Managing Ageing, Death, and Medical Ethics || Insights from Dr. Cajetan Skowronski

Foreign.

Hello, everybody, and welcome to the RealLife Real Kitchen podcast, which is for curious mums who are interested in family, food and community.

Now, normally we are looking at things to do with children or the health of children or feeding children.

Children tend to be a bit of a theme, but this week I've gone a little bit off piste and we are going to be talking to Dr. Kai Tech School Vronsky, who is a hospital doctor who specializes in geriatric medicine, strokes and palliative care.

Kaitech's also a father of four, but the reason I want to have this conversation is because I know that increasingly there are elderly parents, grandparents who need looking after, and you're starting to get kind of a generation of women and mums who are in some ways squeezed between looking after the cares of the elderly as well as their younger children.

So I thought it'd be really helpful to have Kai Tech to come on and we can talk a little bit about, yeah, the care of the elderly, health concerns and what we as mums and parents are able to do to support our own parents.

So, Kai Tech, thank you very much and welcome to the Real Life Real Kitchen podcast.

Thank you for having me.

Thank you for Kaitech.

You became a doctor, you could have done anything.

You could have been into bones, you could have been into appendixes and anything.

Why did you choose?

What was it about geriatric care when you were doing your rounds that drew you in?

I think it's one of the few specialties where you have to deal with the whole person, not just the whole person, but also often the whole family as well, within the hospital setting.

So general practitioners have to deal with the whole person, but they've got very limited amounts of time with each person.

They're very stretched and it's very difficult to even get an appointment, often with a gp.

Within hospital medicine, there are lots of specialties that are organ specific.

So you have cardiology for the heart, renal medicine for the kidneys, and they're really experts at looking after those organs.

But the tendency is to see the patient as a heart or see the patient as a kidney that needs fixing, which is absolutely necessary when there's something wrong with one of those organs.

Um, but as patients get older and they accumulate a lot of different diseases and which affect many systems as well as single organs, they start.

You start to need to be able to put it all together as a sort of a big picture.

So that's one of the things that's fulfilling about geriatric medicine, is you have to you have to take a step back and look at the whole person rather than just one of their organs.

And you have to be able to see what's important to that person and what's important to them, their family, and make decisions around their care with them by getting to know them.

And in other specialties, the getting to know the person side of things, uh, doesn't happen so much.

And it can happen and obviously all doctors should do it, but it's almost an unrealistic demand to make of somebody that needs to, you know, unclog your coronary arteries or to restore your renal function or something like that for them to, to really get you, get to know you as a person.

Um, so I like that.

I also just like old people in general.

I think you can learn a lot from them.

Another one of my passions is history.

So it's always interesting to hear their life stories and hear what they did when they were younger.

And it's, you know, it's like connecting with a different world really.

So it's, it's just very pleasant from that point of view.

But I feel like the, the model of medicine and geriatric medicine is very appealing to me because it's about, it's about making decisions, also about when not to treat as well, which, you know, is different for different people.

But we do have a tendency in modern medicine sometimes to over treat and then we can, you know, so one of my consultants has said that she probably spends about a third of her time protecting her patients from other doctors.

Is that because.

So my, my sense very much on the outside, not medically trained, any of this, but my kind of sense on the outside is that with modern medicine, I'm thinking about, for example, your heart and your kidneys.

That is something that can be fixed.

And there is this sort of sense that things need to be fixed and repaired rather than necessarily do, you know what, we can let these things go.

Is that kind of a fair comment?

Yeah, I mean, we're very good at fixing some things.

So like if you take hearts, for example, you know, having a heart attack, having a blocked coronary artery used to be either fatal or it would, it would cause so much damage to the heart that you'd be quite severely disabled for the remaining months or years of your life before you then died.

Our interventions now can unblock those pipes around the heart and let the heart keep functioning at a good level for many, many years.

And so of course, we should be doing those things.

You know, otherwise you could have a man in his 50s could drop dead and miss out on perhaps 20, 30 years of relatively healthy life.

So there are just some things that we've got very good at doing.

But then further downstream from those interventions and the medications that people end up being on, there's unforeseen consequences which then need to be thought about as well.

So I guess it's just about making thoughtful decisions about what's worth doing, what's not worth doing.

So I mean, you get patients who might have a heart attack in their 90s, they would very rarely have the intervention to unblock the coronary artery.

Some would if they've been, if they're physiologically a lot younger, if they've been, you know, independently mobile, able to walk a couple of miles a day, things like that.

But others, in the context of whatever other diseases they have, you might say, well, let's just manage this with medication, not do a invasive procedure and see what happens.

Because I'm presuming that the invasive procedure when you've already got a lot of comorbidities and they're already quite weak is going to be potentially more catastrophic than the medication and that sort of thing.

So that's the kind of trade offs we're trying to work out.

