Permission to Heal Episode #88 - A Conversation with Dr. Stephen Post about Dignity for Deeply Forgetful People

Dr. Stephen G. Post - Dignity for Deeply Forgetful People

Dr. Post is a leader in research on the benefits of giving compassionate care for improved patient outcomes and clinician well-being. He addressed the U.S. Congress on volunteerism and health, receiving the Congressional Certificate of Special Recognition for Outstanding Achievement. He is an opinion leader and public speaker and has served on the Board of the John Templeton Foundation, focusing on virtue and public life.  He was a co-recipient of the 2019 National Alpha Omega Alpha Honor Medical Society Professionalism Award for the development of the Professional Identity Formation curriculum of the Renaissance School of Medicine at Stony Brook University, Post has taught at the University of Chicago Medical School, Case Western Reserve University School of Medicine (1988-2008), and at Stony Brook (2008-present), where he is Director of the Center for Medical Humanities, Compassionate Care, and Bioethics. 

Martin E.P. Seligman described him as one of “the stars of positive psychology,” 2003 Post was invited to join the Founding Fellows of the International Society for Science and Religion (ISSR), based at Cambridge University. 

Post’s book The Moral Challenge of Alzheimer’s Disease (Johns Hopkins University Press) was designated a “medical classic of the century” by the British Medical Journal (2009), which wrote, “Until this pioneering work was published in 1995 the ethical aspects of one of the most important illnesses of our aging populations were a neglected topic.”

Dr. Post's books:
His newest - Dignity for Deeply Forgetful People: How Caregivers Can Meet the Challenges of Alzheimer’s Disease
Why Good Things Happen to Good People: How to Live a Longer, Happier, Healthier Life by the Simple Act of Giving
God and Love on Route 80: The Hidden Mystery of Human Connectedness
The Moral Challenge of Alzheimer's Disease: Ethical Issues from Diagnosis to Dying

Connect with Dr. Post
His website,  Twitter, recorded speaking presentations. 

Connect with Marci

•   Website, Patreon, Instagram, Facebook, LinkedIn, Facebook Group.
• ·Permission to Heal on YouTube.
• Permission to Land  (memoir) - Hardcover, Paperback, eBook, audiobook 
• Permission to Land: Personal Transformation Through Writing
• Permission to Heal Bookshop - Buy books from the episodes & support independent bookstores. 

Transcript

I'm gonna quote Eleanor Roosevelt. The future belongs to those who believe in the beauty of their dreams. The mind is a gift. I think the mind it's a mystery. It's much more than just derivative of brain tissue and cells and a lot of philosophers of mind. Even talk about mind before matter, and it's big debate in neuro evolution and so forth. How do you get mind from matter? It's very difficult to imagine that actually. Mind is a beautiful thing. Your mind is a gift. Use your mind, discover your callings. Use your talents to serve others, which is what Shakespeare and Picasso said was the major meaning of life. Everybody has a gift. Every human being is a wonder of the universe. I want to let people just realize that they are all miracles in that sense. 

Hello, welcome to Permission to Heal. In today's conversation, I chat with Dr. Steven G Post. He is a very, very accomplished and very compassionate man. He is the founding director for the Center of Medical Humanities, Compassionate Care and Bioethics Renaissance at Stony Brook University in New York. 

[00:00:25] He is an opinion leader and a public speaker. He has served on the board of the John Templeton Foundation, which focuses on virtue and public life. He is a leader in research on the benefits of giving and on compassionate care in relation to improved patient outcomes and clinician wellbeing. He addressed the US Congress on Volunteerism and Health, receiving the Congressional Certificate of Special Recognition for outstanding Achievement. 

[00:00:52] He is the co recipient of the 2019 National Alpha Omega Alpha Honor Medical Society Professionalism award for developing the professional identity formation curriculum of the Renaissance School of Medicine at Stony Brook University. Dr. Post has taught at the University of Chicago Medical School Case Western Reserve University Medical School of Medicine, and at the Stony Brook School of Medicine. 

[00:01:20] Where he is the Director of the Medical Humanities, Compassionate Care and Bioethics. He is an elected member of the College of Physicians of Philadelphia, the New York Academy of Medicine, The Royal Society of a Me Medicine in London Post is the author of 300 articles in well respected, journals, peer review journals throughout the world. 

[00:01:41] Post is the recipient of the Alzheimer's Association National Distinguished Service Award in recognition of personal and professional outreach to the Alzheimer's Association chapters on ethics issues important to people with Alzheimer's and their families. Post's m ost recent book is called Dignity for Deeply Forgetful People. How caregivers can meet. The challenges of Alzheimer's disease was just published this year, 2022, by John's Hopkins University Press. His previous three books are Why Good Things Happen to good people, How to Live Longer, healthier, happier lives by the Simple Act of Giving. The moral challenge of Alzheimer's disease, ethical issues from diagnosis to dying, and God and love on Route 80. 

[00:02:35] The hidden mystery of human connectedness. And he said during the interview that if you asked him where he was from, he would say Route 80, which begins by the George Washington Bridge, at the northern dissection or intersection between New York and New Jersey, and ends in San Francisco, which is interesting. 

[00:02:55] We had a lovely deep. Meaningful conversation about deeply forgetful people, about people who may have Alzheimer's who are, are, are in the throes of dementia or deeply forgetfulness as he puts it. And how we as caregivers can, can help our loved ones retain their sense of identity. Value, and it's just very moving and very informative. So I hope that this connects with you. I hope that you find it as compassionate and necessary as I did. 

[00:03:46] Thank you so much for being here. It moves me beyond words every single week that you show up and that you listen and learn, and share, and grow with myself and my guests. It's truthfully one of the most meaningful experiences of my life, having you all on this journey with me. Thank you so much.

[00:00:00] Well, welcome Dr. Post. How are you? Hi, Marcy. I'm fine. I'm very happy to be speaking with you. It's always a delight. I'm thrilled to have you here. We're we're pretty close. I'm in Kings Park. You're in Stony Brook. Pretty, pretty quick. I teach over in center reach when? During the school year, so that Oh, you do? That's very close. Yeah. I'm a high school English teacher by day or, you know, during the school year. And Good. Do this on the side. And I've just gone back to graduate school to become a mental health counselor. So I will in my late fifties career when I retire from teaching. So. Well, good for you. Good for you. It sounds like a nice plan. Yeah. You gotta keep the brain active. You know, I'm not one of those people who can just sort of retire and putter around. I need an action plan. 

[00:00:46] So, Right. So that's the plan. So tell us a little about yourself. Why don't you introduce yourself? I, I know that I just read this very lengthy bio in the, in the intro, and you have a lot of professional credits to your name, and you're a very busy man, but who, who is Steven Post? Other than his wife's husband of 40 years come August 18th. Congratulations. That's a feat. Well, it is. That , Well, one day at a time. It's called, it's called Sticking with Him, . That's awesome. That's awesome. But you know, I, I lived a very peaceful 13 years now in Stony Brook here, and I direct a Center for Medical Humanities and Compassionate Care and Bioethics in the Renaissance School of Medicine. 

[00:01:45] Okay. Which is the Stony Book School of Medicine. And what is medical humanities? Well, that's where you, if you see that thing on my wall back there, that's where you have students from the time they get here reading narratives and literature about the illness experience so that they can be more sensitive to the subjective side of, of illness. 

[00:02:14] And that includes, by the way, poetry and. Even art and observation. We do lots of things with artistic renditions of people who are ill with various conditions, and the students are writing reflections on these things and, and then ideally this will elicit, empathic virtues. Yeah. So if you see that thing on the wall there, that mandle of the blue, the blue concentric circle is the empathic virtue, like humility, attentive listening, empathy and so forth. And then the outer circle, the green one. That's the actual clinical experience that students and clinicians have here with patients. And hopefully when they have to handle difficult issues that come up and they do come up about treatment decisions and many other things, they'll be more skilled because they have these earlier building blocks. 

[00:03:15] in place. Well, that makes a lot of sense. Yeah. That's what we do. And so we use the humanities, You being an English teacher? Yeah. We use the humanities to try to elevate, uh, the, um, comfort and the care that patients experience when they could easily be reduced to a biological slab and a disease state, if you will. 

[00:03:41] Well, it makes a lot of sense because I, of, of all the things that I could have chosen to teach, I think, you know, not only am I an avid reader and a, you know, like a literature geek, I've always been, but I, I feel like, especially more and more as I become older and hopefully wiser that. We really have access to learning emotional intelligence by reading literature, by experiencing art and, uh, other people's thought processes. And, and what do people write about except the human experience? You know, they write about relationships, they write about conflicts and, and how they resolve these things to me, teaches us emotional literacy.  

[00:04:23] Oh, yeah. And you know, the, the, the primary reason for medical error, and there's a lot of medical error in hospitals is what's called premature diagnostic closure. That sounds like a lot, but it's not just means that instead of really observing carefully the patient who's right in front of you mm-hmm. , you're just, you know, basically reading off computer printouts a hundred yards down the hallway and so forth, and you're not really being attentive to this human being in front of you. People misdiagnose all the time. and it, it's simply because they're not taught to observe. Mm-hmm. , so art and observation classes. Another area of medical humanities, they go on in about 800 medical schools around the country. Um, um, I'm sorry, I'm meant 80 medical schools around the country. They aren't 800. 

[00:05:16] Um, but 800 would be great. Would be great. But there're very nice studies about how students who, um, fine tune themselves neurologically to really notice things. Mm-hmm. in a painting and a rendition of an illness experience. How that actually shapes their own interaction with patients and will become the kinds of people who stop, look and listen and don't just ignore what's right there in front of them. 

