Everyone Deserves A Good Death | STUFF YOU SHOULD KNOW

Welcome to Stuff You Should Know, a. production of iHeart Radio. Hey, and welcome to the podcast. I'm. Josh and there's Chuck and Jerry's here, too. So, this is an oldfashioned root. and tootin episode of Stuff You Should. Know and about something we need to talk. about, Chuck. Okay. >> Okay. Um, do you remember back in like the. like about like the 2009, 10, 11 era.

when like death was all the rage? People. were having like death cafes and like. creating living wills and it was just a. big thing that everybody talked about. >> When was this? >> Like 2009 to 200 maybe 11. >> I don't remember that, but I'll take. your word for it. >> It was a real thing for sure. Unless. I've just completely lost my marbles and. I just made up a whole era of American. culture. I don't think I did. But that. has died itself. Like that it's gone.

back to death has gone back to being a. bit of a taboo topic, an uncomfortable. topic at least at least here in the. United States. Um. >> I didn't know that either. >> It's it's true. I guess I'm just. speaking from for myself anecdotally. >> Oh, okay. That makes a lot more sense. So, um, okay. Well, let's just cut to. the chase here. Um, there's this concept. of, uh, a good death. Yeah. Right. >> And, um, you you can probably fill in a.

lot of the blanks of what that means and. what it means to you at least, but. there's actually like some components to. it that studies have found like kind of. bubble up to the top that most people. can agree this makes a good death. Um, there are things like getting to say. goodbye to friends and family, having. those people at your side if you want. So, a certain amount of control over the. dying process is is something. >> Okay. >> Um being pain-free, not suffering. >> Sure. >> Uh being in an environment and having a. chance to like kind of come to terms.

with the fact you're about to expire. Um. those are some of the top things that. people say like this to me is a good. death. And not coincidentally, those are. the kind of things that hospices, which. we're about to talk about today, are. intended to provide. That's the service. they provide is to give you the. individual a good death. And it's not. something that's relegated to the rich. It's not something that's relegated to. the um the uh the educated. It's for. everybody. Everybody deserves to have a.

good death. And that's pretty much the. um the the motto of hospice. And in. fact, I ran across one motto. It said, "If you can't add more days to life, add. more life to days.". >> That's that's great. It sounds a little. too corporate slogany, but I like the. sentiment. >> Yeah, there's a mascot um Louis the Dead. Guy, >> right? Oh man, >> who uh who's like always saying that. slogan, and he did a partnership with. Home Depot for some reason recently. >> Oh boy. Well, that explains the orange.

uh bed sheets and things, >> right? >> Uh all right. So, that's probably the. last semi joke we're going to make. Uh. you'll have to forgive us for that. We. did a whole episode on dying and um I. don't even know if we made one joke in. that one. So, >> sure we did. you think? >> Yes, I absolutely think. >> All right. Well, we'll pair that with. this one. Uh and and because we got a. lot of great feedback on the dying. episode and how that could kind of help. people out. So, >> yeah. >> Uh maybe this will do the same. Uh we. should probably go back in time a bit. and explain the history of hospice.

because. >> it is very recent if you look at sort of. the timeline of people in the world. dying. Um hospice has only been around. since like the 60s or 70s and in the. form that we know it. Uh because. previous to that uh for all of time. basically medicine was like hey we're. here to cure people. and if if it's it turns out that we. cannot cure you and that the end is near. um for a very very long time until the. last like you know like I said since the.

60s or 70s very shamefully um hospitals. and even doctors would sort of like uh. it it was a reminder that they they. couldn't save you so They didn't spend a. lot of time with you and there are a lot. of, you know, well-known reports of um. people kind of like scurrying past rooms. where people were in their final days in. a hospital and stuff like that. >> Yeah. They left the dying who who were. incurable now to basically die alone. They they withdrew support. That was.

just what they did. Like you said, it. was a reminder of the failing of. medicine. And this was a time when. modern medicine was not in any kind of. mood to be reminded of failings because. I mean the 20th century was pretty. triumphant for it. I mean I saw the um. the infant mortality rate decline by 90%. over the century. There's like. sanitation, clean drinking water, polar. vaccine. Like science could do anything. and people who were incurable were just. a reminder that there were limits to. that whole thing. >> That's right. Uh, and another thing that.

was going on, and this is also pretty. shameful. Well, I guess not shameful, but uh, they've since revisited how they. look at uh, at pain management, but. yeah. >> Um, you had to like. really be in pain to get pain management. and then that had to like wear off and. you had to be really in pain again for. them to administer more pain management. um they were worried about, you know, opioid addiction and stuff like that, but you know, these days it's it's. definitely more like, hey, you know,

we're not worried about you getting. addicted to opioids in the final. possibly days of your life. We just want. to make you feel okay. >> Yeah, that's definitely the hospice. philosophy is you don't have to wait. until one painkiller wears off to get. another dose. You can, you know, stay. comfortable. That's the point is to make. the person comfortable. Um that's called. paliotative care. We'll talk a little. more about that, but it's essentially. just taking care of symptoms to keep. people comfortable. >> Yeah, for sure. Uh nuns were kind of on.

the scene early on providing, you know, emotional support. Uh they couldn't dose. out pain medication of course and stuff. like that, but they, you know, it was a. lot of times it was religious. organizations that were stepping forward. that were kind of doing the hospice type. work that would come along in the 60s. and 70s. uh thanks in part to a couple. of uh big landmark books that came out. >> Yeah, there was this whole thing in the. 60s and 70s that was kind of this. rebellious streak that went across like. or against some of the just unquestioned.

institutions. And one of those was. medicine and doctors and hospitals. But. there was a psychiatrist named Elizabeth. Kubler Ross who very famously came up. with the five stages of grief. That was. in her 1969 book on death and dying. Um, and uh, in addition to being famous for. coming up with the five stages of grief, she also basically interviewed people in. the Chicago hospitals ICU. um, who were dying and just found that. they were just being totally neglected.