In a 60 year old, it's a no brainer.

In a 90 year old you have to think carefully about whether you're going to do those things.

There's more nuance.

The way you were describing at the beginning the kind of the appeal of geriatric medicine, that it's, I'm going to use the word holistic, but it involves family, it involves story.

Actually a lot of the time is that going to, I sort of feel that's going to attract a different sort of temperament of.

Dr.

Yes.

Yeah, yeah.

Somebody who is going to enjoy the conversations and having that bigger picture.

Bigger picture.

There are some doctors who, who can't stand anything less than having a conversation with the patient.

Yes.

So, yeah, and they might be brilliant.

You know, they might be brilliant, brilliant doctors who can, you know, when they've seen the test results, seen the scans, they know what to do.

But the actual process of having a conversation for them is very difficult and leads to misunderstandings and all sorts of problems.

So they try and avoid it or minimize it as much as possible.

But the strange thing is that from the inside, I know specialists who are say single organ specialists like cardiologists or liver specialists who are absolutely brilliant and recognized within their field as, as the best in their field.

And I would want them to be treating My family, if they had those problems.

But the patient's experience of them and the patient's family's experience of them subjectively is, oh, what a nasty person.

And it's quite, you know, it's taken me a while to realize that part of the specialty of geriatric medicine is being able to communicate with people.

And it turns out that a lot of doctors aren't able to communicate with people.

They're able to do amazing things, miraculous things, but they aren't necessarily able to explain them and explain the thinking behind what they're doing to the patients.

And actually, most people really need to have a sense of understanding of what's going on in order to be, in order to be happy.

And there's this weird disconnect between doing very impressive stuff but not being able to talk to someone.

Because also if people aren't, if people feel kind of excluded, intentionally or not, they feel excluded.

They don't feel they have control, they don't understand what's going on.

That's going to mean more fear, more anxiety.

That's not going to be helping improving the health, you know, when you're trying to heal and things that, that's not, that's not great.

I mean, it almost sounds like, actually it reminds me in academia some of the, some of the most brilliant scholars in kind of, I don't know, 16th century Venetian art, fabulous, you know, amazing books, terrible teachers, absolutely terrible teachers.

But it almost sounds like these, these sorts of individuals need a team around them.

Like people who do have that gift of being able to go between the intellectual abstract of these individuals who can heal an organ, but you need somebody in the middle who can do the soft and fluffy and really explain and bring that, because that would be, I mean, I've had experiences with some doctors in the past which have been similar to what you've described.

And that would be quite a huge benefit to both sides, actually.

Benefit.

I think some, some places have realized this.

Like in oncology, they're very good at having specialist nurses, like Macmillan nurses and people like that who kind of give the patient the big picture and kind of break things down for them.

So the oncologists will make their decisions.

The multidisciplinary team with the surgeons and whoever else is involved will make their decisions.

But then it would be the, the patient, as an adjective patient, a specialist nurse who will go through things, answer questions, and that works really well.

Yeah, we also work with our colleagues as geriatricians, we work with our colleagues in those single organ, specialties or in those other specialties, to give.

Sometimes we'll be asked to have a consultation with a family where there's been some sort of breakdown in communication to try and put everything together.

And we do things like ONCO Geriatrics and surgical liaison.

So the surgeons often like us coming and doing the talking side of things, but also helping them to make a decision as to whether a patient would benefit from surgery or not or which kind of intervention.

So we kind of work together to figure that out.

Yeah, no, that's, that's, that also sounds very important to have that collaboration, actually, because then.

Yeah, you as doctors are learning from each other.

It's supporting.

Yeah, of course.

Yeah.

And that's, that's one of the wonderful things about the job is, is I can learn so much from my other colleagues.

You know, I can learn from the surgeons about procedures I didn't even know, you know, were possible.

And then I can put, then I can put that into the context of, well, what's the patient's overall health like and what are the, you know, other.

Their frailty status, how does it fit in with that?

And what would be the best thing for them?

But also then ultimately getting to know what the patient's priorities are as well, and then putting it all together.

So it's, it's, it's great because you're always, you're always learning new things at work, and that's great fun from that side.

Now, just thinking, if you are, you know, you are an advocate for your elderly parent and you are coming up against this seemingly nasty kidney specialist or whatever it is, what would you.

And I'd say, I'd say.

I would say seemingly in a lot of these.

I'm going.

Seemingly.

Yeah, yeah.

Because I know that they.

Yes.

This is all everybody wants to make everyone better.

That's what the aim is.

We all want healing.

But when you have that kind of clash of communication, what is it that.

I suppose Jo Blog's public, but if you're an advocate for your elderly parent or an elderly relative, what can you do to kind of say, this isn't working?

What can you do to, I suppose, empower yourself and really get the treatment that your relative needs?