[00:05:47] Do, do they get some of that information when they're taking a patient history or maybe it's not the doctor who's taking the patient history in the first place. Maybe it's somebody else. Well, they do take the patient history often enough, uh, but often also it's superficial and they don't palpate. 

[00:06:07] You know, there are a lot of, uh, residents, for example, who haven't really been trained to, to touch the patient, to really listen carefully. Uh, with the stethoscope, this is one of the complaints of the older clinicians who talk about the lost art of healing and how they feel they can get a better diagnosis when they're just looking, smelling, feeling, and so forth and not just relying on a lot of technology. Mm-hmm. , AI printouts and so forth, because that's when you start missing the very obvious thing. So a lot of people are subjected to medical error but 70% of those are due to, again, just. Poor observational training. And the observational training comes from observation, from literature, from just being sensitized to what people subjectively experience when they're ill. 

[00:07:02] Now, when you say literature, what do, what do you mean? Do you mean fiction or do you mean like anecdotal discussions of who the patients are, or pa you know, well, we have them, we have the students read fiction, you know, it might be Checkoffs misery or some such classic Right. You know, it, it could be Ivan Illich and, and you know, Dostoyevsky but, or Tolstoy but it, it, it, we want them to read literature. We also want them to read, uh, uh, nonfiction. So things like when Breath becomes Air, Oh, love are important. Love of that. Yeah. They, I mean, when they read that, they see the kind of ups and downs of hope and despair and what, what really is success? For a young resident, young physician whose family is in disarray who's not very happy with life generally, and then he gets a severe diagnosis how does that reorient him and, and make him completely rethink what it means to be flourishing and what it means to be fulfilled? 

[00:08:08] And in the end, of course, you know, he, he does die, but. Before that he, he's able to write this beautiful book where the words all jump off the page. Mm-hmm. , and he also has a child he becomes a father. So it's, it's a really nice story for the medical students, but from their own, just their existential perspective of trying to understand what it is to have a life and be a doctor. 

[00:08:32] Yeah. And not just be a gunner, but you know, if you will. But also it helps them to realize the the journey of an individual, with cancer and where hope comes from. How you, how people find hope. What hope is all the great humanistic themes. Are, are just so deeply embedded in that book. 

[00:08:54] Also poetry, you know, they, they, they read a lot of doctors who have been poet of se of distinction, William Carlos Williams would be an example, but also we have poets here at Stony Brooklyn. Jack Cohan and Richard Bronson, Maria Basil are all very distinguished physicians, but they, they also published poetry and, you know, drama in the New England Journal and the Canadian Journal of Medicine and Beautiful, and, and that's the same kind of thing that a lot of people did in the past. 

[00:09:24] I think we have a little more strongly represented here and narrative medicine, just writing reflective essays on this on the story of your patients. Sometimes enhanced by the way, when you actually visit them in the homes and so they, All right, students all go into the homes because that's where you see the narrative of the patient. 

[00:09:43] They're not just you stripped bare in a neutral environment, they're in their own home. So you see all the symbols that make up their lives and all the things that are, are who they are, which is really good. You see the, the, the person, not just the pathology, You see the whole three dimensionality of this person's existence, of their life, of their relationships, and, Yep. 

[00:10:05] Very much so. And, and, and I, and we have an approach that I like to call the double helix, because it's not just the, the patient's narrative, which is important to be interested in, to be gently curious about, to invite that into your discussion so they feel like you're treating them as a whole self. 

[00:10:24] But also the other, the other, piece of the, of, of, of the coil is the experience that the clinician or the student has themselves emotionally. In their response to that patient narrative. So there's the patient narrative, but there's also the narrative that, that, you know, you have as a reader, you know, as a reader. 

[00:10:46] And so we like to make sure that people understand that and where the transference goes on and how that can be very complicated. But it's, it's, it's, it's kind of the heart and soul of medical education here. And we have, I mean, I'll just say that we, two years ago, uh, Stony Brook was awarded the, the most prestigious award you can get in medical education. 

[00:11:07] Wow. Which is the alpha omega alpha, that's like the cat meow of medical education. Alpha Omega Alpha, Yeah. For curricula in professional identity formation. Wow. Which really means, you know, the formation of certain kinds of core virtues. Like kindness and empathy and humility and compassion. 

[00:11:32] I think those are the, besides a diagnostic and intelligence, I think those are the things that we most look for as patients. Where as, as humans, we both, we look for in, in doctors, you know, the Yeah. Yep. Makes off the relationship portion of the experience. That's right. And so that's what we do here. 

[00:11:53] I mean, we, we also, you know, have a bioethics hospital committee. So we engage in, in the discussion of difficult quandaries with various patients and their families. And we do a lot of other things. We do a lot of clinical teaching we do a lot of bedside type activities. And, and, and so it's not just preclinical, but, but suffice it to say that the heart of it all comes from those concentric circles, beginning with. 

[00:12:19] The humanities, trying to help people become more humanistic in their approach and then better clinically in their conversations with, with not just patients and families, but with one another. Wow. That's, You're doing a lot of good there in Inre. I mean, we, as the, I think as the, the population is aging, we're relying much more on medicine. 

[00:12:45] So being able to create or, or raise better doctors Yes. Who are much more empathetic. Empathetic and, and caring and or, or is gonna put all of us in a better position. Yeah. And have the skill sets. I mean, we do simulated role playing, We do actual, inter interactions with patients that are carefully observed and fatigued and so we really make it a part of the culture. 

[00:13:13] Very cool. So you have written a new book. Yeah, I have right , I forgot. No, I'm just kidding. Just No, no, no, no, no. Well, you've written quite a few books over the years all of which are linked in the show notes of the podcast. But you are sort of an Alzheimer's expert, so it seems Yeah, you know, I, I, I got into Alzheimer's before they even used the word. 

[00:13:38] It was when my grandmother, uh, who was a writer herself succumbeded to dementia in the final years of her life. Was in a nursing home, I would pop by and do assisted oral feeding. They didn't have feeding pegs. I don't believe in feeding pegs. They're not as, as constructive and meaningful as assisted oral feeding. 

[00:14:02] But I used to know what a feeding peg is, but, okay. Well, that's right. Well, there are these tubes that people now in many nursing homes get placed usually through an incision in the, in the abdomen, into the stomach. But, they're not really, very helpful. Uh, they actually shorten life. 

[00:14:19] They cause a lot of aspiration, pneumonia. And so you're better off just doing what they did before 1985, which is to, you know, to go there and say, Okay, apple sauce and brand. And, and even if, even if even my grandmother wasn't speaking with me mm-hmm. Or, you know, clearly recognizing me, at least verbally, there was a lot going on almost ritually, you know, it was kind of a rite of passage and, and there was a lot of emotionality and sometimes her, her eyes would really light up and you could see a lot of emotion. And then I had to be open to surprises because there were those moments when lo and behold, she would call me by name. 

[00:15:00] Right. So, so I, I had the impression as a younger person that you can never, uh, think of these individuals as gone as absent as husks, as shells and so forth. And, and I didn't like the word dementia. Okay. Because it's a, it's, if you think of just, just about it in terms of its derivation, it's a negative term. 

[00:15:26] It's a, it's a decline from a former mental state. Mm-hmm. . But we don't use, we don't call people retard. No, not anymore. Not anymore. Yeah. I mean, we call them, you know, disabled, we call them handicap. We call 'em a lot of different things. Now we call 'em differently abled. Sure. But dementia has the same sort of construction, so I like this language, which is catching on and I'm really happy to have pushed it over the years of deeply forgetful people, because to be honest, Marci, I had an experience a couple years ago. I went out in the parking lot behind this brutalist architecture that we call medical school. Yes. And I couldn't remember where I parked my car. 

[00:16:11] That's, So I asked a medical student. Yeah, I do. Do you, do you know, do you know where I parked my car? Of course she didn't know. And I said, You know, do we even know if I drove to work today, , which was , she kinda shocked her and she left, you know? But, but we all have our moments and, and , I think deep forgetfulness is almost more mystical in a way, but it's one of, it's a con, it's a continuity with common human experience. 

[00:16:38] We, we like to think, okay, they're demented, they're over the line, and we're not demented. Right. But the reality is that, you know, it's kind of a spectrum, and we all have those times in life. And, and some people have what they call pseudo dementia, which is dementia related to transient episode of depression or anxiety disorder or whatever. Right. And, you know, you, you, so, so I'm, you know, when we're babies, of course we don't have memories to speak of. We might have a little emotional memory after six months or a year, but I think it's important to, to, to try to find ways of connection, connecting. And, and so the, the, the language of deeply forgetful, I think encourages me and others to notice, to do the work of noticing those signs, those hints of continuing self identity. 

[00:17:30] Whereas dementia does the opposite. Dementia invites these kinds It invites dismissal. Yeah. Dismissal. Negative metaphors, you know, them, them versus us there, but for the grace of God, go, I, and, and, and, and that gets us in a lot of trouble because, you know, the book is, is, is about dignity. And we, we begin to humiliate, we begin to de dignify. 

[00:17:52] There's a word for it, De dig, dignify. It's actually in the book, you know? Right. Well, it's dignity for deeply forgetful people, so Yeah. Yeah. And even the cover, which, which I had nothing to do with the cover, which you show is. The Hopkins people, John Hopkins Press did that. But you know, it's, I don't, people respond to it in different ways and it, you know, but for me it's opaque. 

