prayer. And it is you know, it’s a it’s a, actually really quite poetic. So a lot of folks know about the Muslim call to prayer um when you’re born, uh 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 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, you know, beef that I have with this person? Do I want to treat this person a certain way? Do I want to, you know, go to bed with with, you know, anger in my heart to whomever? And I, I wonder, you know, as you think about and you told that story. How has being a hospice nurse and seeing death experiencing the death of a of a close friend at a young age, how has that changed the way that that that you live? 


Hadley Vlahos: It’s changed my life in many ways. One of the very big ones, very similar to what you said, is every morning when I wake up, I say, it could be my last day. And if I had to meet someone like meet a maker or meet a higher power, could I stand in front of him or her and say I lived my life the best I absolutely could? I was kind to others. I put goodness into the world 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. 


Dr. Abdul El-Sayed: Mmm. Um. What are some of the other lessons that people tell you? 


Hadley Vlahos: A very big one is, of course, about material things, which I know you people that’s very cliche, but it’s true. People do talk about caring too much about material things. And mostly when it comes to buying material things to impress other people, that’s what they regret. Um. I had one patient recently who told me, he said, do you know what a Thunderbird is? And I said, I think it’s a car. And he said, Yes. So I worked over time 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, okay. 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. 


Dr. Abdul El-Sayed: Wow. What did his daughter say? 


Hadley Vlahos: She is very sweet. She was just like, it’s okay, Dad. 


Dr. Abdul El-Sayed: Um. You know, it’s a it’s it’s it’s something I think a lot about. I have two young daughters and um you know, it’s easy to get lost in whatever it is that you’re doing, whatever it is you’re chasing. And uh, 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 that like, Yeah, but I will. 


Hadley Vlahos: Mm hmm. 


Dr. Abdul El-Sayed: Right. 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 uh could change one thing about the experience of death and dying, what do you think that should be? 


Hadley Vlahos: In the United States, the biggest thing that I see is that our caregivers are not being cared for. It’s it’s a very big issue that I do not see anyone talk about, but I live it all the time. I see caregivers with no options. So when you’re on hospice, you’re expected to care for that person on hospice 24/7. It’s exhausting. It’s a lot. Some people are giving medications every 2 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 $30 an hour with a minimum of 6 hours per day, or put people into a nursing home, which not everyone’s comfortable with that. So for people who cannot afford $30 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. 


Dr. Abdul El-Sayed: What I hear you saying is that we haven’t invested in end of life care. And for that reason, the folks who provide it are burning out because they’re having to make extraordinary choices. And then it’s not available to a lot of people who absolutely need it, um whether they’re the folks who are getting the care in the first place or they’re the folks who are providing the care in the absence of the people who should be. One of the things that is so frustrating about what I’ve seen in the structural features of hospice is that there’s very little incentive on the provider side, to have honest conversations with patients. What do I mean by that? When I was in med school, I uh was working at a hospital that had just built a new ICU, and they had a really, really talented um end of life care doctor who ended up getting transferred out of that hospital because she was too good at having end of life conversations. So what happened was patients who would have ended up in the ICU and would have been billed at ICU 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? 


Hadley Vlahos: Yeah, it is it’s bad. And as much of a dark humor would seem, we we talk about that we have doctors that we say they send them to us cold because they’re always sending us patients that have a day left to live. And you’re like, what in the world? And you look at we look through their chart so we know that they should have been sent to us months beforehand. And you’re right. Things especially like chemotherapy, um surgeries, you don’t do that any more whenever you come on to hospice. So those are huge things that are billed to Medicare. And of course, as we know, Medicare’s one of the biggest payers in our country. And 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. 


Dr. Abdul El-Sayed: And on the back end, that costs our society huge amounts of money. Right. Um. You know, for the most part, if you’re relatively healthy and you have that privilege, the most health care expenditures you’re going to experience are going to be at the end of your life. 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 um taking medications that at times can be experimental. You’re getting surgeries. Um. And uh when when you’re trying to throw a Hail Mary and it’s costing hundreds of thousands of dollars. Right. You got to ask who benefits from that? And the only uh entity that benefits are the hospitals um and and and oftentimes, unfortunately, the physicians and um how 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 uh for themselves or their loved ones? 


Hadley Vlahos: I think what you were saying about having a palliative care or hospice trained person in the hospital can be a good start because they know how to have those conversations. I will do those conversations. Sometimes they’ll call me in and just do a consult where I’m just giving information. And I find that a lot of times people are being given wrong information just because it’s so different. They just they’re not doing it maliciously. 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 um 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. 


Dr. Abdul El-Sayed: Yeah. And that’s the that’s the craziest thing, right, is that when patients choose hospice. Oftentimes they are presented the option as if you either quote, “fight” and you get more time or you choose hospice and you get more comfort. But it turns out when you choose hospice, you both get more time and a lot more comfort. And so, you know, on average, this is just the better choice. One of the the pushbacks when you have a conversation about end of life, is that uh your 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 um in terms of what you’ve seen at the bedside? 