And so she definitely lobbied for dying. and and um, dying people in their. families to be listened to and to be. treated rather than just ignored. >> Yeah, we talked about her uh, and that. book in our dying episode. Um I don't. think we talked about the denial of. death from 1973. uh but that was from an anthropologist. named Ernest Becker and uh he was. writing this as he was dying himself. So. he was in a position to really give a. good you know pretty moving first person.

account and he talked about sort of you. know a good death and accepting the. inevitability and stuff like that. Uh so. these things were sort of happening in. the cultural movement uh when a woman a. hero I think named Sicily Saunders came. along eventually the founder medical. director of St. Christopher's Hospice in. London and she really changed the game. and kind of birthed the whole sort of. modern hospice movement. >> Yeah. She had a um bad back uh from a. young age and apparently it kept her.

from her her um desired career of. nursing. Um, so she instead became. basically a social worker. Uh, what at. the time they called a lady almaner or. distributor of alms, right? So it's. pretty old timey, but it does kind of. it's a nod back to the original hospice. which were founded in the crusades by. the Roman Catholic Church. Um, ironically, Sicily Saunders was raised. an atheist, but she had a conversion to. Christianity, evangelical Christianity.

even, when she went on vacation with a. Christian friend and her family. Um, and. one of the other big experiences that. led her to found found the hospice. movement essentially was she had um like. some friendships with some people that. she helped essentially as they were. dying and um really kind of was moved by. these friendships and wanted to make. sure that other people had that same. experience. So, she did something that. um I mean just kind of I think really. gets across the kind of person she was.

And she went to medical school to make. her voice a little more credible. >> Yeah. She started medical school at age. 33. Uh this is in the 1950s and she. finished medical school. She uh was able. to work as a physician. >> Um she started writing articles and. stuff about this about people, you know, being deserted or feeling like they had. been deserted u by their doctors. just. like the closer they got to death like. we were talking about and said, "Hey, there's got to be a better way to take. care of people um not only physically.

but emotionally and spiritually as they. as they near death." Um so she, you. know, got that medical degree, got a. research job at a hospital, started. studying, you know, she wanted to have a. legitimate sort of background for this. so people didn't think she was just some. right. >> uh some some wacky empath trying to do. good. uh which you know should be. enough, but she figured if she was armed. with medical training and real data and. and uh on like pain management and stuff. that she would go a lot further and she.

did. >> Yeah. She went and studied pain. management firsthand so she could come. up with her own protocols. Um, one of. those protocols that was really. groundbreaking and went against the norm. was to give dying patients uh not just. heavy doses of morphine to make sure. that they weren't in pain, but also. cocaine to keep them from just being. kind of doped up um the for the rest of. their lives. Uh she would find out what. liquor they preferred and would make. sure that they had their liquor. >> And all of this sounds like just.

completely reckless and and careless. Uh. but she had before and after pictures of. these people, terminal cancer patients. who um in the before pictures before. they had been treated with her new. protocol of pain uh management and I. guess mood management too if you think. about it. Um they did not look very. good. They looked like terminal cancer. patients. And afterward they were. sitting up in bed perked up. Some had. taken up uh hobbies like knitting. And. she would show these before and after. pictures when she went around the world.

speaking on behalf of hospice as she was. trying to found it. And like she would. get converts at every every talk she. gave just from the the before and after. pictures alone. >> Yeah, it was it was pretty remarkable. Uh this all culminated in 1967 when she. founded St. Christopher's Hospice like I. like I mentioned earlier in London. Uh. and kind of right off the bat she said, "All right, we have a new way to deal. with pain management. Uh we're going to. get rid of visiting hours and people. family can come and go when it's.

convenient for them. Uh and we're going. to not talk about just you know physical. pain. We're going to talk about what I. call total pain or what she called that. Um you know like we mentioned emotional. support um social support spiritual. suffering that happens with people. Uh. and one of the people that she worked a. lot with was a a nurse in the US named. Florence Wald who ended up doing the. same thing in the US. She said, "I think. we need this over here." Uh, she started. up the very first hospice in Brford,

Connecticut in the United States. And. that was 6 years later after the one in. London in 1973. >> Yeah. That first American hospice, they. tried a few names out before they. settled on the the final one, hospice. RS, McDying, and then they just kind of went with the. straight name. >> Wow. All right. >> So, um, yeah. So, hospice that spread. pretty quickly. I think you said St. Christopher's opened up in 1967. Um, and the one in Brford opened up in.

