Transcript

David: Hi, I’m David Abend, founder of The Bucket and your host for this podcast with Australian oncologist, Dr. Ranjana Srivastava. Ranjana is a Fulbright Scholar and award-winning author and radio personality. In addition, she is a regular columnist for The Guardian newspaper, where she writes about the intersection between medicine and humanity, and a frequent essayist for the New England Journal of Medicine. She is also, and I think this is pretty cool, a recipient of the Order of Australia Medal, the OAM, for her role in oncology and improving doctor patient communication. Today, I look forward to talking with Dr. Srivastava about one of the biggest challenges she faces in her day-to-day role as a doctor who sees death and dying up close: the acceptance of mortality and the benefits that can come of it. I am pleased to welcome to the podcast, Dr. Ranjana Srivastava. Hello, doctor. Thanks for talking with me.

Ranjana: Thank you for having me on.

David: You’re a half a world away in Melbourne, is that correct?

Ranjana: That’s correct. I’m in Australia, not in Melbourne, Florida.

David: It’s your morning. It’s our evening, the day before. It’s pretty cold here now. It’s your summer, right?

Ranjana: It’s a beautiful summer’s morning. I must say that Australia has been lashed by wildfires and bushfires, as you will have heard, but it’s a beautiful morning today and the sky is clear.

David: Oh, that’s great. Well, I really appreciate you giving us this time. I know you’ve written a lot of books and magazine articles, but the one I want to start asking you about is your recent book called A Better Death: Conversations About the Art of Living and Dying Well. The thing that struck me most about this title was your use of the word art, the art of living and dying well. What an interesting word to use there.

Ranjana: The book has been on my mind for a number of years, or rather the subject has. I’ve now been an oncologist for many years, and what strikes me is that I see so many people who are terminally ill, who are dying, and really it does seem to me that it’s an art when people die well, and they’re able to take stock of their life and prepare to die. Many of us don’t do that well, but the people who do are quite inspiring. I thought that we could all learn a lesson or two in our own lives from how these people have managed to do what they do.

David: I’m sure there are some very rewarding parts of being an oncologist, but the downside, of course, is that you’re not just witnessing people die, but you’re entwined in it. How has that changed your outlook on life?

Ranjana: Whenever people hear that someone is an oncologist, often the first question people ask is whether or not it’s depresssing, and it’s actually not. It’s an incredibly inspiring place to be in medicine. It can be very rewarding and, as you said, to accompany people not just to the period of diagnosis and prognosticating etc., but to hold their hand through life and then through their journey of dying, is quite profound. I don’t know of anybody who works in oncology who is not somehow changed by that.

For me, the way it has changed me is to really live more deliberately. I see a lot of people, young and old, whose lives are upturned by a sudden diagnosis of cancer. The good news about cancer is that not everybody dies. Increasingly, survival rates are improving, which is wonderful. We have better and better treatments, but the mere brush with a diagnosis of cancer changes people. Certainly, looking after these people, whether they survive and go on to be discharged from our clinic, never to see us again, or people who, unfortunately, end up being palliated, everybody teaches you something.

David: You talk about living more deliberately, but are there any specific things that you found that you’ve changed the way you’ve lived? Or can you give any example of what it means to live deliberately?

Ranjana: It may sound cliched, but so many of my patients have taught me this, and I see this so much, about getting your priorities straight. On a day-to-day basis, what’s important, what am I going to worry about? What am I going to fret about? And, which things am I going to let go? I know that we all strive to do this in some way or the other, but there is something about working in oncology that brings this very much face-to-face. And, really trying to keep that in my mind is important. The other thing I have learned is thatrelationships matter. We hear about this everywhere, and I see this on a daily basis. The relationships you nurture and the ones that you make time for, they give back to you. That’s something that I am very deliberate about planning, to see my friends, to see my family, and to make time.