I mean, you, you have to, you always have the right, if things aren't clear, you have the right to request a meeting specifically to clarify things.

And people do that a lot in hospital because, I mean, the way things.

A lot of the times, it's nobody's fault.

It's just the way the system works.

The ward Round happens, you know, 8:00am, 9:00am, when the relatives often aren't there and the patient's feeling unwell, they're not taking in all the information they're given in the 10 minutes that the consultant is seeing them.

So from the medical team's point of view, the plan has been given to the patient, but the patient didn't necessarily take it in.

Then later on, the family comes in and says, well, you know, dad, Mum, what's the plan, dad?

And Mum doesn't really know what the plan is.

And then the family wants to get hold of someone to hear the plan again.

And, you know, the medical team is busy doing procedures or whatever it is.

Eventually a junior member of the team, who wasn't necessarily there, comes and tries to fill in from the notes what the plan is.

There's a degree of Chinese whispers that goes on, and so they give a slightly different plan from the morning.

So it all becomes a bit confusing.

We try to do things a bit as much as possible to, you know, do things better.

Say if it's not clear that the patient's necessarily taking information in, we'll make sure we give a phone call to a member of the family to try and summarize things.

But there's often gaps where, you know, you phone the family up and they're not able to pick up because they're at work or something.

But then you're moving on with your jobs and you can't be chasing them all day.

And so people miss each other.

But then that leads to a sense of, oh, we've not been talked to, not been explained things.

So.

So it's helpful then, when there is that frustration, to say, look, can we just meet with a member of the team who knows what's going on and when that's possible.

That can happen.

This is within hospital medicine.

In clinics, it's always useful to have a couple of one or two members of family with the patient.

So there's so much nicer for me when I have a clinic, when the patient walks in with their spouse and their son or daughter, because then I know, okay, that between them they're going to get quite a lot of information.

They will get a letter after the clinic that will summarize everything.

But it's really nice then.

And I encourage people to take notes throughout and go over any questions they have at the time when someone comes in on their own.

Sometimes people come in from care homes on their own and they come with a carer, a paid carer, and the paid carer might not necessarily know the patient very well and also might not be able to take in all the information they're given or might not feel a sense of responsibility for taking information they're given.

But the family who might live far away thinks, well, the carers will take all the information on and it doesn't happen.

So, I mean, yeah, it's always good to talk and I think you can always request that if you can be present, be present when the information is being delivered in the first place and if not, then request a meeting.

I mean, again, from the outside looking in, I'm just listening to this and going, why aren't we recording this on something like alter AI?

And then you have a transcription and a summary.

Just do that automatically.

Yeah, so that's coming.

Yeah, yeah.

I mean, because that would be huge.

Because then you've got the.

That's also covering the backs of the medical professionals and saying, well, we've had this conversation, here's the information, the carers then have it, the family members have it, can listen to it several times, can read the transcription, can read the summary.

I mean that would, that would just as you were describing the process, I was like, oh my goodness.

Yeah, yeah, yeah.

There's so many holes, so many holes.

So, so that, that will come and I think within, maybe within five years that will be the norm.

But you know, everyone's always resistant to changes like that.

Everyone gets worried by things like that.

Okay.

So I mean, ultimately I agree it would be a good thing and I think it would actually.

It would also make our lives much easier.

Yeah.

The amount of time it takes to write clinic letters, you know, we have to dictate the whole letter.

We have to then have it sent to secretaries to be written up and they proofread it.

Then we proofread it again and then it's sent out.

So patients don't normally get a letter from a clinic for about two weeks.

Oh my goodness.

If thinners burning, the washing's multiplying and someone's crying, it could even be you.

If your evenings feel like survival mode, the command, the chaos mum Life management planner is your first gentle step back to calm.

It's a printable 80 page guide and planner to help you reset your routines and breathe again without needing to become someone else entirely.

Start your reset today.

The links in the show notes with.

AI summarizing the consultation.

I could proofread that letter immediately after the clinic and say, yep, that's happened.

Or maybe just change that detail.

That didn't quite happen that way.

And that's what I said.

And this is what the plan is.

And then you could send out the letter the next day.

And so it would actually make.

But you could also have a transcription attached, you know, and you could also have a recording.

It could be a whole sort of little package.

And then they just screenshot the.

What's it called, the QR code.

If they needed that, I mean.

Yeah, would.

Golly.

Golly.

Oh, okay.

For the American listeners, I have no idea what happens over in America because you have got your private.

Private sector, but this is National Health Service over here.

So things do not move.

They don't move at speed, do they?

It will be very slow.

It'll be very slow to, To.

We're very slow to adopt that kind of thing.

But it would be good overall.

Yeah, yeah, yeah.

I mean, I'm immediately thinking that I just, I would suggest.