1973. That's pretty good traction to to. create a brand new idea in both the UK. and the US and start spreading it around. the world. And one of the things I think. you said about St. Christopher's was. even though it was religious or at least. spiritual, it was non-denominational. And that is a huge point about hospice. that is lost on a lot of people. I think. a lot of people associate it with. religious groups still. And like uh if. you're not say Christian, you wouldn't.

really want to go to a Christian. hospice. That is not at all the way that. hospices work. And in fact, there's. plenty of people who are atheists. They're humanists. Um and they just are. like those empathic dogooders that you. were um speaking about earlier. And none. of these philosophies clash because they. all come together to essentially say one. of the big parts of dying is some sort. of spirituality or at least some sort of. peace that that we associate with.

spirituality. It doesn't matter how you. get there. We're all just kind of coming. together to make sure that everybody can. experience that. It's a big. misunderstanding of hospice sometimes. >> Yeah, for sure. Um in the US it's uh. usually uh or at least at first it was. done at home. Uh that was a difference. from the early ones in the UK. They were. inpatient facilities. Uh but in the US, you know, it it was sort of a budget uh. budget issue at first because they. couldn't get these facilities and pay. for them. But I think they also realized.

that people wanted to die at home. Uh. and there was also this sort of. long-running institutional distrust that. Americans had. Um and it was a lot of. volunteer work at first like almost. entirely volunteer early on. It was um. sometime like we mentioned people in the. clergy uh still doing this kind of work. after centuries of doing so. Um doctors. that were moonlighting that wanted to. help out and a movement was was you know. clearly growing. Uh, and it made.

government sit up and take notice when. they realized that it was saving money. on health care because not only was the. movement growing and people were just. feeling better about it, but it was. keeping people out of the hospital sort. of off and on, off and on, off and on. And so much so that the US government. and the Reagan administration said, you. know what, we should um we should get. this covered. And in 1982, the hospice. uh medical uh Medicare benefit went. through um which allowed people all of a. sudden to be able to pay from a you know. staff run by professionals that were.

also paid uh and you know get it covered. through Medicare. >> Yeah. Which opened up the door for. people who wanted to um help people. during the final days or weeks of their. life, but there wasn't a career. associated with it. Now there was. So. you could you could pursue that kind of. medicine, end of life medicine. Um. that's pretty cool that that was a huge. change. Um I suspect that the saving. money had a lot to do with it though.

>> Yeah, that's usually the case. >> And the reason why, let's just spell it. out explicitly. Um, the reason why it. saves money is because you're taking a. patient off of a very expensive track, which is a lot of different medical. procedures and treatments and saying. we're like you're not going to go for. the curative treatment route anymore. We're going to take you out of this. crazy not so medical world and put you. in a much more peaceful, tranquil world. where you can end your days as a um, a. happier person rather than feeling like.

a guinea pig being experimented on. And. it's just much cheaper to do that, too, as you can imagine. >> Uh, it feels like a good breakpoint. Yay. >> Yay. >> All right, we'll come back and we'll. talk about how the the modern system. works right after this. [Music].

Uh so here in the United States, Chuck, um hospice uh is usually paid for by. Medicare, which is federal um insurance. coverage for people who are retirees. typically or maybe disabled. and then uh also sometimes Medicaid. which covers lower inome Americans. And.

the upshot of all this is that if you. are dying and choose to go on hospice. care, you are not charged for this. Um. and that is a wonderful thing that the. federal government does. Apparently the. UK is very much like that, but a lot of. it is donationdriven rather than paid. for by the government, which does chip. in, but the lion share is paid for by. donations in the UK. But there's. eligibility requirements that basically. say like if you don't check these boxes. or if you stop checking these boxes at.

any point, you can't be in hospice. anymore. >> Yeah. And those boxes specifically uh. you have to have two doctors certify. that you have a and this is for Medicare. uh you know to get it covered, not just. to get into hospice, >> right? >> Um you have to have a terminal illness. uh you have to have six months or less. to live and you cannot be going after. curative treatments and we'll talk about. some I I don't even know if they're. exceptions but some things that some. people might think are curative. treatments and aren't curative.

treatments that doesn't mean like don't. ask for anything at all. you can't have a band-aid. >> yeah you're on your own so we'll we'll. get into those but um and this is going. to be a sticking point that kind of. comes up later in in some of the. failings of the current system, but. Medicare pays uh hospice um companies. and agencies a daily rate uh instead of. for specific services they provide like. basically all the other uh medical. treatment you're ever going to get. Uh.

and there are four levels of that care. and they're going to be different rates. depending on the level that you're going. to get uh and also where you are, >> right? Um, so that you if you're running. a hospice, you would get a flat fee paid. by the government for a patient who's in. routine home care, which is um you're. not in crisis, you're still dying, but. you're doing okay. Um, and it usually is. just a visit um maybe a couple of times. a week. They're coming by to make sure.

that their meds are going down right. They maybe have like their nutrition. going. They're just essentially just. checking on you. That's routine home. care. There's also continuous home care. where if that patient slips into a. crisis like maybe they start vomiting. uncontrollably, they um start suffering. uncontrollable pain that their meds. aren't doing anything for anymore, changes in consciousness, all of a. sudden now they have um 247. uh hospice access at home.