David: Obviously, some of your patients who are going through cancer and some that have died, they have to face their mortality, but what is it like to watch the family or best friends of these people? Do you see a change in them as well?

Ranjana: Absolutely. One thing I often say is that cancer affects not just the patient, but also the family, people who are close to the patient. In the medical profession, there is so much to do and say to the patient that, unfortunately, we can forget relatives and loved ones, but they are very important. I see how much they stress and how much they care. We all know about the unpaid labor of friends, relatives, and loved ones when somebody is affected by cancer. So absolutely, I see this all the time, and I have deep respect for people who choose to stay the journey.

David: You mean the caregivers?

Ranjana: That’s correct. It’s hard work. It’s physically hard work. It’s emotionally breaking, and yet time and time again, people make a choice to take care of some of the most seriously ill, needy, and vulnerable patients in our society. And that’s something that’s really admirable.

David: One of the things you talk about a lot in your book is your surprise by how few people have come to terms with their own mortality. It’s an issue with people who have been told that they may be dying and they just can’t seem to face it. It seems like a lot of your day can be spent dealing with that inability for people to accept their mortality.

Ranjana: There’s a quote in my book, and it probably formed the entire basis of writing my book A Better Day, which is a quote from a 3,000-year-old Indian ethic. It’s an interesting story where a noble man is struggling, and a spirit is trying to help the noble man and the spirit says, “In order for me to help you, you must answer a series of questions.” One of the questions is, what is the most surprising thing in the world? The nobleman answered, “Day after day, man sees countless people die, yet he behaves and acts as if he will live forever.” I see this so many times in my own practice and in general in society. I’m not ascribing blame to anyone, but I think we have become such a transactional society. People come into a hospital and they want an antibiotic, or they want an opioid, and they get something. Then they come to a place like having advanced cancer and they’re told that, unfortunately, while there may be some treatments, there is no cure for the cancer and it is quite likely that their life will end with this cancer. So many times people say, “Well, what do you mean? How can there not be something?” We often go through our lives without contemplating that we are mortal.

David: That’s the theme of The Bucket — this idea of acknowledging and embracing your own mortality in order to say, “I am going to die. How much time do I have left and what do I want to do with that time?” But we also find it’s not people with terminal illnesses necessarily, but there’s this inability to accept this and therefore plan. Another book that you wrote After Cancer: A Guide to Living Well, is advice for people who have survived cancer. Do you think that people who survive cancer have a deeper appreciation of life? Or, is it the kind of thing that gets forgotten? Almost like a survival instinct to forget it and not have to deal with it.

Ranjana: That’s an interesting question. I often say to people that, as an oncologist, you would never say to somebody, “Well, now that you have cancer, it’ll really change your outlook.” But so many people come back and say exactly that. They say that the fact that someone thought, for example, that they had cancer and it was actually proven not to be the case, transformed them. Then many more people who survive cancer say it entirely changed their thinking about what matters, what they’re going to worry about, how they’re going to look after themselves.

Obviously, there isn’t a 100% strike rate for everything. Just this week I’ve been talking to several of my patients who continue to smoke quite heavily despite having survived their cancer. We have had a conversation about this obvious risk factor that they know about and they have been educated about, but they find it difficult to tie it all together. But for many people, emotionally and psychologically, cancer does transform them. I’m very sympathetic to the fact that for many people it’s very traumatic. They lose their jobs, they don’t go back to the same positions, their body shape may be altered, their relationships are fundamentally altered. Many of my patients talk about losing friends during cancer treatment because people just don’t know what to say, how to behave. One of the hardest things for many of my patients is losing relationships during their illness. So yes, I think cancer changes lives in so many ways.

David: Which side do they come from? Those lost friendships, lost relationships, the patient or the friend?