[00:18:14] It's, it's, it's the fact that the person is still there. They may be opaque, they may be less able to communicate. They may be in and out. They may be somehow obscured, but they're still there. And, and anybody who spent, you know, 90% of caregivers, for example, will report what I talk about in the book instances of paradoxical acidity for someone who's just, you know, had their chin down and hasn't communicated for a long time, even weeks, even, even a month or two. 

[00:18:45] But with the rice stimulation, it could be deeply personal music with the Alzheimer's poets in Brooklyn who read, say the road less traveled and About 90% of the patients are, of the people with dementia who are brought into this center, will start to chime in for at least a line or so, so you can bring people back with deeply learned material. 

[00:19:05] Because although, although short term memory is very much diminished, and, and it can be the case that their long-term memory also diminished actually their long term memory is, is relatively stable. And so I'm finding that with my dad that he, he forgets. The, the medium things, you know, things that happened within the last few days. 

[00:19:27] Yeah. And he'll forget things that happened within the last 10 minutes or the last hour, but he could tell you what he ate for dinner on January 6th, 1957. Right. Like, like that, that's in there forever. That's, that's in there ever leaving. Yeah. And that's what the music and memory thing is. You know, Dan Cohen, who started that lives in on Long Island Minola, it's a good friend of mine and we've written some papers together about it. 

[00:19:52] But, you know, it's amazing because if you take someone who's say in the VA nursing home here on the Stony Brook campus, it's a big, big nursing home. Mm-hmm. , uh, and there's a big unit for people who are Unquote Alzheimer's patients, um, or residents. And, uh, you know, if, if you, if you approach them with some music that they really identify with from their younger years, like for me it would be, I wanna hold your hand. 

[00:20:17] Mm-hmm. , you know. Sure. Then they will, they will get somatic, they'll liven up, they'll get back into themselves and Good heavens, you know, they'll even be able, a certain percentage of them to converse a little bit, maybe for four or five minutes after this experience. But you have to, But part of the book too is about how to use language. 

[00:20:39] Yeah. Cause you're a linguist, you know, So don't ever ask an open-ended question like, Hey, how are your kids? Because you put the person on the defensive, they've gotta remember names and mm-hmm. , so forth. What you say is, How's Joe And then how's specific? Right. Yeah. And they'll light up and you're, you're using language to remind them. 

[00:21:02] To get them off the hook, if you will, you know, of forgetfulness, right? That works really well. And there are many, many, uh, stories in the book of, of how to communicate more effectively with these individuals by using language in certain ways. Don't ever say what would you like for breakfast, but say, Hey, you want, Right? 

[00:21:23] Are you good with post toasties ? Right. Reminds me of my, my very good friend of mine was the primary caretaker for both of his parents as they were declining, and he wanted to keep them home, which was their wishes for his, their whole life. So they had like a rotation of home healthcare aids and, and he was the primary and his mom hadn't said anything. 

[00:21:49] She was, she couldn't, you know, she was in a chair, she could barely feed herself and. And he came in and put on her favorites, like she was being difficult with one of the caregivers and was refusing to eat. And so he put on one of her favorite songs and he sat down and he took over. And not only did she eat her whole meal, whatever that was with the music, but she was even moving her body a little bit and lifting up her hands and like doing whatever she could to sort of dance with him as he was singing the song to her. 

[00:22:22] And it's one of his favorite memories from the last like year or so of her life, um, that was just this like lucidity, this, the sunshine in the middle of the, the cloud, you know? Yeah. Yeah. And, and, and, and, and, and so, you know, in New York, although, you know, it's been closed down for a little while because of this pandemic stuff, but NYU has a program called The Unforgettables Nice. And it's a choir, uh, of caregivers. and affected individuals. And, you know, when they come together for these big rehearsals, and there can be even a hundred of them, uh, in the choir, uh, and, you know, people graduate and they, and they go on into the, in the more intensive, uh, treatments situations. 

[00:23:11] But so long as they're not very, very severely forgetful. It's an, it's like an awakening for them. Mm-hmm. , they will, they will connect with one another. They wanna dance, they wanna be somatic. And when they do that, they, again, they kind of come back into who they are. Okay. And, and, and this is really powerful. 

[00:23:32] So, so the, actually the nih, National Institutes of Health Funds research now on what's called again, paradoxical lucidity, the things we can do with these individuals to bring them back into themselves. And then how can we study that? In relationship to the neurology of deep forgetfulness itself. And they're making some pretty good progress. 

[00:23:55] They're gaining insights into dementia that they didn't have previously. So, so there's a lot to be done. And also, you know, I'm wearing a shirt, it's got dogs on it. Yes. You, I, we we're noticing that before. Cute little brown dogs. Cute little brown dogs. So I, I was on the, on the board of the Alzheimer's Association in Sterling in Scotland. 

[00:24:18] This is like 25, 30 years ago. Wow. And, we started the Alzheimer's Dogs Movement, . And, and I talk about the dogs in the, in, in the book. So, you know, they're trained dogs and they're well matched. So, you know, they're sort of, you know, smaller size Labrador typically. And this is the hottest thing in in, in the Great Britain and Scotland. It's all over Australia. I give the websites for the Dogs for Australia website. I was in Sydney doing a big national workshop on the kinds of things we can do with music, with art with images that bring people into familiar zones. You know, Joe DiMaggio, Marilyn Monroe, whatever. You know, of course we're all stimulating, but a dog is probably the best thing. 

[00:25:13] So, people have these almost miraculous re experiences of almost re mentioned because they get so engaged with this dog, and the dog doesn't give a damn if they're forgetful or not, right? Right. And, and, and, and, and there they are. It's a beautiful thing. So we had about 50 people with probable Alzheimer's disease and I say probable because in most cases it's a mixed diagnosis. It's not pure Alzheimer's, you know, it's, it's vascular stuff. It could be chronic traumatic stuff because people got hit in the head too much when they were playing football once upon a time. Who knows? But, we, we, we, we went down the main drag of Sydney and all these wonderful dogs had purple forget me, not vests. 

[00:25:57] Nice. Right? And, and everybody was perfectly happy and the dogs were getting people across the street and it was all going so well. Nobody was acting aggressively or agitated. It was just a beautiful, beautiful experience. And a cab driver. Pulls up next to me and he says, Hey, mon dogs are for blind people. 

[00:26:21] Not necessarily. Yeah. And so that's how we think of it. But actually we should do a lot more, with these Alzheimer's dogs. And there are so many other things. I mean our, you know, Vim DeCooning, the great abstract expressionist, he was diagnosed at Cornell with probable Alzheimer's, and he died 14 years later. 

[00:26:42] But for 13 and a half years he painted. And his painting was actually, I mean, his early stuff is that kind of wild ride anxious stuff that people like DeCooning and Larry Rivers and others were kept, were typically producing. But when he got the minute he actually mellowed out, sometimes you hear about the reverse. 

[00:27:03] But in his case, and in most cases, he actually mellowed out and he started painting a little bit more like Georgia oif. Ah, you know, I mean, it wasn't as elaborate, it wasn't as complicated, admittedly. Mm-hmm. , but it was in a way more beautiful, It's like a a, a part of him had been disinhibited maybe cuz he'd forgotten the myth that a lot of people grow up with. 

[00:27:27] Which, which is that I don't do nothing for nothing. Right. You know, he'd forgotten about all of that transactional mentality that kept him just painting for the joy of it. Yeah. He was just painting for the joy of it and he got into more positive emotional elements. So I was very impressed by that. And, and, and, and the, the, there was a postmus exhibit in New York of his work and it was really quite beautiful. 

[00:27:53] The reviewers said, a lot of them said, Well this is an embarrassment to DeKooning cuz it lacks all the rigor and the complexity and the, and the linear depth. Of his earlier work. It's just not the true DeKooning. But someone said, I think it was a, a reviewer from the New Yorker said, Wait a minute, this guy, he had Alzheimer's disease for 14 years, and it for about 13 and a half years, he knew who he was. Right. You know, and he would rise up sporadically. He couldn't talk much. He, he liked his dungaree because they reminded him of who he was. Mm-hmm. . And he dip his paint in the ac his brushing the acrylic, and he'd go up to the easel and he'd paint this stuff. And, and I thought it was a great, great example of, you know, that he, so his linear rationality, you know, like the how to do rationality, You know, how do I get out to the corner and buy a cup of coffee that may be quite deteriorated and in fact, entirely so that the, the, the rationality of doing, of going from point A to point B over time, but what's not gone in these individuals ever is symbolic rationality. So I knew a guy who, who worked in the steel mills on the west side of the Cuyahoga River in Cleveland. I've been a clevelander, you know, originally. And oh my goodness. he, he just, he always dressed country in Western. He becomes quite severely demented, in fact, very severely demented. He's even in the final stages of what we, of what we would call terminal dimension, but he's still clings to his cowboy hat, you know, and, and sleeps with it. 

[00:29:35] It's better his identity. Yeah, because he, because it, because he knew that somehow his identity was wrapped up in that mm-hmm. and out in my Ohio days, I went with a famous neurologist, Joseph Foley, who'd come to Case Western from Harvard. And he was just the premier neurologist of his decade, of his generation actually and we went to a nursing home called Heather Hill, and they had a special care unit for people who were deeply forgetful. So we read the bios sketch on the wall, which is a nice humanizing idea. That's a use of narrative, you know? Mm-hmm. told, told about this fellow's family and what he had done in life. 

