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with transcript
Hospice doctors can offer a unique insight
into what it's like right before you die.
For healthcare professionals who
work in the field of palliative and hospice care,
providing support for terminally ill patients can
give a rare insight into questions many of us face
when contemplating life and our own mortality.
Now, in an exclusive interview with Health
Digest, Dr. Simran Malhotra — a triple board
certified physician in internal medicine, hospice
and palliative care doctor, and lifestyle medicine
coach — shares firsthand how her patients have
influenced the way she leads her own life in hopes
it will inspire others to do the same.
Dr. Malhotra details why she became
so passionate about this line of work:
"I remember one of my very first rotations
during my internal medicine residency was in the
ICU and I just felt so much for the patients and
their families because I felt like they didn't get
enough time and attention from the medical team.”
“And so for me, when I did my first palliative
care rotation, I got to sit down with a family,
I got to understand what their goals were,
what their hopes were, what their worries were,
and it really allowed me to get in with them
in their experience and try to provide the most
personalized and compassionate care possible."
When it comes to regrets, Dr.
Malhotra asks patients about what
holds personal meaning in their lives.
"I have thousands of patient stories
from my experience, and if you ask someone else
that does what I do, we could probably narrow
it down to three common themes or three
common regrets that most people have."
One of the three common regrets most
frequently voiced by patients was not
spending more time with loved ones, including
years lost due to a trivial disagreement.
"I've had so many patients share that specific
regret of like, I wish I didn't lose 10 years of
talking to my daughter or my son over whatever
the issue was, that's a very common one."
Another common regret was working too
much. She points out that in the U.S.,
success is so often linked to productivity that it
drives us to dedicate much of our time to work.
"When you're working all the time, that means
you're missing out on that time with your
loved ones or your family and yourself."
Lastly, she has found that patients' third
most common regret was a lack of courage
to pursue their passions and desires.
"...we don't want to let people down, especially
when it comes to our parents. And there's a lot of
cultural things that tie into this and everything,
but that is probably one of the biggest ones,
like I wish I had done X, Y, or Z for myself."
She goes on to explain that while her patients can
have such unique personal stories, the regrets,
in the end, wind up being much the same.
"In my several years of practice now,
if my patients are able to talk to me,
there's two things that I always ask them in
my encounters and that is, what brings you joy,
and then what's most important to you? And from
these questions, everyone shares their answers
but then eventually it leads to this conversation
about the things they wish they had done."
Dr. Malhotra says there is a lot we can
learn from patients' lived experiences,
including taking better care
of ourselves while we’re alive.
One thing she frequently hears patients talk
about is the lack of care they had for themselves,
which is becoming a more common
problem in the modern era.
"People are getting sicker at a younger age. And
so before when we used to think about end of life,
we were thinking about our 70s and
80s and 90s, but now it's not uncommon
for us to be seen and caring for people
much younger at the end of life.”
Although fear, anxiety, and sadness are among
the most common emotions Dr. Malhotra sees
patients experience before they pass,
she says hope is the most predominant.
Many communicate their fear of the unknown,
concerns about their families, anxiety about
potential pain they may experience, and sadness
around leaving the world and their loved ones
behind. But many others feel a sense of peace.
"I've kind of witnessed over and over again that
there's this dance between what people hope
for desperately and what they fear the most,
so it's like this dance between life and death."
Fear of the unknown may also be a very challenging
emotion for most — particularly
if they don’t practice religion.
"When you get into religious
and spiritual beliefs, there are
thoughts about what is coming, but for many
people, if they're not religious, they don't
know, and so there's a lot of uncertainty
of dying and not knowing what's coming."
Someone’s age and life stage can also play a
role in how much anxiety they experience.
"There's a lot of anxiety specifically for our
younger patients who might have young families,
young children. There's a lot of anxiety around
what's going to happen to my children if I'm gone,
who's going to raise my children?”
Being a palliative care doctor has
given Dr. Malhotra a rare opportunity
to see both courage and vulnerability
in her patients and their families.
“All of these really difficult emotions that most
of us I think have been taught by society to keep
in, right? When they don't share them openly but
near the last several hours to days to weeks to
months of life these are things that you see in
the hospital setting, or in the hospice setting.”
“Most people share that they want to be home,
they want to be without pain, and they
want to be with the people that they love,
they want that certainty.”