And your thoughts on this, but if you are going with an elderly relative is that you automatically record it just so you can come back later.

Because if you're being given information, for example, there is a terminal cancer or medication choices you need to make.

That's a lot of information to take in when people are already quite worried.

You know, you've been waiting a long time for an appointment to have that recorded.

And then at your own personal transcription would be.

Would be helpful.

I don't know.

That's my, my thought on that.

Some, Some doctors are more comfortable with that than others, I think, I think, I think it's.

It's one of those things where some doctors see it as a threat in a way, because there is the more kind of litiginous side of medicine as well, you know, be of complaints and being sued and things like that.

Some doctors feel like it would, it would prevent them from speaking freely with patients because they'd feel like every sentence they say is something that they would then have to be answerable for at some later stage.

And it's.

And I understand that.

That fear even in, Even in the most mundane way of, you know, say, joking.

You know, we like to build rapport with each other.

We like.

We're human beings.

We like to have a human relationship with our patients.

You know, 99 patients you make a joke with, they'll get it and they'll enjoy it and it will build rapport.

One patient out of those hundred will say, oh, I didn't like that joke.

And if it's recorded in a transcript, and then it's.

I think that's what, that's one of the reasons People will be cautious about.

About wanting everything recorded.

In the same way that, you know, outside of medicine, for young people, the fact that their whole lives are recorded and there's this sense of they could be canceled at any time by.

By anything they.

They've said that might have been perfectly fine in one context, but then isn't in another.

I think it just makes people a little bit more tense.

And you could argue, well, overall, it's better if doctors feel more tense.

You know, I don't know.

I don't know.

It's a bit of a new world.

Yeah, it is.

It is.

Okay, I'm gonna.

I'm gonna let that one lie, and I'm going to mull on it myself, I think.

Yeah, it's a tricky, tricky one.

Okay, next question.

What is actually happening to the body when you get old?

The body and the mind, what's going.

On in terms of aging?

Why do we age?

Yeah.

Oh, that's a big.

That's a big question.

You could summarize.

It's accumulated stresses.

And I don't mean in the psychological sense, in the sense of physically, every cell in the body becomes stressed.

The DNA itself becomes stressed, and its ability to reproduce itself reliably becomes reduced.

So you end up having more and more errors with subsequent replacements of old cells.

With new cells, the rate at which we can replace those old cells reduces.

So that's a kind of.

On a.

On a.

On a cellular level, and there's damage.

That's.

That stress is coming from all sorts of sources.

You know, some are modifiable.

You know.

You know, there are some lifestyle elements that we can.

We can modify.

So things like exposure to smoking, radiation, other toxins, they're kind of very obvious, like high alcohol intake, things like that.

But an awful lot of them, you know, doesn't matter what period of time you're living in, what toxins are out there, you're still going to be accumulating those stresses, and you're still.

We've still got a limited lifespan, and our DNA will still inevitably be breaking down.

So.

But then on the kind of the slightly bigger level, a lot of age, a lot of aging is down to vascular aging.

So our ability to provide our tissues with a good blood, a good healthy blood supply with oxygen reduces over time as those smaller and solar blood vessels get blocked up with calcium or cholesterol or.

Or what else?

Whatever else.

And diabetes is a big kind of contributor to that as well.

So, I mean, yeah, you can.

You can look at it inside.

You can look at It.

You can look at aging in lots and lots of different ways, but.

Yeah, the way, the way that I kind of.

I almost don't think about it weirdly, because I see it's an inevitability.

With some people, it's accelerated by lifestyle or just illnesses that they're unlucky enough to have, but it's still happening to everybody.

And that's, you know, I do meet some people in their 90s who are remarkably fit for someone in their 90s, but they're still old, so.

And it's always a pleasure to see them.

Yeah, yeah, but they're still old.

And so they still have to deal with it, and they still have to deal with the fact that they will die.

It's.

It's the universal birth, death and taxes.

That's.

Yes.

Isn't that.

Yeah.

When this is going to sound macabre.

But, but what does death actually look like?

What is happening to the body when things start shutting down?

What does.

Yeah, what does, what does that look like?

Because obviously we're living in a time where things are very kind of cut off.

You people will go into hospital, they die and then it's sort of finished.

Then they end up at the funeral home and then they're in, you know, then the funeral happens.

Whereas in the past you would have had your wakes, your open coffins, there would have been much more attending to the dying relative at home and things like that.

So in modernity, we've been very kind of cut off from the physical realities of death.

What does that look like?

Yeah, it's a good point that you're making, because people, people don't see death, whereas they used to see it a lot.

So it wasn't as alien as it has become.

People are very, very, very afraid of death, not just for themselves, but of sort of being around it, being near it.

And people don't like to.

Even when people's language around death and dying is, is very evasive, they don't like using the word, they prefer to use euphemisms.