[00:30:13] So we asked the nurse to take us out and introduced us to Jim, which she did. And I took Jim by the hint and we took him to a table, sat him down, and I said, Jim, now I used language poorly. I said, How are your sons? Cuz I knew he had two sons, right? And he, he, he couldn't respond at all. But then I said, How's Zach? 

[00:30:33] He just got euphoric. He wasn't coherent, but he got euphoric, right? And, I said, How's Suzy? And he was just smiling like a radiant beam of light. And, so that's when I really began to realize how we use language makes a difference. So then this guy, he had a white twig, like a branch, you know, about a foot long. 

[00:30:53] And it was, and it was very, it was carefully sanded and it didn't have any sharp edges, thank goodness. And, and he put it in my hands. And when he did that, he smiled this effusive smile. And I'm telling you, you know, if, if joy was electric, that place would've been on fire. And I said to the nurse, I asked the nurse, Oh, okay, what's the story with Jim in this, this twig? 

[00:31:15] And she said, Well, when he was a boy, he grew up on a farm and he was very, very close to his father and he's now mostly living back. You know, that's the deeply remembered stuff we're talking about. He's mostly deep living back in that time of his life that he most associated with tender loving care. 

[00:31:38] And, and his father gave him a, a chore every morning, which was to bring kindling and for the fireplace. Oh. So there was purpose in that, that we, you know, you and I wouldn't pick that up. Right. But there was purpose. And when Jim was giving that to me, was saying, You know what, this is a symbol of, of, of the love of my life. 

[00:31:57] Right. And then there was this beat up ragged. Do, I don't know if when you were a kid, if you had a puppet doll that you could put on your hand that was sort of, you know. Yeah. Okay. So there was this really ragged puppet doll. I mean, I tell you, it had to have been 40 years old and it had been stepped on and sled on and so forth. 

[00:32:15] Well, loved and Yeah. Yeah. Well loved. And, and it was right there on the floor and Jim actually slowly ambulated to it, picked it up. And he brought it to a woman in the corner of the unit who was whimpering and crying. It was harder. He put, put it on her lap and it was hers. And I, I asked the nurse Yeah. 

[00:32:37] Because that was hers. So, so he had some emotional intelligence. Right. And some symbolic. Right. I mean, he, I mean, and, and you know what I mean? You think about our lives and how we rush from place to place, uh, at the speed of light. And, and we, we ignore each other. I mean, he had slowed down. He was living mostly in the pure present and he had slowed down enough and he was noticing things that maybe he, he wouldn't have noticed otherwise. 

[00:33:05] Mm-hmm. , you know, That's beautiful. Yeah. So, so both of my, my parents, my dad's in his early eighties, and stepmom's in her late are in the beginning stages of this and they're still living on their own. And my sisters and I have just taken over, you know, legal financial control and power of attorney and healthcare proxies and so and so forth and we're having lots of conversations with them while they're still mostly lucid about how they want their lives and their deaths to go and before it's too late, you know, getting directions from them now while they still remember what they want and they still have some shred of their identity or lots of shreds of their identity left, how they want the rest of this to go so that we can take care of them in the manner in which they want to be taken care of. 

[00:34:08] How do we know? or how does anybody know when it's time or if it becomes time to take them out of their homes and bring them somewhere else? Or is it always advisable when possible to keep them in their homes with caregivers? That's a good question. And there are a lot of variations on the theme. 

[00:34:32] Most older adults will extract a promise from their adult children like yourself. don't ever put me in a nursing home, but, you know. Well, but even in assisted living kind of thing. Assisted living. Yeah. Yeah but, you know nursing homes, it's such a drab sort of hospital type image. Assisted living is, is much more creative now. 

[00:34:56] And I think there comes a point where it is very difficult for family members. And even with a Live in caregiver to manage behaviors. Mm-hmm. . And so at that point when it just becomes overwhelming, you definitely do want to make use of professional help and get someone to assisted living. It doesn't mean that you're abandoning them because you can still hop in and visit every day. 

[00:35:27] I always recommend that to families and, and you can be a part of their lives. It's, it's, it's just a relocation. And, and caregivers, family caregivers do have on the whole a higher depression rate than the general population. It's, it's not hugely higher, but it's significantly higher. And that's, that's something that we have to think about. 

[00:35:52] There's a book called The 36 Hour Day, which, which discusses sort of what, what it's like to be a caregiver and you can never really get to sleep because. Your loved one's sleep. Wake cycles are interrupted. Right. And so like a little kid again. Yeah. Yeah. So this is a big problem. Uh, you know, the, um, the thing I like to say is that, uh respite care makes a huge difference. 

[00:36:20] So some years ago, the whole Alzheimer's Association nationally had a big meeting in Washington, DC and the whole focus was to have the government support respite care for Alzheimer's caregivers in the home. And that's how I kind of broke into this field in, in like 1988 when I was out a case Western. 

[00:36:43] I spent about a half a day a week doing respite care. And What do you mean by that? Take giving, giving caregivers a break. Give them them a break. Yeah. Just, Okay. So coming into a home and let, letting the caregiver go out to the movies or go out and get a cup of tea with friends go shopping, just relax little bit, take a walk in the park. 

[00:37:04] It's incredibly beneficial. And we had some reliable studies showing that if you just gave a caregiver five to six hours a, a week, one day mm-hmm. that that would, ameliorate this problem of increased depression. Makes a lot of sense. It's a lot, a lot of sense. And it's actually cost effective. So, yeah. 

[00:37:27] we, we, we had, there were hundreds of people from every state in the us. We went up, early that evening to Capitol Hill with our candles and we approached our senators and congressmen and showed them the data and that we wanted to start this movement and needed to be paid for. And it was very worthwhile, probably more beneficial to a lot of these people who were deeply forgetful and even drug studies cuz the drugs aren't doing too much. 

[00:37:56] And they said no, because if we did it for the, for Alzheimer's caregivers, we'd have to do it for other caregivers as well, which kind of gets, we should, which we should, which we should. Which sort of gets to, to another issue, which I, I highlight in the book that a lot of times affected individuals, but also their caregivers. 

[00:38:15] They just really, what do we do in terms of justice, economic justice? Mm-hmm. . So, you know, we, we give them scraps, we give them leftovers, we wait till they've spent down. You know, in, into relative poverty, like, say about $15,000 in assets, including whatever is left in their home, you know, before they can qualify for public, benefits. 

[00:38:35] It's ridiculous. It's ridiculous. It's re Yeah. Now in Canada, I'm, I'm not gonna just, you know, say Canada's the best place in the world because it's not. But in Canada, you know, they, their healthcare system, it doesn't spend every penny possible to rescue someone from death like we do. And by the way, 95% of older adults in many studies, if you're just questioning them in the, in the lobby of a primary care office, they will tell you if they were to become deeply forgetful, you know, with a profound dementia they don't want any aggressive treatment. 

[00:39:13] They don't want a tube in any or office, natural or unnatural. They don't even wanna get shots anymore for diabetes. They don't want, they don't, they don't want their. Treatment for say, a chronic cardiac problem, which could be very complicated. Mm-hmm. they don't even wanna necessarily be treated for a cancer. 

[00:39:34] Right. They just want to go in peace and we need to assure them of that. But unfortunately, you know, it's often not the case. I mean, in every hospital in America right now, I guarantee you that, you know, five to 10% of the people in the intensive care units have, you know, deep forgetfulness. So need to work the family members who are clinging tightly while the deeply forget for person wants to let go. 

[00:39:57] Yeah, absolutely. So, so one of the things I did, and I actually got on the cover of the, of the Wall Street Journal about 18 years ago, because I'm against the use of artificial nutrition and hydration. You know, look when people can no longer swallow, although it can be stimulated. Did you point out by personalized music? 

[00:40:19] I have a study out. With Dan Cohen who founded Music and Memory showing that if you, if you give people who are losing their capacity to, to swallow an intervention with personalized music and an iPod and get them back into themselves, they actually remember how to swallow and then they can feed themselves and they can have dinner or whatever. 

[00:40:41] But you need to get them back into their bodies. Yeah. Need to get them back into it. And, and it can work very effectively. But, you know, low and behold, I mean, you know, the, the, the, these feeding pigs, which were only invented by two surgeons at Case Western actually for children, they were in the Rainbow Babies. 

[00:41:01] Children's hospital and it was for children who had esophageal blockages and you couldn't put a tube down their throat because it wouldn't, it wouldn't hold up over time. And it would, it would, it would have negative side effects. So they just, they figured out this percutaneous endoscopic, uh, feeding, Don't, don't write that down anybody. 

[00:41:22] No, that's a lot of multi words there, but I gotta tell you that, that, um, you know, that causes aspiration pneumonia also, if someone who's deeply forgetful has no insight into what that little three inch white rubber tube is seeking out of their belly button area. So they pull it out. And that's the main reason why people still get tied down and physically restrained in nursing homes. 

[00:41:46] And then they're sitting in their urine or whatever it might be, and they're getting lots of skin infections and they're. , right at that point, there is no quality of life at all. No quality of life at all. And you know, historically up until 1985, nobody in the world with advanced dementia who was in the, in the end stage was given a feeding P It just didn't happen, was all assisted oral feeding. 

[00:42:10] Mm-hmm. , which is what I did with old grandma Post, you know? Sure. And now, you know, in Canada they don't do any assisted oral feeding. In most parts of the world they don't. But somehow or another, it's partly financial because there's more reimbursement for nursing homes if, if you're doing skilled nursing care than what's called routine nursing care. 