Hadley Vlahos: I have heard actually, someone just told me that recently, a family member uh who’s a physician. And I said, we have extremely strict guidelines and criteria. To me, it is not just some doctor says you have six months or less, here go into hospice. 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 stay. 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 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. 


Dr. Abdul El-Sayed: As as we think about this and you know, most of our listeners are a range of folks, but most of our listeners just based on the statistics, are folks for whom basic life expectancy, statistics would suggest that you’ve got a long time to wait. But for a lot of us, uh parents might be getting a little bit older or grandparents might be getting a little bit older. How do we prepare for death? What are the things that we can do right now, both to prepare for our own eventual death, but also to prepare for the deaths of loved ones? You know, people that we don’t want to think about dying ever, how do we facilitate um the conversations that really we ought to have before what is imminent becomes obvious? 


Hadley Vlahos: I think I’ve never told anyone this before except my family, but I think that there should be a day every year, whether that be your personal day, where you just go to your family and say, hey, every year, whether that be like January 1st or whatever it is, I review my wishes for end of life, whether that be for ventilators or IV fluids at the end of life or whatever it is, CPR. Um. I want to review that with you because you’re the person who would be making the decisions. Just want to make sure that you know my wishes and hopefully they’ll also share what their wishes are by opening up that conversation. But what I find is that many people, like you said, always think they have more time. So they always think I should have that conversation one day, but they never do. 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 that we need to change. 


Dr. Abdul El-Sayed: I find that one of the other things is that if you approach an elder loved one and try to have this conversation, they’re like, Wow, like you’ve just given up on me already? Like you just want me out of here like, no, I just want to understand what you want to do. Obviously, in our family, um you know, my my wife Sarah is a doctor, my my brother’s a doctor. I’m a doctor. So these are conversations that um we’re 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’d take it the right way. Um. And usually the way I put it on myself is like, hey, I’m somebody is 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 this is the only reason I’m asking, um but it still would be super uncomfortable. Do you have a couple of ways in um to have that conversation with someone you love without without them feeling like you’re, you know, beckoning it or just turning the mood sour? 


Hadley Vlahos: Interestingly enough, I wouldn’t have really known what to say a couple of weeks ago. But interestingly enough, I’ve gotten enough messages now where people said, I’ve read your book and I’ve used it as an excuse to go to my husband, my mom, my dad, and say, I just read this book on death and dying. Can we talk about it? Can we have that conversation and kind of putting it on me like, Oh, I’ve never thought about this before, but now I read this book and just, I think little ways that you can work it into a conversation naturally. It is great. 


Dr. Abdul El-Sayed: Mm. Now, I really appreciate that. So it’ll be the um the Hadley Vlahos um book club to open up a conversation. Hey, so there are a lot of a lot of themes in that book I, one of them was Death and uh I was thinking maybe while we’re here. [laughing] Um well the–


Hadley Vlahos: But also on that note, um the media is another good way. So we just saw Sandra Bullock’s partner die of ALS. And it seems like stuff is happening in the media all the time. That that’s another good way to say, you know, I just saw this happening and it looked like he was in the hos– from what I read, 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, as like, hey, happy Sunday, what do you want me to do with you when you die? [laugh]


Dr. Abdul El-Sayed: Yeah. So I’ve been thinking about you dying and–


Hadley Vlahos: Yes! 


Dr. Abdul El-Sayed: –uh trying to figure out how that was going to go. [laughing] Uh. Well, I really appreciate you um 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 uh was Hadley Vlahos. She is uh a hospice nurse and she’s the author of a great new New York Times bestselling book, The In-Between. Um. Hadley, thank you so much for joining us today and sharing your wisdom. 


Hadley Vlahos: Thank you so much for having me. [music break]


Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. I know you’re sick and tired of COVID. And look, it’s still mostly good news, but fall is right around the corner. And we’ve speculated for some time now that Covid was going to fade into a seasonal disease with upticks coming in, you guessed it, the fall. And with that, a new sub variant, EG.5, which scientists are also calling Eris, has climbed to the top of the Omicron sub variant heap, accounting for 17% of all cases as of last week. Remember, when it comes to new sub variants, the questions you should always ask are, one is it more transmissible? 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 sub variant, 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. Ladas 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 the 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: 


Hadley Vlahos: On Friday, the Food and Drug Administration approved Zuranolone, the first of its kind fast acting oral tablet to treat PPD. 


Dr. Abdul El-Sayed, narrating: This is an important step in treating a disease that affects millions in a particularly vulnerable period of their lives. Depression is cruel, but postpartum depression attacks in a time when everyone wants you to be happy, when you have a newborn who’s utterly helpless and when it’s so much harder to do the usual things like sleep or self-care that can help. 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 improvement starting as early as three 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. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher, our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Suigura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me, Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.