And that is a modern phenomenon because as you say, most people used to die at home.

Now it's always hovering around 50, 60% people dying in hospital or in another institution as well.

So you do have people dying in the home, but it depends how you define the home.

But it's less than 50% of people dying in their home in the way we think of it as their house or their flat where they lived.

Because a lot of people will be dying in a care home or a Nursing home.

The actual kind of physical process of dying for most people, particularly older people, but for most people is quite a peaceful, gradual process.

We do, depending on what you're dying from.

But with palliative care for those people who do have disturb.

Any kind of disturbing symptoms, we can control those pretty well.

The kind of general process of dying is quite.

You kind of.

For the.

The average death is only quite gradual.

You see it in the kind of days and weeks leading up to it of people sleeping a lot more, being awake for a lot less of the day, moving a lot less, being, you know, so they start with getting out of their bed less and then not getting out of their bed at all, then eating a lot less, drinking a lot less.

And then you start to see changes in, in breathing where breathing becomes shallower, secretions can sometimes build up.

So you.

Sometimes people talk about the death rattle, but it's normally, it's normally just a very small amount of fluid just at the, at the top of the airway.

That's just like.

It becomes like a film, you can hear it as a rattle, but it's not really normally disturbing the patient.

And the brain starts shutting down in terms of the higher centres until you've only got the centres controlling breathing that are still functioning.

And then you start to get more erratic breathing and then often the breathing becomes more and more erratic, more and more pauses until you have a last breath and then you don't breathe anymore.

Very soon after that, the heart would stop beating.

So that's kind of an average death, normal death, yeah.

Most people.

What most people would go through.

Yeah, yeah.

I had a wonderful story years ago.

It was a lady I knew in Croatia and she talked about her grandfather.

He'd had, I don't know, like 10 children or something and they were all, most of them, scattered around the world.

And at one point, imagine a Monday morning, he says to his wife, and he's in his 80s, he says, right, this is it, I'm going to bed.

Call the children, call the grandchildren.

And he went to bed and he just was sitting there quietly and as you say, there was like this gentle shutting down.

No, no more water, didn't want any food, Nothing, nothing, nothing.

And he died a week later.

But it was enough time for all the family to make it to say goodbyes to him.

But it was a really.

I found it such a powerful story because he had a real sense of, ah, this is my time, this is my time.

Do you, I mean, do you find that amongst patients that they have a sense of this, you know, it's happening now, or are there people who fight it?

A lot of everyone's different, but a lot of patients, some, some will even say, I think I'm dying.

And if a patient says that to you, if they say, I think I'm dying, almost always they're right, you know, you know, unless they're being a drama Queen and they're 25 years old and they're, they're fine.

But, but, but, you know, people, people have a sense and where that comes from, it's hard to say.

But then others don't necessarily use those words.

They honestly say, I think I'm dying, but they behave very much as if that's what they're thinking.

And a lot of people.

It's actually quite remarkable to me how, how many people are very accepting of it.

Like you do have some people for whom it's, it's, I mean, obviously for younger people, it's, it's a, it can be a absolute shock and tragedy depending on what their, the, what the build up, what the months leading up to it have been.

If it's come out of nowhere, then it's, then it's absolutely devastating, for sure.

Um, but, but we're talking about older people, you know, people once they're in their 80s, 90s, and it's normally the family who's much more upset than they are about the fact that they're dying.

And often it comes from the fact that they've seen people die.

A lot of like we, we are as social beings, we're very much conditioned by, well, what do I, what have our peers done?

And if a lot of your peers have died, it doesn't become as scary.

Yeah.

Whereas if, you know, very few of my peers have died.

So if I were to find out I were dying, I would be really scared and shocked.

And I have a great sense of unfairness about it, which they don't have.

It's not unfair.

They've probably been.

A lot of people in their retirement are attending a lot of funerals, so they've got time to get used to the idea.

Yeah.

Yep.

That time is passing.

You do get the occasional very.

You do get the occasional kind of odd case of like a 95 year old who's shocked when you tell them they're dying and is in an absolute state of denial.

Yeah.

And it is fascinating to see that.

That.

And they, they.

Yeah, they.

And they.

And they have, have made no preparations whatsoever.

That's, that's often a.

And I, I think that that type of person may be they're not making preparations.

Is, is, is a form of denial of their own mortality, you know, like, or a sense of if I start making preparations on wills and all these sorts of things, then it means I, I'm admitting I'm going to die.

Well, yeah, yeah, yeah.

Death, death, birth and taxes, that, that's it, it will happen.

I mean, considering what you've just described, with the majority of deaths being this sort of, this kind of shutting down.

I mean, here in the uk there's been much discussion about the assisted suicide, assisted dying bill that's been pushed through.