[00:42:33] So there is a revenue element to it That's awesome. As there is to most things. Yeah. But I find that's so disturbing. Oh, it is. It is. And, and so I, the reason I got on the Wall Street Journal, you know, way back in the day was that there was too much this going on in Greater Cleveland and. I was working with adult children. 

[00:42:54] Cause I mean, adult children usually have a little different viewpoint than the spouse cuz the spouse, you know, like, like their husband or wife, whomever, they've been there, done that. They're looking more retrospectively at life. Mm-hmm. . And they may not see much value in sort of trying to push it to the nth degree for that last little, little bit of time when quality is not there but the adult children, because of attachment, you know, this is my mom and I've been able to call my mom on my cell phone forever and Hey mom, it's me. You know? Right. You know, it's a little harder. They're likely to let go. Yeah. Less like, and that's proven. It's in the literature, they're less likely to let go. 

[00:43:36] So I, I organized a whole movement in Cleveland and we were doing clinical ethics consultations in nursing homes and in hospitals too, but mainly in nursing homes. And I, I was very skilled at nicely diplomatically convincing adult children not to use feeding pigs. And, and it wasn't, I wasn't being brewed or, you know, I always say, you know, it's your choice in the end. 

[00:44:04] It's your choice. I mean, you have every legal right as a, as a family member or as a legal proxy or whatever to make this decision. But think of it in terms of compassion. Yeah. Not in terms of whose right it is to make this decision or even necessarily of what mom or dad would've wanted, but just think about it in terms of what they're going to go through. 

[00:44:29] And it's not necessarily a good thing. They may get an an, an additional. In some cases, not in general, but in some cases a few extra weeks of life. But not if you give them assisted oral feeding, if that's available mm-hmm. , then they, they'll probably live less time than they would other otherwise. So I, so I'm, I'm all for hospice treatment. 

[00:44:53] I'm all for minimally invasive treatment. I think it's ridiculous that these people wind up in the intensive care unit and, and I gotta tell you that the students don't like it either. I mean, the medical students, they see this stuff, you know, you talk to them about it and they just can't, they can't fathom it. 

[00:45:11] They just don't, they don't get it. It's heartbreaking. Yeah. Now, if we could go back to earlier stages, you know, when maybe when diagnoses are first being given, when the. Dementia is, is first starting to take hold. How, how can the caregivers, the children, let's say mm-hmm. help the I don't know how to, how to, how to phrase this as the deeply forgetful, the, the, the, the not so deeply forgetful yet person reestablish their own personal identity. 

[00:45:51] You know, if they, if they've always imagined themselves as strong or cognitively flexible. And how, how do you, how do you help them mitigate the change of that? Well, it's, it's, it's difficult, especially while they still have insight into their losses. You know, I, I hate to use the word kind mm-hmm. 

[00:46:15] when it comes to something like Alzheimer's. But if there is a kind point. It comes when people forget that they forget. Well, that's a spot where my dad's in. You know, He's forgotten what he no longer remembers. So although he's constantly living this retrospective of his life and wants to tell me about all sorts of things that happened in his childhood and what he did when he was younger, it's like he's reliving everything. Mm-hmm. . And so I'm constantly going down memory lane with him over and over and over again, which is fine. That's what he needs to do. He's in a happy place. Yes, he is. But other people who are aware of their losses, right, They're aware of the loss of, of what they, they, they remember what they used to be able to do. The the thought processes. They were able to remember the multitasking that they could do, the, the things they, you know, that they were able to handle and. They're depressed and anxious and lonely and irritated and really in a very bad place and exceedingly frustrated. Like, how, how can we help them? Yeah. 

[00:47:28] Well, you, you what you have to be very present and you have to work with them in areas where they do have some history and some competence doing things that they can identify with. But it's going to be difficult, you know, while they're still insightful into this loss. There are higher levels of depression in those very mild stages, and you're not going to necessarily have a, a smooth emotional transition at all. 

[00:48:06] There can be a lot. Agitation and, and someone who's been perfectly kind and compassionate over the years can become very edgy and difficult. So I would say, and, and by the way, you know, a fair number of people will be asking their doctor, if they can engage in assisted suicide. Many neurologists report this. 

[00:48:30] Oh yeah. But, but, but when they forget that, they forget, then, they can have a, a relatively benign emotional adjustment. Now, not always, there's a certain percentage, maybe 20, 30%, who do have issues of, of aggression and agitation and make it very difficult. But they can be cared for in, in special ways. 

[00:48:54] Mm-hmm. And that doesn't mean sedated. I mean, there are, there are pretty good medications for some of these behavioral, challenges. I think that, that, yeah, I mean, when they get to a certain stage, that's where, you know, Oliver Sax comes into play. You know, the man took his wife for a hat. I mean, you have to enter into their reality now, you know, So, so in the old days, I mean, 40 years ago, 50, 35, 30 years ago, a lot of times you'd have big rooms in nursing homes and people with dementia would be sitting there, and some, some fool would be up at the blackboard asking them, What year is this? 

[00:49:39] Oh God, maybe a couple of them would, would, would respond, but most one, then you write 1984, and this was called reality therapy. It didn't work out very well, but now, you know what you, what you have, you have, for example, in Brooklyn, in the, in the Brooklyn Memory Disorder Center, you have the Alzheimer's poets. 

[00:50:00] What they do, they're like, almost like musicians. You'll get 20 or 30 people coming in from the community with their caregivers. They'll sit in these nice chairs along the walls in a circle and some will, will, will read with energy and musicality like a Robert Bly, who's my poetry teacher at Reed College by, by the way. 

[00:50:19] Wow. They'll do the road less traveled cuz they, you know, this is a co a cohort that's likely gonna respond to Robert Frost. Sure. And they don't, they don't just read it, you know, they, you know, the road less, they get dramatic and they do it beautifully. And by goodness, you know, and I've witnessed this many a time cause I used to be on the board of that organization, the vast majority, I'm talking about 90% Will, will, will chime in. 

[00:50:43] They will not necessarily recite a verse, but they'll be able to pick up on a line or two. Mm-hmm. , you know, they'll get somatic they'll get emotional and, and they'll lighten up and brighten up. It's a beautiful, beautiful thing. And then afterwards, some of them will even be able to have some brief conversation with their caregivers who are with them, you know? 

[00:51:08] Mm-hmm. . Now, my, this, the, the, the, some of the people I know and the ethicists, they say, Well, this is completely meaningless. Meaningless because it's a fleeting experience. I mean, they're still gonna drift back into the, into the, into the doldrums of deep forgetfulness. But you know, I say, Look, for their caregivers, it's fabulous because what they realize is that they're not wasting their time. 

[00:51:34] Right. This isn't a husk or a shell or someone who's, you know, quote unquote half dead. But this is still grandma. That's why step chapter seven of, of the book mm-hmm. is, is called, Is Grandma still there? Grandma's still there. All right. Grandma's still there. And, and anybody who says anything to the contrary is, is being completely presumptuous. 

[00:51:57] And, and by the way, the, the, you know, this gets so, so there are a lot of things that you can do to connect with these people, you know, early on and also in the, in, in the intermediate phase. But even in the advanced stages, there are things that can be done. I mean, I knew a guy, I, well, I knew a woman at Yale who was, she was at Yale University. 

[00:52:19] Her husband, Leander Ke was a distinguished professor at Yale Divinity School. Okay. Was a professor of New Testament exigesis all right. And world class. And Janet Ke his wife, became deeply forgetful and. WA is a book written about her. She would wander around the Yale Divinity School campus and people would be polite and gracious and generous and try to help her out a little bit. 

[00:52:45] But, you know, eventually she became very deeply forgetful. But when she came into the Yale Chapel on Sunday mornings, you know, it's a pro, a pro Protestant outfit. Mm-hmm. And she heard those hymns that she grew up with and remembered meaningfully when she heard a familiar prayer. When she saw the lights through the stain glass windows, she would just liven right up and she would get back to herself. 

[00:53:16] And so with all of that symbolic stimulation, that's why I say, you know, symbolic rationality. Is actually more important than linear rationality. Linear rationality is the rationality of what we do. And in our society, we're always thinking about what people accomplish, what they do, you know, and that's where your value comes. 

[00:53:36] Otherwise, you're a, you know, as the German said in the World War, that you're a useless eater and then they exterminated people. Right? But no, but, but, but what's more important ethically is the rationality of who you are. And that's captured in symbols more than anything else, you know? And so for Janet Kick, it was the symbolic environment. 

[00:53:58] So that's why, you know, it is good to keep people in a familiar environment where they can connect with symbols and, and stimulate them with symbols, as much as you can. And when they go to a nursing home, if they go to a nursing home or, you know, assisted living, make sure that that, that symbolic reality is still around them. 

[00:54:15] So you go into a good nursing home and they'll be in a room, and they've got all these things from home that are up on the. shelves Yeah. And that's very, that's very important cuz you know, there's a great philosopher named er Cost Ray. I used to read him when I was a college student and he was the, he was the philosopher of symbols and he says something that you want, Marcy will understand because you're a literate person. 

[00:54:39] Sure. He said, We live in symbols and symbols live in us. We live in symbols and symbols live in us and all the good people with, uh, you know, uh, uh, the, the org the was a Caring connect in New York. All these organizations, people we're trained to really connect with the deep, deeply forgetful. They do it, they have every kind of imaginable, imaginable, little artifact device, you know, And it, and they're so skilled. 

[00:55:14] It's a beautiful thing to see them work and bring people out of themselves. . So that's, that's the point of, of language, of deep forgetfulness is that, you know, the person is still there, you know, dementia, it's like you said earlier, it's so much easier to just kind of write them off. They're mented, they're not functional, but deep forgetfulness, you know, is it invites more compassion, more interest. 

