Beyond a Side Effect: When Mucositis Becomes an Oncology Emergency

Most people undergoing cancer treatments know to watch out for fatigue or hair loss, but far fewer expect the severe impact of oral mucositis. While it often begins as a painful side effect of chemotherapy or radiation, severe cases can rapidly cross the line into a critical oncology emergency.

Learn why Stage 4 mucositis becomes a medical emergency and about life-threatening complications like sepsis, severe dehydration, and treatment interruptions. Then, we share a rebroadcast of our comprehensive guide with daily steps patients can take to protect their mouths, manage symptoms early, and preserve their quality of life.

https://bit.ly/3Tqfl18 for helpful visuals, resources, and a mouth rinse recipe

Timestamps:

• 00:00 - Mucositis - What it is and Why it Can Become a Cancer Emergency
• 07:34 - Intro S6E22 Mucositis with Cancer Treatment and How You can Prevent It
• 09:18 - The Sharks of Rockaway Beach
• 13:50 - Road Trip to Nebraska - Famous Murder Spree and Reuben Sandwich
• 17:59 - Oral Mucositis - Common Symptom of Cancer Treatment
• 21:24 - Why it is Important to be Proactive to Prevent Mucositis
• 29:05 - Mucositis Discussion
• 34:18 - Nutrition Tips for dehydration, taste changes and decreased appetite or pain while eating
• 36:18 - Holly Butcher: Advice to World 24 Hours before She Died of Cancer
• 38:16 - Outro with words from Killian Murphy

#OncologyEmergency #OralMucositis #CancerCaregiver #ChemotherapySideEffects #CancerSupport #PatientEducation #SupportiveOncology #SepsisAwareness #MouthSores

Transcript

Hello and welcome to Everyone Dies, the podcast where we talk about serious illness, dying, death, and bereavement. I'm Marianne Matzo, a nurse practitioner, and I use my experience from working as a nurse for 48 years to help answer your questions about what happens at the end of life. We decided to take a vacation for a few weeks this summer, which we haven't done since we started this podcast.

So today we have a quickie podcast for you that is part of our series related to emergencies in cancer, with a discussion about how mucositis can become an emergency. And as a bonus, we are including a re-release of our podcast about cancer-related mucositis, where you will hear all the details about mucositis. So mucositis is a painful inflammation and ulceration of the mucous membranes.

That's that outer wet coating of our mouth, but it also lines the digestive tract. It most commonly affects the mouth, oral mucositis, and is a frequent weakening side effect of chemotherapy and radiation therapy because these treatments damage rapidly dividing cells, which are the cells that are in our mouth. Chemotherapy and or radiation therapy have many painful side effects, including mucositis.

In severe cases, people can develop ulcers that reach the submucosa, which is a layer of connective tissue that supports and connects the oral mucosa to the muscles and bones. While mouth lesions are the easiest to diagnose because they can be easily seen, mucositis can affect any part of the gastrointestinal tract, the GI tract, which goes from the mouth to the anus. Mucositis occurs in 20 to 40 percent of people who receive chemotherapy for cancer and typically occurs within 5 to 14 days of receiving chemotherapy.

People who develop mucositis have twice the risk of developing infections and four times the risk of death compared with patients who do not develop mucositis. Although mucositis most often results from cancer treatment, you should also be aware that opportunistic infections can also cause the condition. Opportunistic infections are illnesses caused by organisms that take advantage of a weakened immune system, making them more severe or more common in people with immunosuppressed conditions.

For example, we always have yeast in our mouth, but we also have what is called normal flora that keeps the yeast from getting out of control. But suppose we take an antibiotic or chemotherapy that eliminates the normal flora. The yeast sees this as an opportunity to take over and when that happens, we have a condition called thrush, the opportunistic infections of yeast because the normal flora that kept the yeast in line has been killed off.