>> Yeah. There's also there's a couple of. more. There's inpatient respit care. Um. that's when a patient goes into like a. you know they have to leave home to go. into a physical hospice center uh for up. to 5 days. A lot of times this is to. give their caregiver time off because. that's one of the the brutal parts about. end of life is um and I say burden on. the family not like what a hassle but. you know it is a burden on the family. Um yeah, >> people have to. >> besides the emotional devastation. they're going through a lot of times.

have to to rearrange their um jobs and. like even leave jobs sometime to do this. kind of thing full-time. So it can be. quite a heavy burden on a family. Yeah, actually Chuck, that that's a um if you. look up downsides of hospice, that's. pretty much the number one uh issue with. it is that it it transfers. responsibility for caring for the dying. patient from say like a hospital to. their family. And that's a that's it is. it's a very big deal. >> Yeah. And then the last one is general.

inpatient care. And that is when you're. addressing pain control um or any kind. of symptom management that you can't um. that you have to like go in and take. care of at a specific place. It's not. the kind of thing you can do at home. generally. Um and then you know pal. paliotative care is a big part of it. That's what we kind of mentioned earlier. is is just making people feel better. toward the end. Um, you know, I. mentioned things that don't count as um. curative treatment, like if you're uh if. you have heart like active heart.

failure, they can try and reverse that. Or if you have some like nasty bed sore. that gets an infection, um that's not. cons that's not going to boot you off uh. covered hospice care to get that taken. care of. No, the key to being covered. for uh hospice under Medicare is that. you are not pursuing treatment to cure. the thing that's got you terminally ill. Yeah. Right. So, like you said, if you. have develop a heart condition, but. that's not what's killing you. You have. terminal cancer, they can, you know,

treat your heart condition. And even if. you do have terminal cancer, if you have. nausea from cancer, pain from cancer, they're going to treat that because. they're not trying to cure the cancer. you have to give up things like. radiation or chemotherapy. Those are. curative treatments. But um there's the. idea that they're just like, "Nope, sorry. We're just going to put you in. bed and basically let you lay there.". That's not at all what what you have to. give up in order to enter hospice. >> Yeah. And you know, the hospice workers.

are doing a a a lot of stuff for you. that goes above and beyond just making. you feel better or maybe sitting with. you and like, you know, brushing your. hair. Like there's all that stuff that. they're doing, bathing you, um. housekeeping sometimes, you know, helping out with gathering and. administering the medications. Uh but, you know, they're doing all kinds of. stuff. They might be shopping for you. They might be babysitting for your. family to give, you know, the the like.

we mentioned the people in your family. that are caring for you, like to give. them a break. Uh they may help with. fundraising. Um if you have like, you. know, money you need raised for your. treatment, they may be bring in uh music. and comedy performances to hospice. centers. Um uh people that cut hair, like volunteers that will come in and. style somebody's hair. Even I remember. they that was a big deal for Emily's. grandmother near the end is you know. that she wanted her hair done and and to. look like she looked and uh that stuff.

goes a long way to just putting people. at ease you know. >> Oh for sure. Another one um that. volunteers can do is take care of the. person's pet to make sure that if the. person is um opting for inhome hospice. that their pet doesn't have to go live. with somebody else because they can't. care for it anymore. So, you can go and. feed somebody's pet, take them for a. walk, change the litter box. Uh, and. then something as simple as just sitting. with somebody and watching TV with them. is enough. And like this is just a. volunteering opportunity in the United.

States, in the UK, basically anywhere. there's hospice, they would very much. like you to volunteer to just basically. be there. And just being a human being. who can drive a car over to somebody's. house is essentially the qualifications. >> Um, that's that's basically all you need. to do. and they'll tell you what to do. from there. But no one would expect you. to like, you know, inject the person. As. a matter of fact, you'd probably get in. big trouble if you did inject the person. with anything. You just need to be. there. And in addition to just being. there for the person, the patient, like.

you said, that gives the caregiver some. time to just go take a shower, do. something, just stop being a caregiver. for a couple of hours, too. >> Yeah. And you know, even though a lot of. them are professionals, like most of. them now, there's still quite a lot of. volunteers that that do this kind of. thing, >> um that Medicare law that I talked about. in 1982 that stipulated that um hospice. facilities have at least 5% uh of the. patient hours. >> um provided for by volunteers. So that's.

one of the reasons and also just because. there are people in the world uh you. know some people have maybe gone through. this with a family member and then they. want to give back. Some people are just. wired this way um as empaths to want to. help people. Uh and then sometimes it's. people that are preparing for a career. in health care and you know getting in a. hospice and kind of going through the. the worst of the worst um situations is. I imagine pretty good preparation on. dealing with any kind of patient.

>> Yeah. And you would prepare for a career. in that because hospicees, like you. said, they are professionally staffed. and not just with nurses, not just with. hospice doctors, but social workers, bereavement counselors, some of those. clergy um and just general aids uh who. can come together and help with that um. that thing that Sicily Saunders started. kind of seeing clearly, the total pain. where you know if you have um. psychological pain, it's going to make. your physical pain exacerbated and vice. vice versa. And the worse off you are,

the more hesitant people might be to. come visit you because they feel. hopeless or they're just freaked out or. something like that. So now you have. social pain. So if you have all these. people coming together to treat the. person's total pain, you uh have a much. calmer, happier, again good death. And. those are called in the hospice. industries interdisciplinary groups. And. they they do they form a team for each. patient to figure out what to do for. each of the patients to to help them. um. basically find peace and comfort and.