[00:55:39] Yeah. More of a gentle curiosity, you know? Mm-hmm. more kindness. More patience, forbearance forgiveness, more love. I, it helps us. I think, I know with me, it helped me realize that that memory is a continuum. You know? That, that, I mean, I'm 54 and there's a lot of shit that I already forgetting, , you know, And so when I see my dad, who's 82, you know, I don't know. It just, it just, it brings, it brings more compassion. I start to, to see it as a different thing rather than, Oh, he's just demented. It's not, Well, that's ridiculous. I don't even like saying that, you know, he just forgets stuff. So he repeats himself. I remind him that he already told me, and he forgets that, and then we say it again and Yeah. 

[00:56:29] You know? Yeah. And, you know, and, and, and a lot of people react. Okay. They can't even remember my name. Mm-hmm. that's really not very relevant, Right. I mean, you know, I, I mean there's like 500 medical students in this building, and at some point or another I've been introduced to every one of them. 

[00:56:49] But when I ride the escalator up, well, that's too many names to remember anyway. But, but he, but I'm always forgetting names. It's, it's, and it, and we often get embarrassed a little bit and we kind of confabulate and we skirt around or forgetting someone's name cuz we feel embarrassed that we shouldn't be forgetting that name. But, you know, it happens to us all. And, and the fact that, that it's more common for someone who's deeply forgetful to miss names, it's not something we should really worry about. The point is, are they present? Are they mm-hmm. , emotionally present. And, you know, in this book, I actually go out on a little bit of a limb, so you'll notice it's endorsed by his Holiness to Dai lama. I noticed that. Yeah. So, so I have this in front of my desk here as I'm speaking with you. So in 2015, I was invited to the Indian National Institute for Advanced Studies to head a conference they were having on the deeply forgetful. Okay. And it was renowned neurologists and philosophers from India. So the more, some, most of them were Hindu. There were some Americans like Owen Flanigan and others, but, but it was mostly Hindu. And you know, the Hindus are great. I tell a story in the book of going with Joe Foley, Dr. 

[00:58:14] Foley, to a geriatric psychiatric hospital in Mount Vernon, Ohio. Okay. About an hour south of Cleveland, about an hour west of Pittsburgh, in case anybody wants to know. And there it is. And they have a special unit with about 40 or 50 folks who had down syndrome. And now they're in their fifties and sixties and they're also having increased deterioration because most people in that category do in fact have probable Alzheimer's disease. Interesting. And so there were these incredible Hindu nurses and nurses aids and a couple of doctors. Couple of physician assistants and they had a little community, this hospital. 

[00:58:56] And Joe Foley and I walked in there and we were atra, We were ATRA by the calmness, the, the beauty of their interactions with these individuals. They weren't reacting, they were responding with self control, with mindfulness, right? Mm-hmm. , you know, and it was a beautiful thing to see. And, and they were calming these people down left and right when they got kind of panicky and a little bit off, off kilter. 

[00:59:25] So we took several of these nurses and nurses aids out to a diner in Gavir, Ohio, uh, actually a pizza restaurant and we just asked them, So what is it that makes you care so meticulously in which, such, with such warmth in patient, And they said uniformly namaste which means technically it's an Indian, it's a Hindu greeting. 

[00:59:52] It means, Yeah, I honor the divine in you as you wanted the divine in me. Sure. And so when I was in Bangalore, getting back to Bangalore . Okay. I gave this talk about how, you know, we in the West were so influenced by what I call hyper cognitive values. Mm-hmm. a word I invented when I was at Case Medical School in about 1995. 

[01:00:16] Hyper cognitive values. We, we think that people are only useful and of worth and dignity if their cognition, their linear rationality is intact. And when that's gone, we just, we, we just don't really care much anymore. So I gave this talk and I said, what's really important is their consciousness. I mean, someone can be deeply forgetful, I'm perfectly conscious of, of the beauty of a piece of music or the, the beauty of the fall leaves. 

[01:00:49] Or they can smell an apple of a loving hug. Yeah. More of a loving hug. Or, or, or, you know, or they can still smell that apple pie. That's just kind of like the one grandma used to make sure it's the only thing I ever eat at McDonald's about twice a year is an apple pie. Cause it reminds me of Yeah, well it, it, it reminds me almost exactly what my grandmother McGee used to make out in Sagaponic when I was a kid. 

[01:01:15] Okay. So there you go. You know, it's not healthy. It's not healthy, but, but I, you know, it just makes me feel comfortable. So, you know, that's, that's the thing that, you know, a fabulous bakery out that way. Oh, what the heck's it called? . I, I'll think of it. They, they're just famous for their pies. Oh yeah, yeah. 

[01:01:35] No, there is one, There is one on 25 A. Yeah, yeah, yeah, yeah. Your way on our way out to the Oregon Point ferry, we always stop there. I can't remember what it's called. Great stuff. So that, I like going there too. But, you know, so basically my point is, you know, they have consciousness and what's important is that they have, they, they are aware of their existence. They are self-aware they may be deeply forgetful, but they'll have moments of relative lucidity. Mm-hmm. . And so you have to be open to surprises and you can't treat them like they're dead. Now if someone is in a persistent vegetative state, which is to say they have no brain function going on other than the brain stem, but all of the, you know, all of the personality, everything you've associate with being human is kind of gone. 

[01:02:25] Well, that's different. And we actually, Take people who are PBS and we extubate them typically. Mm-hmm. or they could be brain dead. They could even, their brain stem could be nonfunctional, in which case we just say, Well, they're dead. So, but, but per a person who's deeply forgetful is not dead. 

[01:02:43] No, definitely not. Yeah. There's a great website called Not Dead yet, . That's great. Which, which I wanna, I wanna recommend to your listeners. It's, it's actually, it's actually supported by the disability movement because the disability movements, you know, they're kind of hesitant about bioethics. 

[01:03:04] Cause a lot of what we bioethicists do is we kind of figure out, okay, when is it okay to pull a plug? You know, it's that sort of thing. Right. And how can we respect people's autonomy and their decision making when they don't wanna be overtreated? But for the disability movement, a lot of times it's not about the individual. 

[01:03:23] but it's about the group they represent. Mm-hmm. , right? So if, if you look at, you know, World War Two, people with spine bifida, people with cognitive disabilities wound up in the hypothermia experiments. And so, so, you know, it, it's, it's, it's not so much a question of, you know, can we limit treatment? 

[01:03:46] But can we keep people here as a community to be respected? It's a very different take. So it's, it's so interesting. I'm not sure we want to go with this, but I just tell you that, that this is, this is important. I wrote, you know, I spent 30 years traveling around the US visiting Alzheimer's chapters all across Canada, every province. 

[01:04:12] I love Canada because they, you know, they have these things called Good Samaritan organizations and they provide free, Getting back to that point, we missed before free long-term care and hospice for everybody, with a diagnosis of dementia. Wow. Plus, plus they give them, if they need it, a free iPod so they can do personalized music. 

[01:04:36] Wow. Yeah. Yeah. Peter Whitehouse and I actually were part of the Alzheimer's Canada National Task Force, and we got these things moving forward in there. But so that they, so they're not gonna be resuscitating people who are deeply forgetful and not gonna be pounding on their hearts. They're not gonna be throwing tubes in them. They're not gonna be insisting that they be treated surgically for a tumor unless it's absolutely necessary for palliation. There are some cases like that. But look, I mean, you've basically, this is a good time to count your blessings and get ready to go. And even if you're not Luci of mine, most people, while they still are lucid of mine, would prefer that a chapter there in the book on preemptive assisted suicide would you to do not agree with. 

[01:05:28] Well, you know, I'm clear that I don't promote it, but when I was at the University of Chicago, I had two psychiatrists who were mentors. Cause I did a lot of stuff in, in, in psychiatry, in medicine and, and philosophy and, you know, deconstruction, all that kind of stuff. And they both had a diagnosis of probable Alzheimer's. 

[01:05:51] One of them had a beautiful family and he loved his family and he trusted them to keep an eye on him as he progressed. And his life still had quality. So he lived another 12 years. The other one took 40 seconals and put a plastic bag over his head. And I read about him the next day in the Chicago Tribune. 

[01:06:13] Oh my God. And so that was a real contrast, but he had no family at all and he just didn't have confidence in the system to kind of not overtreat him and just sort of let him let him go naturally. Right. And, and so well the key difference there is family. And is family successful caregiving? Yeah, absolutely. 

[01:06:35] So about 20% of people with dementia don't have families. I mean, I tell the story in the book, and this is a true story. I wrote an article about it in, in one of the major journals about a California San Francisco street clown. So this guy, you know, Yeah. He, so, so for ye for like 30, 40 years, he was the guy in San Francisco on the steps of the library who was doing these great skits, you know? Mm-hmm. and keeping everybody laughing and happy. He becomes quite deeply forgetful. Lives in a one rep bedroom apartment, and he's got some money stashed away and nobody can convince him not to go get on an airplane and go to Switzerland, where they have a program called Dignitas. 

[01:07:25] Yes. Yes. And that's, that's where he, he went and he was never seen again. And they do assisted suicide, but they also is, someone is really incapacitated in terms of their ability to push the button or whatever. They will, um, they will do su they will do, uh, euthanasia as well. Mm-hmm. . So that's what he did. 