Ranjana: I interestingly receive a lot of calls from friends and acquaintances who say, “Oh my God, someone’s been diagnosed with cancer in my workplace, and I just don’t know what to say. I don’t know how to behave around them.” I think that leads, in a lot of instances, to detachment. My patients, on the other hand, say that now that they have been diagnosed with an illness and many of them are going to treatment, they feel acutely that they don’t want to be a burden to someone. Sometimes they stop reaching out to people because they feel bad about it, they feel as if they have nothing positive to offer, but only something to ask for, whether that’s company, or someone to walk the dog, or someone to take them to an appointment. That’s how the break occurs when the well person doesn’t know how to respond. We don’t really talk about this kind of stuff when we are well.

David: We’re trying to get people to talk about that. One of the reasons for The Bucket is to get people to talk about it. We can’t, obviously, prevent a diagnosis like cancer, but we can get people in the frame of mind that they’re making the most of their lives. One of the things that you talk about in your book that really connected with me was the idea of equanimity, to be calm in the face of a tragic diagnosis. Do you see that as a path towards peace when facing your own mortality?

Ranjana: The first thing I’d like to say is that you don’t just die from cancer. Mortality happens to all of us for whatever reason. So, to cultivate attributes that help us die well, no matter what what we die of, is really important. Equanimity is something I really admire.It’s probably my favorite characteristic to watch, to reflect on when I’m in the clinic, because I’m constantly astonished by how some people manage to keep steady and calm and not be complacent, by the way, but to have their wits about them as they go through a very difficult time in their life. I’m very curious about what makes people that way. Were they always like this? Did they become like this? Did they choose to do this when they got sick? It’s a wonderful attribute to cultivate because I think it really helps you navigate an illness well.

David: I was wondering about what you thought about the causal nature of that. Are people who are like thatbetter able to handle a diagnosis? Or can someone who isn’t like that act that way in order to deal better with a diagnosis? Is that something you can control or are people just born that way?

Ranjana: I don’t know. I think about it often and I doubt that you either have it or you don’t.  In my book, I talk about patients who are quite young, in particular a young mother whose only dream was to have children, to look after them, to grow old with them and so on. She was diagnosed with advanced cancer and it was quite interesting. I don’t think this woman had thought much at the age of 40 about her own mortality yet, or even contemplated that her children might still be very young when she would die. But the calm she brought to the clinic was very impressive. Once I said to her, “I’m really sorry that you’re going through this. You can’t help but feel helpless in this situation.” And, she sort of shrugged her shoulders and she said, “Well, we all have to die, my time just came earlier and no one is to blame for it.” That way of thinking helped her so much in coping with all the trials and tribulations of her illness. It settled her family, too. Everybody accepted that she was going to die and it was all about maximizing time, maximizing quality of life, taking holidays together, and planning ahead. I write in the book about attending her funeral.Several times a year I will go to a funeral as much for my own closure as to support the families. What struck me about this funeral was, I went there very apprehensive thinking about what the funeral of a young parent might look like and how much grief and bewilderment there might be, but it was one of the most serene things I have ever witnessed. It was quite incredible. Everyone was calm and quiet, and it was as if they were marking something that they had been preparing for.They knew it was coming, and the day had arrived, and they had a plan to go forward. I found that amazing.

David: That is amazing. How can we help people have this perspective, have this calm, without having to go through this terrible thing? It seems like it’s something that can help you everywhere in life, but it also seems like, in most cases, it’s only brought on by a sickness or something like that. I’m on a mission to figure out how we can get everybody to feel this appreciation and preciousness of life, not just people who are sick.

Ranjana: That’s a great question. I believe that part of the answer comes from not shielding ourselves from stories that will make us sad or uncomfortable. We are all mortal and how do we help ourselves and how do we help each other live better and die better? Sometimes that comes from quiet reflection,allowing ourselves to think about some of the deeper aspects of our lives in the day-to-day busy-ness which catches us all.

David: This idea of acceptance is something we’re trying to do with The Bucket. We’re trying to get people to accept their mortality long before they are forced to due to illness.