And I know that you, you have places like Canada, you've got the maid scheme, Oregon, the Netherlands, Belgium, various countries around the world that have this assisted dying sister suicide.

For older people who say I'm done or terminal, terminal illness going to play a bit, I suppose, a bit devil's advocate.

Why, why can't someone just say, do you know what I'm done before I reach that decline?

I just want to, I want to stop.

Why shouldn' people have access to that?

You can answer in a couple of different ways, but in terms of the principle of is killing yourself so different people have different attitudes to, to whether killing yourself is a good thing or a bad thing.

But most of us think that killing yourself is in most contexts a bad thing.

And that's why we have suicide prevention.

We don't necessarily know with suicide.

We've moved away from it being necessarily a blame that the person we used to have, it used to be criminalized that the person was to be blamed for being suicidal.

And we've moved towards a more of a medical model of it's almost invariably a.

Caused by some, some mental illness or some just very, very deep unhappiness.

And therefore the person who's trying to kill themselves isn't in the right state of mind.

And that's the model that we've been approaching suicide with for the last 50 years.

And it's very effective in suicide prevention because we as a society are agree that suicide is a bad thing, is a tragedy, and it's something we need to identify people at risk of suicide and support them so that they are less likely to commit suicide.

So then if you introduce into that mix saying, well, most suicides are bad, but some suicides could actually be great, it then becomes very difficult to draw the line of where, where that is.

So you then end up undermining potentially the, you know, suicide prevention for, for those other people, if you start involving medicine in it as well, and start involving doctors, which most countries have opted for.

Which is, which is a, which is a, an interesting decision because it, it doesn't have to be like that way.

So if you start saying, well, people should be able to kill themselves if they're in a certain state, like they, they're terminally ill or something like that, or, or they're suffering in some way.

It's curious as to why doctors and, and the healthcare should be involved.

Why, why are we saying this is a medical issue?

And it's curious as to why we go with giving toxic doses of medications in order to achieve that goal.

Because there are much faster ways of dying than chemical.

And I think that the reason that countries do that is because it's, it's a way of hiding it, really hiding what we're doing.

Because we are executing people.

At the end of the day, if we're poisoning them with high doses of anesthetics that cause them to be paralyzed and go into respiratory arrest and essentially suffocate to death, it looks peaceful if you do that.

It doesn't look peaceful if you hang someone or, or chop their head off.

But it is actually faster to hang someone or chop their head off in terms of.

From that person's point of view, they will die faster.

But the medical model makes it look to an observer like a peaceful process, because once someone's been paralyzed by paralytics, you can't tell if they're suffering or unhappy or anything before they then suffocate to death.

Yeah, it also sounds, I mean, it's going against everything that as a doctor, you've trained for.

Yes, yeah, yeah.

So it does then undermine.

And you go back as far as Hippocrates.

Hippocrates is very clear that in an age when suicide and a society where suicide was common and not necessarily always seen as a bad thing, Hippocrates made the point that doctors should never be involved in giving people poisons.

Even if the patient wants it, they should have, because it will undermine the entire profession and it will undermine, undermine other patients.

Trust in those doctors.

If you go to, if you go to a doctor who's poisoned 500 patients, you might not trust them as much as a doctor who hasn't.

And that was the kind of the logic there.

So medicine has always been very, very strongly against this.

And it's only in the last 30 or so years in those countries you named where they've decided to redefine the scope of medicine to include poisoning people.

I mean, you had quite a Bit of it in the, in Nazi Germany as well.

But they weren't remembered as great doctors.

No.

And I think there's also really worrying implications.

If you've got somebody who, an older person who feels like a burden, there are family members who possibly might not want the best for them, care workers who might not want the best for them.

That's quite.

There are some vulnerable people who could really be pushed into this, which is deeply, deeply troubling.

So these are the practical consequences.

And so if you kind of ignore the principal side of things and we say, okay, let's put to one side, whether or not killing oneself or being killed by a doctor is a good or a bad thing or can be a good or a bad thing that, you know, there are people who really want assisted suicide or euthanasia for themselves.

And they're often people who have been very much in control for a lot of their life.

Often what you know, you might call privileged.

You know, they've have the good education, the good careers, high power type people and you'll often see that they're the ones campaigning.

It's often celebrities who campaign for it.

And in their case it might be something that makes them perfectly happy and they're perfectly at peace with.

But in order to legalize it for the whole society, you have to make it available to everybody.

So you haven't a lot of people in society who have, don't have much agency who will then be offered these things.

And they'll be offered these things in less than perfect contexts where they haven't necessarily got access to housing or palliative care if they're terminally ill. Because even in this country which has the best palliative care in the world, it's one of the few things in healthcare where we're seen as global leaders.

We're still about 20% of people die without access to palliative care because it's not easily available.