calm. >> Yeah. Uh and this is a you know it's a. booming industry now in the United. States and we'll sort of get to the the. downsides of that in a little bit. Um. but statistically uh from 2,000 hospice. centers in 2001 um to about 5,700 today. uh 20 you know 24 25 years later. Uh. it's really grown a lot. um utilization. grew by 32% between 2013 and 2022. Um.

there was a 25% increase in Medicare. beneficiaries um obviously is um the. boomer generation is aging. Um but that. doesn't account for all of it. You know. 25 compared to 32%. Um about half of. people now in the United States enroll. in a hospice before their death. Uh if. you have cancer you're far more likely. to to do so. uh as well as being female. and more educated and also older. Um.

which at first seemed like a like a of. course, but just so far as to say if. you're someone very tragically in in. your younger life that is stricken with. something like this, you're far less. likely to enroll in hospice. >> Yeah. And there's actually a lot of. reasons why people don't enroll in. hospice. A good majority of them just. don't either aren't really aware of it. or don't understand it. Um, and there's. stigmas about hospice, too. Like, there's a a whole idea that if you go. into hospice, you're giving up on. fighting for your life. You're giving up.

on living. And that's just absolutely. not true. Like, if you have a terminal. illness and it's really no longer. treatable, a good doctor will say like, "There's nothing more we can do for you. There's plenty of stuff we can do for. you, but none of it is going to extend. your life. It's going to make your last. days pretty miserable. We recommend that. you go into hospice and have like good. last days. hang out with your friends. and family like be peaceful. Um that's. actually as far as the um American. Society of Clinical Oncology is. concerned. That's a sign that you've had.

good cancer care that toward the end in. the last you know few weeks your cancer. team says you've reached the you know. incurable stage. There's nothing we can. do for you anymore except let's put you. into hospice. Um the problem is is there. are plenty of doctors out there who do. see that as quitting, do see that as. giving up and are known to um steer. people into hospice too late to where. essentially they just spend like the. last couple or few days in hospice and.

they don't have a chance to actually um. develop what again is is referred to as. a good death. >> Yeah. And they've uh they there's even. evidence that going like trying to cure. yourself and sort of ceasing that. process and starting up with hospice can. actually make people live longer. Um a. lot of reasons. Maybe you're being. monitored a little more closely. Maybe. maybe your symptoms are being managed a. little little better. Uh and just. everything that goes into the. non-physical, you know, sick and dying.

part that we've been talking about, the. emotional part and everything else. It's. like if all of that is eased, um studies. show that you can you can make it a. little bit longer. >> Yeah, that actually happened to Yumi's. dad. Um he was in hospice and given Oh. man, I remember not very Yeah, there was. just a a just a pretty raw time. Uh he. was given not much time to live at all. I think like days. Um and he didn't. didn't pass. And Yumi started to notice. he was actually kind of he was eating.

more. He was his mood was starting to. improve. and she convinced the hospice. doctor that he was not dying anymore. And one of the things that became really. clear that being in hospice at home can. do to improve your health is that you're. getting better nutrition. You're getting. good sleep. You're surrounded by people. who don't have to come see you in the. hospital setting during visiting hours. And all of those things are terribly. managed in the hospital. So at home, you. can just get better and better. And um.

he Yumi's dad eventually left hospice, was discharged alive, and went on to. live for another 3 years. >> Man, I remember all that going down and. Jerry and I, all of us being like, "Oh. man, this is like this seems like it's. it." And you were bringing reports, you. were like, "Man, the darnest thing.". Like, >> yeah. >> And then I just I think we all suspected. it was just going to happen again right. after that. And it was Yeah. It was a. few years. It was just what a what a.

story. >> Yeah. I'm I'm I'm I've never been more. proud of anybody than I am of Yumi. She. was the only one who saw like she saw it. and she had to convince everybody else, including me, that no, he's he's not. dying. And she brought him back for. sure. >> So, what a gift. >> It really was a gift. I'm Yeah, I'm very. proud of her. >> Uh all right. Shall we take another. break? >> I think we should, man. >> All right. We'll be right back and we're. going to finish up with Hospice right. after this.

Stop. You should know. [Music]. Uh, one thing we should mention kind of. briefly, we don't have to get too much. into it. Um, but hospice and, um, right.

to die and assisted dying, uh, the these. are two things that, you know, don't go. together, but they obviously kind of do. go together in a lot of ways because. you've got a, um, a group of people that. are, uh, it's the same group of people. mainly. Um, it's even, um, I think. legally designated uh, in places where. you do have the right to die. um you. have to have doctors sign off that. you're within 6 months and there is no. cure and it kind of is in lock step with.

hospice but it's not the same thing. because the you know it's it's just not. the world health organization very much. defines palative care uh as something. that neither hastens nor postpones. death. It is not the point of hospice to. go in and um you know uh find an empath. who will who will help assist you along. a little quicker. >> Uh if you live in one of those states I. think it's an amazing gift to be able to. do that and there are um there's a track. for doing that but it's not hospice.