Considerations to help determine an individual's risk for developing mucositis include the specific chemotherapy agent or radiation used as well as the dose, the frequency, and the duration of the treatment. Individual characteristics that may influence the risk of developing mucositis and how severe it is include smoking, poor oral hygiene, younger age, female sex, pre-treatment nutritional status, and pre-treatment neutrophil count. There may also be genetics that are related to an individual's risk for developing mucositis.

We have a table in the show notes that show the stages of mucositis. Today, I'm only going to talk about stage four mucositis. The other stages are going to follow in the re-release of our podcast.

Mucositis becomes an oncology emergency when severe inflammation and open ulcers in the digestive tract lead to life-threatening systemic infections called sepsis, uncontrolled lack of fluids, or malnourishment. Because cancer treatments often weaken a person's immune system, these broken barriers make the bloodstream vulnerable to dangerous bacteria and fungi. In this case, mucositis is considered a medical emergency due to several overlapping complications.

First, life-threatening sepsis. The primary danger of severe mucositis is bacterial and fungal invasion. Open ulcers in the mouth or gut combined with chemotherapy-induced neutropenia, which is a low white blood cell count, allow the normal oral and gastrointestinal flora to enter the bloodstream causing fatal systemic infections.

Two, severe dehydration and weight loss. Lesions in the mouth, throat, and esophagus make swallowing extremely painful. This often prevents people from taking in basic liquids or food requiring immediate hospitalization for intravenous fluids and total parenteral nutrition, TPN.

Three, airway compromise. Massive swelling and ulceration in the pharynx or larynx, the throat, can sometimes lead to airway obstruction, which requires urgent airway management. Four, uncontrolled pain.

Severe grade 3 to 4 mucositis causes debilitating, agonizing pain that generally requires intravenous patient-controlled analgesia, PCA, with narcotics, making outpatient management impossible. Five, interruption of cancer treatment. If mucositis becomes severe, oncologists are often forced to reduce the dosage of life-saving chemotherapy or delay crucial radiation schedules, which directly impacts long-term cancer survival.

As I said, this is a cancer-related emergency, often treated in the hospital to closely monitor vital signs for fever or signs of sepsis. Aggressive IV support will include broad-spectrum intravenous antibiotics and antifungals to combat systemic infections, as well as IV fluids and nutrition. Pain is managed with the use of systemic opioids like morphine or specialized topical coding agents to allow for basic oral function.

Interdisciplinary care will include dental oncology, speech-language pathology, and dietetic involvement to improve oral hygiene and swallowing function. If you can't swallow your own saliva or cannot drink fluids to maintain hydration, you should immediately contact your oncology care team and get medical attention. And now, stay tuned for our Season 6, Episode 22 rebroadcast, where we do a deep dive into mucositis.

We talk more about what it is, why it is common with cancer treatment, how to be proactive to prevent it, and how to make your own rinsing solution to ease mouth sores. Hello, and welcome to Everyone Dies. This week, we're talking about some of the symptoms that you might see when you're having cancer treatment.

And this week, we're talking about mouth pain, otherwise known as mucositis. So, put your feet up, get something to drink, and settle in for our podcast as we talk about serious illness, dying, death, and bereavement. I'm Arianne Matzo, a nurse practitioner, and I use my experience from working as a nurse for 47 years to help answer your questions about what happens at the end of life.

And I'm Charlie Navarette, an actor in New York City, and here to offer an every-person viewpoint to our podcast. We're both here because we believe that the more you know, the better prepared you are to make difficult decisions before a crisis hits. Also, this podcast does not provide medical nor legal advice.

Please listen to the complete disclosure at the end of the recording. This podcast is a combination of education and entertainment, you know, edutainment, delivered in three halves. Our main topic is in the second half, so you can fast forward to that Yak Free Zone if you want to get right to this week's topic.

In the first half, Charlie has our recipe of the week and the story of a Nebraska murder spree. In the second half, as part of our ongoing cancer series, Everything You Always Want to Know About Cancer But Didn't Have Anyone to Ask, we're going to talk about the common side effects of cancer treatment, starting with mouth pain. In the third half, Charlie has some advice about living from Holly Butcher and some advice about how to eat after cancer treatment.