While our material possessions may be very
important to us in the present, Dr.
Malhotra shares that it's not often
what patients feel most proud of at the end of
their lives. However, items that hold personal
significance might begin to take on new meaning
as death approaches, such as written letters.
Dr. Malhotra promotes the idea of "legacy
work," or finding ways to leave parts of
ourselves behind for our loved ones
— especially for younger patients.
"...write out birthday cards for their kids
until the age of 10 or 15 or record videos,
especially nowadays with iPhones and tablets, it's
very easy to keep those things for a long time,
or create ways to feel like they're,
one, in control of being able to share
the things that are most meaningful to them.
And number two, that they won't be forgotten,
that they're leaving behind something if
they don't have the time to live that life."
Dr. Malhotra tells us patients often take
the most pride in personal relationships,
milestones, or accomplishments
towards the end of their lives.
"It's always about their relationships or
about how they're so proud of their children
or their great-grandchildren or the things that
they're doing with their life and their education
and the things that they've accomplished."
When taking stock of what we're most proud of,
Dr. Malhotra suggests posing a series
of guiding questions to ourselves,
known as the rocking chair test.
"When I'm 90 years old and I'm sitting
in that rocking chair looking back on my
life, what would I have wanted to accomplish
and what would I be most proud of?"
Dr. Malhotra states that the rocking
chair test can help bring clarity when we're
feeling conflicted in our day-to-day lives as
to what ultimately matters most.
As a patient nears death, Dr. Malhotra
says that their final words often
vary based on a sense of fulfillment.
"I found that my elderly patients will often
share things like, I'm at peace or I've lived
a good life. Whereas, for my younger patients,
they never, at least from what I can remember,
I haven't really had any patients that have
shared openly any specific words. It really
comes down to like, I'm not ready to die,
I have so much more living to do."
Dr. Malhotra also suggests that
while each person may wish to share what’s
uniquely individual to them, there are common
expressions when the end is near.
"When we're talking about the last
hours to days, I think one thing that I make
certain to share with my patients and families
is to share the very simple things I think
that matter most, right? Like I love you,
please forgive me. I forgive
you. Thank you. I'm sorry.
And oftentimes, when I'm telling this to a patient
or family, you can just see tears streaming down
because these are some of the most meaningful
when said with intention, words that we can
share with someone that we love."
It's not just the words of our dying loved ones
that are important and meaningful. In fact,
the words we say to those who are departing
are just as important. Amid grief, it can be
so challenging to find exactly the right words.
"Oftentimes when you're at that point, sometimes
you just don't know what to say. You're at loss
of words, right? And you just kind of, a lot of
times people are thinking ‘I wish this wasn't
happening’ instead of thinking about the things
that they do want to say with their loved ones."
Dr. Malhotra explains it’s important to understand
that just because a patient isn’t alert
doesn’t mean they can’t hear. She recommends,
"Share the things that you want them to know
because hearing is often the last sense to go."
The same holds true in reverse as well, she
says. You wouldn’t want to say anything you
wouldn't want them to know or hear.
As a palliative doctor, she’s found
deep connections and community,
particularly when it comes
to her own health risks.
"I've cared for a lot of women at
the end of life, a lot of young women
who have had the same genetic mutation as
I do. I carry the BRCA1 genetic mutation.
For those that are not familiar with
it, it's the Angelina Jolie mutation.
And it radically increases your lifetime
risk of breast and ovarian cancer."
Some of her patients shared impactful words with
her on their deathbeds. One patient told her,
“This doesn’t have to be you,” which
changed the entire trajectory of her life.
It empowered her to take the extra initiative
to care for herself and get the answers she
wasn’t getting from her medical team.
In addition to living a healthy life,
Dr. Malhotra’s patients have inspired her
to live her life with intentionality.
"Since the pandemic I've been doing so
much inner work, I've been trying to
figure out what's most important to me, I've
really, really started focusing on forgiveness
and mending my relationships that
were not where I wanted them to be."
When it comes to living fully, she
encourages individuals to share their
stories and to find strength in a community
of people that inspires and uplifts them.
"I know that every day I wake up, it's a gift, and
every day I wake up, I can create the life that
I want to create. And if you ever feel like you
can't just know that this life that we're given
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