>> No. And the reason why it riles up um. hospice people who are against that is. because there are one of the reasons. that people do choose um medically. assisted dying is to end their suffering. and hospice people are like no we know. how to end their suffering without them. having to die. >> Yeah. >> And that's why it really gets under. their skin. Although that said, there. are plenty of hospice people probably. humanists who are like it's it's. anybody's inalienable right to choose.

how or when they die. >> Yeah. >> So yeah, it is kind of a tricky thing, but it it isn't I think it is generally. unfairly associated with hospice and. even paliotative care. I don't think we. said explicitly that is to treat and. manage symptoms, pain, nausea, that kind. of stuff, symptoms that come along with. terminal illnesses. Um and that is a. part of hospice but not all pal p p p p. p p p p p p p p p p p p p p p paliative. care is hospice. You can get that same. stuff as you're pursuing like curative. treatments, right? So it's not like. they're going to be like you're getting. curative treatments for cancer. Sorry,

we can't do anything about the nausea. then. It makes it it has a place in both. of them and it has nothing to do with. assisting someone in dying. It has to do. with helping them die comfortably when. they die naturally. >> Yeah. And it, you know, you're not going. to get uh you'll get morphine and you'll. get like the good stuff. >> uh these days. Morphine Plus, but you're. not going to get the cocaine and the. liquor. >> No, I mean, unless you have a family. member who knows somebody. >> Yeah. I mean, there's somebody's got a. guy maybe. >> Yeah.

>> Uh or if you just have like a, you know, pretty uh empathic, like really empathic. like on the down low hospice worker, >> right? And I mean, even if you do score. for them, they might not even want it. Like, I tried to give Yumi's dad a bunch. of cocaine. He's like, "No, I'm good. with with the pain stuff I'm on now.". >> Yeah. And then what to do with it, you. know? >> Uh, so, >> hey, look, we found another joke. Amazing. >> So, um, >> right right before the dark side.

>> Yeah. Because there is a dark side to. this. And again, the one downside to. hospice is it puts it shifts the burden. on the caregivers. We'll talk a little. bit more about that in a second. But the. the kind of generally agreed upon dark. side of hospice is that there's such a. thing as for-profit hospices. And. contrary to our private equity um theme. in our private equity episode, we should. say that there are plenty of. for-profitos. hospices that are perfectly well-run. that they the people who the family.

members who have patients and family. dying there are totally happy. Give them. great reviews. Being for-profit as a. hospice isn't necessarily a bad thing. Where you they start to get lower marks. than other kinds of hospices, specifically nonprofit hospices, is when. they are part of a publiclyowned. corporation like a hospice went with the. IPO at some point. >> Yeah. Like a chain. >> Exactly. Or surprisingly um or not, private equity owns the hospice. And the.

reason why it's problematic is because. the way that payment is structured has a. built-in incentive for for-profit. hospices to cut corners and cut costs. >> Yeah. There was a survey in 2024 that uh. 25% of hospices in the US are owned by. private equity firms now. >> Uh so you can refer to that episode as. to exactly what goes into that. But, you. know, I said earlier to put a pin in the. uh payment structure, which is they. don't get paid uh through Medicare. Um.

they don't get paid out per treatment. given or for specific treatments given. It's just this flat fee. Uh, and. obviously if you have a a a chain, a. hospice chain that is for-profit and has. gone through the IPO process and has. shareholders to answer to, um, very. sadly, many times you're going to get. hospice centers that um that get that. flat rate, but they're cutting staff and. people are getting the bare minimum.

treatment required by law. >> Right. And I saw there's a there's a a. thing where it's supposedly federal. regulations say that you have to visit. an inhome hospice patient no less than. twice a month. >> Yeah. Just twice a month, >> right? And then a lot of for-profit. hospices um like just basically do that. minimum. And if you most people agree if. you are in some sort of crisis, you're. getting more visits. But if you're not. in a crisis, you're getting fewer visits.

because they need to balance that out to. cut costs, right? Or keep costs down. It. turns out that's a myth. The federal. government doesn't require two visits a. month at minimum. The federal government. doesn't have any requirements for how. often or how little a hospice has to. visit a patient at home. >> They have no requirements or they're not. enforcing anything. >> They don't have any requirements. And. that's another problem, too. um they. don't enforce a lot of the rules that. there are and there's already a lot of.

rules that have loopholes. So, this is a. system that is just set up for abuse. Luckily, most of the people who run. hospice companies, um they're not in it. to abuse the system. uh they're in it to. help people, but there it's there is a a. place for bad actors to um milk the. system, overcharge, like apparently. there's it's extremely complex, but. there are ways that you can charge more. than the flat rate per day. And I guess.

a study from I think 2021 in the journal. of geriatric care I think um found that. for-profit hospices tend to charge. Medicare 34% more than nonprofit. hospices. There's just a lot of stuff. you can do to game the system. >> Yeah. And you know to be clear uh. hospice in general gets good marks from. people. Um, even for-profit hospices. generally get good marks from people,

but they've drilled down and they found. the ones that get the lowest uh ratings. um for care are the ones that are. publicly traded corporations and owned. and or owned by um private equity firms. So. >> yeah, >> uh do your research, you know, if you're. getting into this because there's there. are all like we said there's 5700 of. them in the US and hopefully uh there is. one near you that will take care of you. a little bit better. Um to remain on.

hospice, there's also, you know, all. kinds of rules as far as what's called. live discharge, >> right? Um you have to demonstrate. ongoing steady decline um at uh. reertification intervals uh every 90. days for the first 6 months then every. 60 days after until death or discharge. Um and discharge is is basically exactly. what it sounds like. You're discharged. like you're discharged at a hospital. It. may be because you want to try you know. curative care again which is which is. great and you're right. Um, it could be.