So, would it be redundant to say, is it hot enough for you, Charles? A little redundant, but I'll tell you what might be just as worse. I guess maybe worse. Sharks.

You have sharks in New York City? Yeah. Well, not exactly in the city, but certainly on the beaches around New York City and not on Long Island. So, there are drones now.

Drones? Drones of sharks? Yes, drones of sharks. Did you just make that up? Yes, I just made it up. So, a couple of people have either felt sharks bump into them as they're swimming or wading in the ocean, or taken a nibble out of a couple of people.

Nothing serious. Yeah. So, drones were sent up, and there's, where is it? At the Far Rockaway? The Far Rockaway is in the southern part of the Atlantic Ocean.

Yeah, I mean, you know, the drones showing sharks swimming around, and people constantly get told, you know, get out of the water by the lifeguards. And, yeah. So, you know, it's the 50th anniversary of Jaws, so maybe they're celebrating.

You know, David had never seen that movie. Really? Yeah. A few weeks ago, I said, oh my god, you've got to watch this.

And it was much scarier on the big screen, but, you know, it holds up. Absolutely. And, you know, I mean, they had so much trouble with Bruce, which was the affectionate nickname for the mechanical shark.

So, I guess Spielberg had just much bigger plans for the shark, but the damn thing kept breaking down. And in hindsight, it seemed like it was a good idea, kept breaking down, because it would just suddenly appear and then disappear. So, he had to cut back on what he had planned to do with the shark.

And I don't know, it looks perfect to me. You don't see that much of the shark. Well, you know, we scuba dive, and when we've gone diving, like, you know, like the end of July-ish or so, the waters are full of sharks.

And they'd come and they'd, like, there was this one, you know, they would kind of follow us around to different sites. And there was this one that would, like, always want to swim between my legs, like, you know, like would come under me or go between my legs. And it would be like, you know, you must have something else to do.

Go away. And then there was one who was all wrapped up in fishing lure, and it would come every single day. And we just got the feeling, like, it wanted us to get that lure off of him, but none of us were brave or stupid enough to attempt it.

But you knew it was the same shark, because it's the same lure every single day. Oh, dear. No.

Yeah. Uh-huh. No.

Not for me. Thank you. Nope.

Ah, I prefer land. Land sharks? Oh, my God. Land sharks.

I forgot about that. That Saturday Night Live skit. I forgot about that.

Oh, candy cram. Are you sure you're not a shark? Uh, special delivery. We are old, Charles.

No, we're not old. We're just well-informed. Land sharks are old.

We're not old. Yes. In our first half, Everyone Dies travels to Nebraska.

In an annual survey about which state tourists most wanted to visit, the state of Nebraska came in last place every year between 2014 and 2018. In 2018, the Nebraska Tourism Commission joked about the lack of visitors with the slogan, Honestly, it's not for everyone. Nebraska did have some notoriety for one of the most terrifying killing rampages in the Midwest.

Carol Ann Fugate was 14 years old, an eighth grader in Lincoln, Nebraska, when her boyfriend whisked her into a stolen 1956 Packard to accompany him on a murder spree. Springsteen immortalized the story in the song Nebraska. Here are the lyrics.

I saw her standing on her front lawn, just twirling her baton. Me and her went for a ride, sir, and ten innocent people died. From the town of Lincoln, Nebraska, with a sawed-off 410 on my lap, through to the Badlands of Wyoming, I killed everything in my path.

I can't say that I'm sorry for the things that we done. At least for a little while, sir, me and her, we had us some fun. Now the jury brought in a guilty verdict, and the judge, he sentenced me to death.

Midnight in a prison storeroom with leather straps across my chest. Sheriff, when the man pulls that switch, sir, and snaps my poor neck back, you make sure my pretty baby is sitting right here on my lap. Well, they declared me unfit to live, said into that great void my soul to be hurled.