And I was also going to say, coming back to the earlier point of our conversation where there is this sometimes this miscommunication between the medical professionals and the patients and whether we should be recording those appointments and then to throw into the mix this possibility, that's a very, very dangerous situation.

I also want to come back to the kind of the stereotype of the person who would be pushing for this or advocating for this.

I wonder how many of them have actually been vulnerable, unhealthy or have had, I don't know, maybe, maybe I'm being judgmental.

But having had, I mean, sometimes the argument Is, well, I've had a family member who really suffered.

What is your response to that one?

Well, I think it does go back a little bit to what we were saying before about just people's general exposure to death and dying.

Generally, the people who are pushing most strongly for assisted suicide or euthanasia are people who have had the least contact with death and the least contact with their own disability or disability of someone, but very close to them.

So in all kind of studies of, say, even of doctors who, who's most strongly in favor of it, it's always doctors who are the furthest removed from dying patients.

So it'll be radiologists, you know, who don't really often meet any patients in person, pathologists who look at specimens, but not necessarily the patient.

They'll be the most likely to be in favor, about 60, 70%.

And then the people who are most likely to be against will be palliative care doctors, GPs, oncologists and geriatricians, which are exactly the groups who deal the most with very sick and dying patients.

And it's the same in society in general.

So in our votes that we've had In Parliament, younger MPs were always the ones who are most in favour of it, whereas older MPs were generally more.

More against.

And then in the House of Lords, which is generally an older chamber, there's a lot more scrutiny, a lot more distrust of, of the bill.

And, and I think, I think that is true that for a lot of people, their support for it comes from a fear or a disgust of being vulnerable and weak.

And it is a scary thing when you're not disabled, to think about being disabled.

And you often hear people say things like people who see a severely disabled person will say, oh, if I were ever in that position, I'd want to be put down, or something like that.

But the person.

I mean, it is awful, but it is understandable as well.

If you haven't lived that, then you can't process, well, how could anyone live that?

But actually, the severely disabled person who's lived it their whole life or for a long time, they've managed to process that and they enjoy their life, right?

But it's just, it's just impossible for somebody who isn't disabled like that to, or is very difficult for someone to empathize with, with, with them that, that this could be a very fulfilling life.

And so it's like a, like maybe like a defense mechanism or something to say, oh, no, I'd rather be dead.

And then they, then they Campaign for it.

But the strange thing is that, like, I've.

I've had patients who have been in palliative care have said, oh, I wish we had assisted dying because.

Or assisted suicide, because then I would.

Obviously, I'd definitely take that up because this is unacceptable, the conditions I'm living in.

But, you know, weeks down the line, they, they change their minds or they all, they, I mean, very few people say.

Say things like, oh, you know, that conversation three weeks ago, I've completely changed my mind.

But their attitude has changed.

They.

They're getting satisfaction out of things, contact with family, all this sort of stuff that they, Weeks before, when they were in a state of shock, when they first realized they were dying, they weren't able to enjoy.

So people can change, even over the course of a few weeks, to accepting a new reality.

Yeah.

And I think also, I mean, my thoughts on this as well is the, you know, if someone is offered such a kind of final option and people's moods, people's attitudes can change over the course of a couple of days.

You know, you can have.

You.

It's.

It's this interesting idea of it being a fixed and permanent decision, but that isn't the reality of human condition.

We're constantly changing.

We're adjusting to different situations.

Whether we've had breakfast or not.

You know, that can have profound effects.

So it's always struck me as just such a.

Such a strange thing to try and manage within a legalistic framework.

But that isn't.

Yeah, it's.

It's just been a.

It's been a.

It's been a very, very odd thing.

What is the state of play?

Because I heard yesterday that it's been rejected up in Scotland.

I don't know.

Yeah, very good news yesterday.

Yeah.

So if it, if it had been accepted in Scotland yesterday, then it would make it very likely that in the coming years in England it would, it would have to be accepted as well.

But the rejection of it yesterday in Scotland kind of gives me renewed faith in the democratic system because it looked like it was.

It was going to be terrible.

It was.

It was the third and final vote yesterday, but then the first two votes had been quite heavily in favor.

But in the meantime, the members of the Scottish Parliament had had to scrutinise the bill and consider its practical effects.

So although, although majority of them were in favor of it in principle, the more they considered the practical effects and how vulnerable and disabled people would inevitably suffer because they'd inevitably be pressured into it by the system and by Potentially, you know, individuals around them, the more they realize, well, we can't in good conscience do this because you're essentially sacrificing that the poor, the vulnerable and the disabled for the wishes of the privileged elite to have their control of everything up until the moment they die.

And a lot of them came to the conclusion that they couldn't go ahead with it.

So they rejected it yesterday quite strongly.

And so that means in Scotland finished, they're not going to proceed with assisted suicide in England and Wales.