[01:07:46] Now, all I say in the book is I. I don't support this because the book is really about being there and being with these people and counting them in our shared humanity. But I, you know, there's a statement that I always like, Judge, not less you be judged. Mm-hmm. and I am not gonna judge. Well, those two psychiatrists I knew in Hyde Park, Chicago, I wasn't gonna judge the second one. 

[01:08:10] I knew what he was looking at. I knew his personality and for him it actually made sense. I'm not defending it on any philosophical ground. You can understand his point of view. I sure as heck can. Yeah. And so, so I, and I think we have to be aware of this because people now can go to Quebec. 

[01:08:28] That's not a big trip. You know, just get up on the northern on the, on the New York throughway and head up to Yeah. Head up to Canada. Take a few hours and you'd be there. Yeah. You know, and, and, and, and you know, this is going on and it's going on in the Netherlands is going on in, in Switzerland, and frankly it's going on off the record in the US a bit. 

[01:08:52] So I tell a couple of stories in, in that chapter about individuals with who were deeply forgetful but still capable, and they knew they were heading in this direction and they were able to get medications prescribed for them. Now, their neurologists wouldn't even be within a mile or two or 10 miles of them at that time, but they, I knew some of these families in Cleveland, these 10 tended to be pretty well to do families. 

[01:09:22] And they would, they, they would ask me almost as a pastoral favor if I would just be there with them. And I said, Well, no, I don't, I don't condone this. But on the other hand, I can understand it. Mm-hmm. , So I actually was, was there on a couple of occasions and you know it, and I, but I did say, No grandchildren can be around for this i, I mean, no, no young grandchildren. Okay, sure. Absolutely. Yeah. Be, be because you know, that's, that would be a real problem. That doesn't need to be your legacy to your grandchildren. No, but, but you know, so, so the, the Yohan Sebastian Bach would be playing on the, on the CD and , you know, and they'd have the fire going and you could see Lake Eerie through the picture window and spouse would be there, adult children would be there, maybe a few friends and, a farewell bondy and, and, and, and, and it would be you know, very beautiful moment. And, and they would ask for a prayer. And since I'm sort of a meditational, prayerful guy, I would offer that for them. 

[01:10:29] Usually, well, oftentimes ones that they helped composed and, and, and then they would someone would bring out a milkshake with the, you know, 40 seconals and they would drink it down and after half an hour or so, they'd kind of fade and that was it. And it wasn't brutal or cruel or ugly. Sounds peaceful. 

[01:10:51] Yeah. It wasn't hopeless. I mean, some people say this isn't that giving up hope? Well, I mean, these are people who, who, I mean, there, there are two kinds of hope psychologists say there's active hope. Mm-hmm. . And there's passive hope pass. Hope is, Oh, they're gonna come up with a medication. Well, you know what? 

[01:11:06] They haven't, There's nothing much too good out there. There are some things that, on a scale of one to 10, if, if insulin is a 10 for diabetes, what we have for Alzheimer's is about a one or a 0.05. Okay. I mean, it's not very impressive. And, and it's like treating a brain tumor with aspirin. Neurologists give. 

[01:11:25] Aspirin to people with brain tumors for certain symptoms, but obviously it has no impact on the underlying tumor. Right. It might get rid your headache, but the tumor's not going anywhere. Yeah, yeah. And you've still got the same kind of situation and, and, and the benefits are very temporary, very fleeting. 

[01:11:39] So there's not much out there. That's why you all the controversy recently about, I won't even go into the FDA approving a very questionable drug. But that's my feeling is that, that this is a big issue and many of our medical students are sympathetic. It would be sympathetic to that clown. Again, I don't promote this, but, you know, and I've done studies asking caregivers around the country. 

[01:12:02] Okay, so what do you think about preemptive assistant suicide? A third of them? Oh no, never. A third of them. Well, under the certain circumstances maybe. And another third, 'em say, Well, you know what, Given, given the circumstances, it's, it, it's not the worst thing in the world. Yeah. Yeah. I've debated this issue or had my high school students debate this issue ah, for, for quite a few years, and they come up with a, a very pretty creative realm of arguments for and against. 

[01:12:39] Yeah. And a lot of cautions for potential abuses, which, you know, is quite insightful on considering they're 17 years old, quite insightful on their part. Well, that's the reason the healthcare system matters. So, at least in Canada, if someone avails themself of preemptive assisted suicide, they weren't doing it because they were going broke otherwise. 

[01:13:02] Right. There's public support. The same in the Netherlands, the same in Switzerland. But here, you know, you, you gotta look at your family's situation and realize that all these assets are gonna be spent down mm-hmm and you almost feel. Morally obligated to get out of the way. Yeah. There are some of that for sure. 

[01:13:25] Yeah. Absolutely. Yeah, absolutely. So I'm happy to have written this book. You know, I've written a lot of things, but this is the one that really, I hope people, people read it, they know it comes from the heart. It's, it's, it's a book for everybody. It's full of caregivers, anecdotes, little vignettes. It's full of stories. 

[01:13:44] Right. Stories are wonderful. The stories are wonderful. And, and even the list of questions, you know, questions and the explanations and your answers that, that caregivers and patients might have are really helpful in navigating our own feelings about this. Yeah. They're not questions that I came up with Marci cuz I was doing all these dialogues that actual families and patients have asked. 

[01:14:08] Absolutely, absolutely. And so I think it, it has a kind of, Usefulness, if you will. Well, it's easy to connect to them because you know that they're legit questions, you know? Yeah. Not created just to fill a book. Yeah. Just, you know, or just sort of philosophical quandaries, you know? Right. Yeah. I, it's, I, I haven't finished it yet. 

[01:14:32] I mean, it's a lot to get through and some is emotional, especially considering where I am now with my family. But I'm planning on passing this along to both my sisters. Oh, good. Because I think, I think it'll help the three of us as we navigate the future with our parents, you know, and try to figure out how to make things the best we can for them along their journey. 

[01:14:57] Well, they're lucky to have you. Well, and your sisters. We're trying. We're trying. We're trying. We're committed to their commit. Before this, the deterioration started. So yeah. As they're panicking or changing their minds about things, through the panic, we're mandating that we stick with the baseline, You know, what we had all decided months ago, and Yeah. 

[01:15:25] Not follow along the crazy train . Yeah. Well that and, but that, that's, that's to respect them. Yeah. Because I mean, I, I actually take that view myself. You'll notice in the book that I think that, you know, while it's true that people can quote unquote, change their perspectives as they go forward into this experience, there's something about the, in the, you know, honoring the, in the, the relatively intact self mm-hmm. 

[01:15:56] as you understood it and knew it. And that even goes for, for. Intimacy, you know I mean, some people in assisted living or nursing homes, um they, they're almost like teenagers. They'll just have crushes and you'll get all kinds of things going on. But then, you know, the, the, the real husband, real wife, you know, looks at that and feels that it's demeaning and is against it. 

[01:16:20] And, and we usually have a big say, but I know others who say, Well, you know vila difference, whatever makes him happy. I think you wanna be very careful about just focusing on the, the pleasures, quote unquote, and happiness of the person in the pure now mm-hmm if that violates their identity over the course of a lifetime and their meetings over the course of a lifetime. 

[01:16:50] So I like to err on that side, and I think that's what you're, you're trying to do. . Yeah, absolutely. Absolutely. As, as things go it's a little unpredictable, but we're trying to do our best to do right by them and to help each other through it. You know, like I, I know too many families who when they get to this stage, they start infighting over things that they disagree or there's financial concerns or different emotional concerns and Oh, no. 

[01:17:22] But my thank goodness we are the three sisters are on a hundred percent the same page. So I don't take that for granted at all. Yeah. I know how it's very, it can be, It's very good that you're doing that. That's great. So before I end each interview, we do the seven quick questions. Are you ready? 

[01:17:42] Oh, okay. ? Sure, sure. Okay. So what six words would you use to describe yourself? 

[01:17:54] Any words you want, any part of speech? Doesn't matter. Peaceful, responsive, joyful, generative, dad and husband. Great list. What's your favorite way to spend a day? Well, recently, taking my laptop on the Port Jefferson Bridgeport Ferry. Ah, yes. I frequent it. Yes. And, getting a cup of coffee their coffee's okay. And I buy a round trip ticket. It's only 21 bucks if you don't get off, you know? Right. And so you, and, and, and so you land in Bridgeport and then they'll say, Well, are you getting off? No. Okay, just stay on. So I get three and a half hours of seagulls and waves and beautiful sunshine, and I can work on my latest piece of writing. 

[01:18:56] What a really great idea that's, So I do it about every two weeks. It's just, it's just something I love to do and I get inspired by nature. I really honor. Do you sit inside or do you sit outside? Well, to do, you know, to be plugged in, You've gotta be inside pretty much. Well, yeah. Yeah, that's true. 

[01:19:14] But, but you know, it's still a beautiful experience and I feel a little cost too. Yeah. Oh yeah. Yeah. That's right. I like their pretzels. Yeah. And maybe I feel a little claustrophobic on Long Island. I don't know. But getting out there on the sound. Brings out my creativity. and I cherish, I cherish that experience. 

[01:19:36] That's a good idea. Sometimes I take my laptop and I go sit in a Starbucks or something, but, you know, and that's an interesting atmosphere too sometimes. But I never thought of using the ferry for that. So that you're moving, there's a different energy to that. There. There is. And, and just the humming of the o of the engines. 

[01:19:55] Yeah. Actually it's meditational and it's very creative. By the way, I do have a favorite Starbucks. It's the one in St. James. Okay. On 25 a newer. It's really nice. I mean, there's Starbucks and there are Starbucks, but that's a great one for writing. So I've been going there a little bit. But, so that's what, you know, that's what I like to do. 