Have you had a chance to look at our website at all?

Ranjana: Yes, I did have a look at it when you first got in touch with me. I really commend you on this mission. It’s an important subject to talk about. It can have less attraction than some of the other things that we talk about in our lives, but it’s so very important to engage with this.

David: On the website, we have something called a Bucket Age. Did you happen to check to see what your bucket age was?

Ranjana: I can’t think that I did.

David: We can do it right now. The Bucket Age is simply your statistical life expectancy minus your current age. Mine is about 85, I’m 61 so my Bucket Age is 24 and that’s how many years statistically I have left on this planet.

Ranjana: (laughs) I like that. It brings it home for you as to how many years you have to try to make a difference or do something.

David: Exactly. It’s like in in your book, all of these examples you gave of people who weren’t accepting that they were going to die. It’s the same with the Bucket Age. No matter how many people I talk to, when I watch them calculate it, they look at their age and they say, “Wow?” They’ve never thought of this before. We think it’s a great way to put things into perspective and say, ”What do I want to do in those years?” So that when I do die, I don’t have regrets and  I don’t sit there and say, “I wish I had done this. I wish I had started The Bucket, for me.” So, my question for you is, what is your Bucket Age?

Ranjana: I can tell you my age and you can calculate my Bucket Age.

David: I can try, but I don’t have the calculator in front of me. The purpose isn’t to be exact. The purpose is to just get the perspective.

Ranjana: I would hope that my Bucket Age is about 40 or 45 years.

David: That’s great. So, now that you know your Bucket Age, you have to start planning and thinking about what you’re going to do and what are your priorities? We have this zoo metaphor where you take the whole family to the zoo, everybody’s excited. You want to see the reptile house, you want to see the apes, you want to see the lions, you want to go to the gift shop, but you never checked to see what time the zoo closes. At one o’clock they say the zoo’s closing, and you say, “Whoa, wait. I had all these other things I wanted to do.” I think that most people live their lives this way; they’re not checking to see what time the zoo closes and they say, “Wait a second, if I had known the zoo was closing at one o’clock, I would have spent more time with the reptile house,” or something like that. We’re hoping that people use their Bucket Age like that, to think about how much time they have left and how they want to use it.

Ranjana: That analogy is very close to my heart. I’ve never heard it, but I’m the mother of three children and I have a zoo membership because I love going to the zoo.

David: Has it ever closed early on you?

Ranjana: Well, usually I get there quite early and I leave late, so it hasn’t closed early. But, I love the analogy because, at the larger zoos, I’m always torn between catching this and catching that. It really is about prioritizing and saying how many things can we get to, and also not be so tired and cranky that we don’t enjoy them. So, it’s not just about getting to the things we want to see or do in life, but also about having quality of life, isn’t it?

David: Absolutely. So, another question I ask all our guests is, and in your case I think it hits close to home because I’m going to flip roles with you for a moment and I’m going pretend I’m the doctor and I’m giving you a prognosis. I’m telling you that it looks bad and you only have a week to live. If you got that diagnosis, prognosis, what would you think? Would you have regrets? Would there be things that you wished you had done? And, I’m not talking about regrets like you wished you could’ve lived longer, but just are there things that you say, “I wish I had gotten to this.” In answering that, would that change how you think about things?

Ranjana: No oncologist can predict, no doctor can say that somebody has just one week or two weeks, but broadly speaking, many of my conversations with patients are about people having weeks to months, months to years, few years, several years prognosis, and so it’s something quite close to my heart. I think that those regrets, for me, would depend on at what age I was being told that. As a parent to young children, the first thing that would come to my mind at present would be the regret of not seeing my children grow up and realize their potential. That’s a very visceral response that you hear from many parents who say, “I accept this for myself. This is my greatest regret.” Other than that, I have really tried to limit my regrets and I’ve learned from my patients. I have close relationships and I’m satisfied with a number of the relationships that I’ve cultivated. I have a very close family. I think partly it is driven by what we spoke about before, you cannot be an oncologist and not think about this stuff and not change your own ways and your own thinking. Otherwise, it would be a wasted profession in a way. I think that would be a great regret that I would share with many parents of young children.