because of an emergency that you have to. go to the hospital for, which will boot. you off, which really stinks. Um, but. there are guidelines about discharge and. not all of them seem fair. >> Yeah. And you can imagine if you're. dying of a terminal illness, being moved. from a hospice to uh a hospital to to. continue treatment, maybe home, where. you have a bunch of uh emergency room. visits ahead of you because your. symptoms are going to flare up. It's not. a comfortable thing to be discharged. from one place to another. Um it's also.

a huge burden on the family too because. again the care is being transferred from. medical professionals to the family. Um. but also the the whole premise of it is. just faulty because not all diseases. follow the same trajectory in the. decline of the person and yet they're. all held to the same standard which is. essentially the standard that cancer. creates a decline in a patient too. So. essentially just saying if you have a. terminal illness that's certified by.

doctors that um doctors reertify say. every 60 days, you don't have to face a. live discharge like you can stay in. hospice until you die. Your death. doesn't have to cooperate with federal. guidelines. That would be a huge change. and a really simple one to to hospice. rules, but apparently that is not that's. not happening right now. >> Yeah. And even if you know uh you aren't. moved home, let's say let's say you move. to a different facility uh because there. definitely is a problem with like you.

know not having enough beds at different. places and uh the the family gets can. get uh ideally into a routine at least. >> Mh. Um, and you know, they kind of. figure it out. And then, uh, with. Emily's grandmother, it seemed like once. we, everyone got into the routine and. everything had kind of been figured out, then all of a sudden some change would. happen where Mary would have to go. somewhere else and then all of a sudden. it's uh, new visiting hours. It's in a. different place and everyone and, you. know, that's just on the family, of. course, just like you mentioned, the.

move for the patient is really. burdensome. So, uh, there's still so. much, uh, they can do, I think, to to. clean this whole system up, you know, >> for sure. And even Chuck, if they're not. impatient, just at home, med um, hospice. basically overlays this support. structure for you, the hospice patient, in your home, right? So, you have like. medical equipment, you have um, medications that are like delivered to. you at times. If you need a walker, you. got a walker. um just all of the support.

like you've got bereavement counselors. dropping by you have a social worker. you're doing teleaalth visits with all. like all that just stops when you're. discharged from hospice alive they come. and they take the medical equipment they. take your walker away you stop getting. your medications delivered to you um you. might not even have those prescriptions. any longer after that if they were. prescribed by the hospice doctor it's a. it's a really bad jam um and the other. thing about it too that Medicare is. often taken the task for is they don't.

really pay enough for inhome hospice. Like that's the lowest um pay rating I. guess is inhome noncrisis hospice care. Um, and that means that if you are. trying to stay at home, you either have. to have a bunch of family members who. are willing to commit their lives to. taking care of you in your final days or. you have to have a bunch of money to pay. somebody to do that same thing. And if.

you don't and you want to die at home, you're so because you have nobody to. take care of you at home because there's. not enough pay to pay people in hospice. to come by and not enough volunteers to. take care of you uh take care of your. needs on a regular basis. >> You know, Grandma Mary, uh former. foremost general in the stuff you should. know army. >> had a t-shirt that says, "You can take. my walker when you pry it from my cold. dead hands.". >> That's a I would love that, dude. Oh my.

god, that would be such a great t-shirt. We got to get that one up. >> Can you imagine taking a walker from. somebody like to for that? That's your. job. Like you're the person you're like, "Yeah, go over to. >> go over to Grandma Mary's house and and. take her stuff.". >> I know. It couldn't even be the person. who also delivers it because it's such. an mean job that there has to just be. one specialist who doesn't like anybody. who just goes around to houses and takes. the medical equipment back. >> Yeah. It's Ronnie. >> Uh you got anything else? No, I have.

nothing else. Uh hopefully this serves. some people. Uh and you know, just just. look around and and do your homework and. see if you can find a place that works. for you and your family. >> Yeah. And another good piece of advice. is to do that uh sooner than later. Like. um share your wishes with your family. Maybe even go so far as to create a. living will or some sort of medical. document saying like, "I do want to go. into hospice. I want to stop curative. treatment at some point." Um, and then. yeah, do like read reviews like just. find out who you would go to if it.

starts to seem like that might be a. possibility coming down the the pike. >> Yeah. Oh man, my god. Get a living will. >> I don't care how old you are. That's. it's very easy thing to do. And it's uh. that and a will are the two biggest. gifts you can give your family as you. grow old. >> That's right. You want to impress your. parents and you're seven, start thinking. about a living will. Start talking about. a living will to your parents. and they. will just be blown away. >> Totally. That seems like something in a. like a TV show about a precocious kid. >> Yeah, for sure. Like um Alex Paton, he.

would do that. >> Yeah, exactly. Oh, you know he had one. >> Um so before we finish, I just also want. to give a huge shout out to Yumi's dad's. hospice doctor, Dr. Pari. >> Awesome. >> Who did not have any sort of ego and was. totally willing to listen to Yumi and. and helped get uh her dad out of. hospice, too. So, >> I love it. >> Shout out Dr. Pajari. And since I. shouted out Dr. Pajari, as was foretold. by the runes in 2008, I've just unlocked. listener mail.