We've still got the Kim Leadbeater bill going through the House of Lords, but it's facing so much scrutiny there that they're running out of time in this parliamentary session to properly discuss it and amend it and then vote on it again.

So it's almost certain, I think this parliamentary session will finish sometime in May.

It's almost certain that there won't be enough time.

And so it will be, you could say, talked out of Parliament.

But that's not really fair because the Lords are doing a very good job of line by line saying, well, what about this consequence?

What about that consequence?

You know, what about anorexic people?

You know, what about people who don't have access to palliative care?

And they're really going through it very thoroughly and there are no really satisfying answers.

So it's getting stuck in this process.

But partly that's because it's a private member's bill.

So the way that it looks like Keir Starmer tried to introduce it was by using this park private members bill.

So that officially it's not his and officially it's not government policy.

But private members bills are normally supposed to be quite something, quite simple.

So they're not supposed to be for incredibly complicated legislation of this.

So it looks like it'll probably be talked out in this session, but it will rear its head again in the coming years because the side that wants it, they've got a lot of money and a lot of kind of high profile backers and so they'll make another attempt.

But you know, it will probably in the next five, ten years.

Gosh, it's nuts because I just think of, you know, coming back to Kim Leadbeater and the private members bill, there are more important things.

I know there are other things within society be really good if the government deal with rather than all this time and energy.

Yeah, yeah, yeah.

It's quite, quite misplaced.

So.

Okay, all right, Kitech, I think we'll wrap it up there.

I'm just wondering if there Are for those moms who are listening whose parents are starting to get.

They're starting to see things are getting a bit crumbly, not quite sharp with their brains as they used to be.

Are there some sort of basic tips, gentle interventions they could do that would help support their, their parents as they get, as they get older.

What do you think would be a.

As.

As a, you know, a doctor who's dealing with really quite elderly and vulnerable people, what do you think is kind of best practice for a family to do?

I mean, the best thing is to live together.

We've gone into this direction of everyone living separate lives, but the best thing is to live near each other.

And then when your family members become too frail to manage on their own, if you can move them in with you, that's the best.

And for the elderly family members to be spending lots of time with children, I mean, that's how we developed as human beings, was in multi generational tribes and families.

And it's very, I think, damaging mentally what we've done of separating everyone out so that they're, you know, the elderly are with the elderly, the children are only with other children, even Mark's children.

Each child is at school any one year with just people their own age.

You know, we're supposed to be constantly stimulating each other.

And children benefit from having the elderly around, but the elderly also benefit from having children around.

And it does keep them physically stronger by keeping them stimulated, keeping them moving.

Because a sedentary, unstimulated lifestyle, which is what has become the norm for our elderly, is the worst possible thing for their health mentally and physically.

Okay, okay.

No, that's.

Thank you.

That is a profound lifestyle change, but would be really quite transformative for families, actually.

Hard work.

But then the thing is that at some point your elderly relatives will die.

Yeah.

And that's a tremendous gift for them to give to their children, their grandchildren, to give them the gift of a, an opportunity to care for somebody you love when they're so vulnerable.

So to learn from that and to experience that love.

But also, and it's also a good example for your own children for how you should be looked after, you know, when you're older.

And if you, because if you don't do that, then why, why would they do it for you?

But, but then secondly, it's also, you know, really helpful spiritually to see, okay, granddad was with us.

We saw him get more unwell, we saw him die completely surrounded by people he love who loved him.

And now I have a.

Have a better understanding of my own mortality and, and what.

And what life means and what's important in life and all this sort of stuff.

So it's really, you know, reversing that process we talked about earlier with death being hidden away.

Yeah, yeah.

No, that's huge.

That, that, that could transform civilization.

Kai Tech.

Yeah, I think just living in big families would transform civilization.

Yeah.

Yeah, it would.

It would.

Kaisek, thank you so much for your time.

Now, in terms of people finding you, you're not really an Instagram, Facebook website, sort of.

You tend to hang out on X.

So what is your handle on X?

People want to follow you for more.

My handle X is very long and difficult to remember.

So it's trad T R A D and then Skovronsky, which is my surname.

S K O W R O N S K I.

Okay, I will put those in the show.

I probably won't be posting anything on X though, from now on because it looks like for now we've won the assisted suicide debate.

But yeah, you can follow me for next time it comes back.

Okay.

Bless you.

All right, Kitech, that was wonderful.

So to everyone who's listening, thank you for your time.

If you found this helpful or interesting, please, like, share, subscribe.

Let's get the word out.

And thank you again, Kitech, for your time.

God bless.

Thank you, Zoe.

Thanks.

Bye.

Love the podcast and want to help keep the kettle on.

You can support the show.

Think of it like buying me a cup of tea or helping cover the cost of the biscuits.

You'll find the link in the show notes.

Thank you for keeping this kitchen conversation going, Sam.