[01:20:14] I like to write, I love writing. Yeah. Me too. I find it somewhat frustrating though sometimes, like I, it's an activity that I adore, but. Sometimes it, it feels very angsty. Like a cerebral, like birthing of something, you know? And it's, yeah, I just go with like, uses everything. That's awesome. 

[01:20:37] You know I just relax and go with the flow and I have to rewrite a lot. But, but, you know, I, I love writing. It's a very spiritual thing for me.  

[01:20:47] What is your favorite childhood memory or one of my favorite childhood memory? Okay, well, I have lots of things, but since I'm wearing my dog shirt. Yeah. 

[01:20:58] In honor of Alzheimer's dogs. I had a collie named Joe John, and I just remember, resting my head on Joe John, in front of the fireplace and feeling very happy and peaceful. Well, that's lovely. How old were you, do you think? Probably four or five years old. That's very sweet. Very sweet. What is your favorite meal? 

[01:21:26] My favorite meal, You know, I'm, I, I'll pretty much eat whatever there is, but I like, uh, I like shrimp tacos. Ooh, nice, nice. Yeah. Yeah. There's a place in Smithtown or St. James, I think it is. Salsa. Salsa is the name of the restaurant. They have a lovely fish taco. Yeah. Which it's so good. Oh good. That stuff is really good. Yeah. 

[01:21:56] Yeah. You might have to eat them tonight. . I'm very suggestive when it comes to food.  

[01:22:02] What is one piece of advice you would like to give your younger? 

[01:22:09] Well, I'm gonna quote, I'm gonna, I'm gonna quote Eleanor Roosevelt. Uh, it's one of my favorite quotes. Okay. The future belongs to those who believe in the beauty of their dreams. I love that. Yeah. Because you know the mind, and this is for younger people, you know, for me as a youngster, the mind is a gift. 

[01:22:36] And I think the mind is so much more, it's a mystery. It's so much more than just derivative of brain and tissue and cells and a lot of philosophers of mind. Even talk about mind before matter, and it's big debate in neuro evolution and so forth. How do you get mind from matter? Mm-hmm. , It's very difficult to imagine that actually. 

[01:22:59] I've never seen a convincing study to suggest that that can happen. But mind is a beautiful thing. Your mind is a gift. And so use your mind, discover your callings. Use, use your talents to serve others, which is what Shakespeare and Picasso said was the major meaning of life. Right? Absolutely. 

[01:23:23] And those was the time I feel the most alive. Absolutely. Yeah. And that's what, and that's what you do. This is why you're such a good podcaster, you know? Thank you. So I think that, that, that this is, and it comes across and, and so remember, you know sometimes people will try to humiliate. and they will try to de dignify you and they'll try to tell you that you don't have any gifts, you don't have any talents, you know 

[01:23:44] well, they're speaking about themselves, I think. Yeah, yeah. That's right. But, but everybody has a gift. Everybody is a, in my view, every human being is a wonder of the universe. Mm-hmm. And I want to let people just realize that they are all miracles in that sense. Absolutely. And every, every young kid, you know, you walk up to a young kid on the street and you say, you know, you're a wonder of creation, they're probably gonna look at you like you're nuts. 

[01:24:13] Bad shit crazy. Yeah, absolutely. But, but I think that that's, that's actually the truth. And so if we could just believe in ourselves and our minds and our gifts, believe that we are miracles and wonders, and if we could then know that the future will belong to us. If we can believe in our dreams, our beautiful dreams about serving others with the gifts that we have, I'm so beautiful. 

[01:24:42] And basically the mission of this podcast, okay, good. You know, like there were so, so much of my life that I spent because of my upbringing, the toxic, crazy dysfunctional upbringing that I had. I spent so much of my adult life looking external to myself for direction and permission and, and I ignored all the things that were going on inside me. And then it wasn't until my early forties when I had this epiphany that looking outside for all of that was not gonna get me anywhere meaningful. That everything that I wanted, everything that I dreamed of, everything that I would need in the future was all gonna start. Inside me, and it was my, my, I had to give myself permission to begin to do anything that I wanted to do. 

[01:25:32] So that's beautiful. Inner peace. Inner peace. That's it. That's it. It's empowering, you know, if I'm the one that's in control Sure. It's overwhelming, but it doesn't have to be, It's inspiring. It's, you know, empowering. It's where it all starts. Yeah. Also, also a nice thing for you is that you blurred the line between work and play. 

[01:25:57] Right. Right. I mean, you working, you're working now, but you're playing. Oh, absolutely. Absolutely. I even consider a good portion of my teaching job play. Mm-hmm. , you know, like the, the grading of the papers and the paperwork is definitely work, but when I'm actually teaching my classes, 99% of the time, that's playtime, you know? 

[01:26:20] Right. I'm really happy. Standing in those rooms with those teenagers talking about life and books and communication and expression and love. Love it, love it. And I thought, you know, was the seventh career that I chose, so I thought that, you know, within 5, 6, 7 years I was gonna be bored and on my way, but I ain't bored yet. 

[01:26:43] There you go. Absolutely not.  

[01:26:46] Okay. What is one thing you would most like to change about the world? Well, the world's getting pretty acrimonious. Yeah. Yeah. I think the hard part is picking one to answer the question with. Yeah. Yeah. Yeah. And, you know, I, I think we're too divided as a nation. Mm-hmm. , I mean, there are a lot of serious issues out there. 

[01:27:18] So the divisiveness is exacerbating everything. It is exacerbating everything. And, you know, people, like I say, you know, I'm, I'm, I'm an Ohio, but I was actually born in New York. And, you know, my grandfather married a woman named Emily. So I'm, I'm sort of a New York product in some respects. And I went up to New Hampshire for high school at one of these hoardy toy places that really didn't do me any good. 

[01:27:44] But, but I love my years in Chicago and Cleveland, Ohio, and in the Midwest. And, and I met so many caring people where they really took the time to connect and they didn't just rush past each other. And there's, and, and they're thoughtful people. And, and so this whole thing of red states and blue states I think is just overdone and, and I'm, you know, I wrote that book, God and Love on Route 80, right? 

[01:28:14] And, and I'm a Route 80 guy. If you asked me where I'm from, I'll tell you, I'm from Route 80, which begins the George Washington Bridge, Oh God, where it says Route 80 West. Right? And then if you're in downtown San Francisco, there's science that say Route 80 East. It's the same road. The same road. And so I want us all to realize that this is a good land. 

[01:28:38] That it's fields and it's rivers are blessed that there are good people everywhere. And we just need to work harder at understanding one another and not getting caught up in this incredible, judgemental attitude. There are many perspectives about everything in, in life, and. My perspective is not the only perspective. 

[01:29:08] So other people have perspectives too. I may agree to disagree with them. Mm-hmm. , but I don't hate them. We're not enemies because we disagree. Of course not. Absolutely. And that's what's happened, I think. I think people, have gone over the line and we need to realize that, we are all very lucky, very blessed, and that we can connect as a community better than we have as say, in the last 20 years. 

[01:29:36] Mm-hmm. . Yeah. It's changed a lot. Yeah. Okay. The last question is really shallow and superficial . Okay. What are your favorite movies or TV shows? . Okay. My favorite movie. Has not changed for, oh my goodness. You know, like how many years, 40 years. Harrison Ford and Kelly McGinness and witnessed Oh, good film. 

[01:30:07] I just love it. I love the, the music, you know, that French composer, uh, who does the beautiful stuff, the music when they raise the barn, you know, and you've got the Mogue synthesizer going and the contrast between the Amish community. Yeah. And, and, and, and, and rough and tough Philadelphia and the Murder and 30th Street Station. 

[01:30:30] I mean, it's so powerful. Yeah. And there's so much that goes on there. And when I saw that movie, I thought it was the best movie I'd ever seen. And it still is. Wow. I, I remember the little boy who played, Samuel Samuel. Yeah, yeah, Yeah. He looked exactly like my cousin Michael, who was the same age. Yeah. 

[01:30:56] And I just immediately identified that connection. That's interesting. Mm-hmm. . Interesting. Yeah. Do you binge watch any television? I wouldn't imagine you have time with all the things that you're doing. Well, you know, I don't, I don't watch television to speak of you know, I do like when I get home in the evenings, you know, I'll put my feet up and talk to my wife for a while, and then I'll usually do a little writing mm-hmm. 

[01:31:19] but I may I may take some time and on my phone and just watch a few snippets of, of of some of my favorite movies, like Witness. Okay. I also, by the way, I like, I like the Gladiator. Okay. Russel Crow. There are a lot of things. That was a good film too. . Yeah. So I'll just look at those little snippets that you can pick up on them and, and enjoy those. 

[01:31:43] But I don't really do a lot of TV watching or that kind of thing. Makes sense, . Well, thank you so much, Steven. This was really wonderful. I learned a lot and I think the listeners have as well. And, you're such a compassionate, empathetic man. I just loved this conversation. Well, I don't know, I, you know, we, we, we do the best we can and I've had, I've been shaped by some wonderful people in wonderful environments and teaching in med schools has been great for me over the years because, you know, difference between this and a college of arts and sciences in a lot of ways, you know, there's such commitment to the, to the wellbeing of, of patients and everybody's wanting to develop and form their character strengths in that direction. So to be a part of the community, even though I'm not an md, but to be part of that community has been a great gift and I think has helped me a lot. 

[01:32:52] Wonderful. Thank you so much. So pleasure, Marci okay. Good luck to you. This is great.