>> Uh this is Jen Z Stair speaks back. Um, I have three emails I'm going to try and. sort of uh hit the highlights of because. we got what I felt like was three really. sort of uh legitimate answers as to what. the Gen Z stair is all about that um. that now I understand. You know, it may. not be my jam, but like it doesn't need. to be my jam because I don't have to put. my Gen X stuff onto Gen Z. >> That's true.

>> Uh, hey guys, 22 years old, Gen Z, very. much in the Gen Z stair era. Uh, I work. in customer service, which is where I. use it the most. >> But, uh, we were raised with if you have. nothing nice to say, don't say anything. at all. So, hence staring. Uh, so I. guess they took that very much. literally. >> Yeah. >> Um, it's not something just done to. adults either. And this person uh points. out that they do it for their friends. Uh, as far as the phone call, no one. calls us. When they do, it's a spam. call, which I was always told uh the. double hello people. Um, I didn't know.

that was a thing. When they answer the. phone, it cues the robot. Did you know. that? >> Yes. >> Okay. I didn't know that. Um, so I just. answer and sit in silence until the. awkward uh, is this Josie follows. Uh, and that is from Josie Boozer. Uh, this. is another one. Hey guys, Jenz person. Uh, I think the explanation you're. probably looking for is a lot of jinzy. are using it to um are used to being. interrupted, >> not taken and taken seriously or have. our responses to stories be given a.

weird look. uh the example for someone. finishes a story and the person just. standing there can either be one, I. don't have anything interesting to say. about that story and I don't want to. make something up. >> Uh two, I'm so used to having my. opinions not taken seriously that I'm. just not even going to bother. responding. Uh many of us are socially. awkward and have trouble creating small. talk with people that aren't close to. us. Another reason maybe because most of. our conversations are online and have. been online as we uh as we aged and many. people will give an emoji reaction to it.

along story uh or just get a smile and. that's cool in response. Um that is from. Sam. >> Okay. >> So it's kind of tracking along the same. lines, right? >> And then this is from Katherine uh who's. been listening for 5 years as a. 23-year-old. I've heard people blame the. pandemic, but I don't think it fully. explains the generational trend since we. all live through the same period. I. think there are two main causes. First, my generation has spent much more time. in front of a screen than any previous. generations did. We've grown used to. one-sided content consumption.

>> You would look crazy if you responded to. a YouTube video the way you would a. phone call or an in-person conversation. So, we're a little out of practice with. responding to prompts instead of just. watching something. This is all makes. total sense. >> It totally does. Uh and then secondly, Gen Z um seems to be more likely than. previous generations to forego the fake. politeness that used to be expected in. conversations. I think this is partially. because uh we're constantly inundated. with advertisements. We become highly. sensitive to fake niceness because.

someone is trying to manipulate our. emotions at every turn and sell us. something. My generation seems much more. likely to prefer genuine reactions, even. if they're negative, because uh when. we're online, that's the only way to. know something is not an ad. >> Woo! Man, this is something else, huh? >> Yeah, those were deep to from Josie, Sam, and Catherine, right? >> Yeah. And I think they all sort of track. along the same lines, and that that. explains a lot. So, um, yeah, if a Gen Z.

person is just staring at you, maybe. think maybe maybe they think you're a. real jerk and just don't want to say. anything, >> right? They assume you're manipulating. them, right? Then. >> yeah, or or the other reasons mentioned. I think they're all valid in their own. generational way. >> I feel like that really explains the. discomfort that people like say from Gen. X get when we're treated like that. because we are used to fake niceness. >> I know. you know, and like we're willing. to go along with that kind of thing just. to keep from a situation being. uncomfortable.

>> Yeah. Also though, quick tip, uh the if. you don't have anything nice to say, don't say anything at all. Uh I recently. went through an experience with a uh. tattoo artist uh getting my my a tattoo. covered up with my dogs. >> And this guy did he I appreciate it. He. did a great job, but um he let's just. say we weren't the same kind of person. He had a lot of interesting theories on. on things. Uh and here's a little tip to. my Gen Z friends. You don't have to not.

say anything. Just keep nodding and go. interesting. >> Oh yeah, >> I did that over and over and over for. hours. >> It goes a long way. >> Yeah, interesting. And sure. Well, no. I. don't even know if I am lying. It was. interesting. Yeah. Okay. >> Just not just not for me. >> Right. Exactly. Maybe the tone was a. lie. >> Maybe. So, >> the guy did do an amazing job. You said. he did it like freehand, too, right? >> Oh, yeah. I I'll put pictures up at.

Chuck the Podcaster. Um he's a sort of. amazing artistic uh dude. >> Yep. >> Just like looking at pictures of dogs. and drawing them on my arm. Not It. wasn't like stencled out on my arm. first. >> It's nuts, man. Uh, well, thanks a lot. again to Josie, Sam, and Katherine for. explaining that to us. You guys did a. knockout job, and we appreciate it. Uh, and I'm not being fake nice right now. I'm being quite legitimate and serious. and genuine.

>> If you want to get in touch with us and. tell us about your generation, we love. hearing that kind of stuff. You can send. it off to stuff at iheartradio.com. >> Stuff You Should Know is a production of. iHeart Radio. For more podcasts from. iHeart Radio, visit the iHeart Radio. app, Apple Podcasts, or wherever you. listen to your favorite shows. [Music].