David: Do you see many senseless regrets?

Ranjana: Well, it’s funny. Nobody has ever said, “I wish I had finished that PhD. I wish I had built a bigger house.” Time and time again, the regrets come back to relationships. It’s quite profound to listen to it and very moving. When people reckon with their regrets, almost universally it’s about the closest relationships that somehow failed.That either they did not honor or were not honored by the other person. I see this both with patients and with relatives, loved ones who come in and say, “My dad is dying and I’m so sorry that we have not had a meaningful relationship for the past 10 – 20 years.” Then there can be this rush to reconcile, but for many people it’s overwhelming. It’s overwhelming to think that all this time they have not been able to repair a relationship or actually not thought about it or said, “Well, I’ll just wait.” We all get older, or something happens, or when I retire I will find more time and then suddenly you have no time. A lot of my time goes into observing this, listening to this, and trying to help people come to terms with what it is.

David: That reminds me of a great quote from your book, from one of your patients. He said, “But I’m not done with life. My head is always churning with ideas that I always assume I will have time for later.” That must be crushing when you hear someone who thought that they would always have time later and they’ve run out.

Ranjana: You feel disappointed on behalf of the patient. It’s difficult to not put yourself in that situation and think about all the plans and projects, from tidying up the cupboard and drawers to writing another book. We all have plans to travel somewhere, to catch-up or connect with someone, and it must be very harsh to suddenly put a limit on that. The limit is not necessarily by saying you have two months to do this, or three months to do this, often it’s not just the prognosis, but how ill people are feeling. So, all of a sudden, the trip that you had always meant to take, it’s not safe to take anymore. You wanted to go trekking somewhere and there are no health care facilities. Although you are well enough to remain in the city of Melbourne and you will be fine, but all of a sudden, that trip you wanted to do with your son is not going to be possible. That brings me back to this issue of seizing the day and doing things as much as we can now, rather than storing them up for later.

David: I love that. I know you’ve done a lot of interviews over the years for this book.I want to ask, besides all the questions I’ve asked you today, what has been your favorite question?

Ranjana: Oh, gosh, that’s a good one. Well, I’ve never been asked my Bucket Age before. So, now you’ve given me something else to think about.

David: What question haven’t you been asked that you wish you had been asked?

Ranjana: People ask all kinds of questions. I think many people are genuinely curious about how one immerses oneself into oncology and sees cancer patients all day on many days of the week. I think many people assume that it’s depressing or wonder why you wouldn’t pick another career. I’m a fairly open person. I share a lot of my personal experiences as much as it’s appropriate and useful. I think that the things that we need to keep talking about, and I can answer them and many others can answer them articulately too, is just this whole idea about cherishing life and about leading a meaningful life. In the modern era, there is such a rush to do things,and being busy is a status symbol. I think it’s to our detriment.

David: Well, my last question was actually going be, what does it meaningful life look like for you? But you just answered it.

That’s perfect. I want to thank you so much for your time. This has been great and I really appreciate it. I think our listeners will get a lot out of it.

Ranjana: Thank you. It’s been such a pleasure talking to you.

David:

What a great perspective and approach to living a more meaningful life. I hope none of you out there have to be forced into dealing with something like a cancer diagnosis, but I do hope that you can let the concept of mortality be a catalyst that can help you make choices that will help you lead a more fulfilling life and eventually die without regrets about the things you wish you had done. To learn more about how to get the most out of your life by embracing your own mortality, go to TheBucket.com.That’s the bucket, all one word, dot com. If you know someone you think should be in a future bucket podcast, let us know at bucketfeedback@thebucket.com.