They want to know why I did what I did. Well, sir, I guess it's just a meanness in this world. Ooh, that's dark, huh? It really is.

I hadn't heard that song in a while. I remember when it came out, and I thought, this isn't Springsteen, this isn't Rosewood Pebble, what the hell is this? But yeah, on occasion, I'd listen to the album. I hadn't listened to it for a while, so you know, so for this week's show, I listened to most of it again.

Yeah, I guess I'm a little older now, so it, yeah, I don't know, it just hit a little differently, but yeah. So, our recipe this week is the Reuben sandwich, which was invented in Nebraska. Reuben Kolakowski, a Lithuanian-born Jewish grocer residing in Omaha, Nebraska, asked for a sandwich made of corned beef and sauerkraut at his weekly poker game held in the Blackstone Hotel from around 1920 through 1935.

The hotel's owner's son, who worked in the kitchen, made the first Reuben for him, adding Swiss cheese and Thousand Island dressing to his order, putting the whole thing on rye bread. You can make them on small sandwich rolls for your next funeral lunch. Bon Appetit, baby! Please go to our webpage for this week's recipe for a Reuben sandwich and additional resources for this program.

This is the part where we ask you for your financial support. Your tax-deductible gift will go directly to supporting our non-profit journalism so that we can remain accessible to everyone. You can donate at www.everyonedies.org. That's every, the number one dies.org, or at our site on Patreon under Everyone Dies.

Marianne? Thanks, Charlie. As part of our series about cancer over the next few weeks, we're going to talk about some of the common symptoms you could get when treatment includes chemotherapy or radiation. This week, our topic is oral mucositis, which is inflammation in and around your mouth.

Continuous or high-dose chemotherapy increases the risk of severe oral mucositis. In the case of radiation therapy, the severity of the mucositis is related to the type of radiation, the dose per day, total dose, and how much of your tissue that is irradiated. Mucositis occurs when cancer treatments break down the rapidly divided cells that line the gastrointestinal tract, particularly in the oral cavity, leaving the mouth tissue open to ulcers and infection.

You might think that this side effect is not really a big deal, but not treating it can have serious consequences. Specifically, developing mucositis puts you at risk for oral complications such as pain, infection, bleeding, and dry mouth. Mouth pain can interfere with your ability to swallow, which puts you at risk for severe dehydration, malnutrition, heart problems, airway obstructions, and problems breathing.

One aspect of chemotherapy is the importance of continuous treatment, but mucositis can result in dose delays, decreased chemotherapy doses, or even discontinuation of treatment. Finally, mucositis can result in decreased quality of life such as psychological distress, problems eating, drinking, and swallowing. Mucositis can occur anywhere along the digestive tract from the mouth to the anus.

Oral mucositis is probably the most common debilitating complication of cancer surgery, chemotherapy, and radiation. It occurs in about 20 to 40 percent of patients treated with chemotherapy alone and up to 50 percent of patients receiving combination radiation and chemotherapy. The consequences of mucositis can be mild, requiring little treatment, to severe like low fluid volume, electrolyte abnormalities, and malnutrition that may result in deadly complications.

Taste loss tends to increase in proportion to the aggressiveness of the cancer treatment. Nausea, pain, vomiting, diarrhea, a sore or dry mouth may make eating difficult. So maintaining suitable nutrition is a challenge for people living with cancer.

Low caloric intake can lead to weight loss, loss in muscle mass strength, and other complications including a decrease in immunity. You might think this symptom is no big deal, but you put yourself at risk if you don't report it to your healthcare practitioner. Chemotherapy and radiation to the head and neck prevent cells in the mouth and the GI tract from reproducing, which makes it hard for tissue to be repaired.

The mouth has a delicate balance of natural bacteria and fungi, so if you receive any one or both of these therapies, it can lead to a decrease in salivation, you know, spit in your mouth. This decrease in salivation upsets the natural balance of bacteria in the mouth, causing infections, mouth sores, and tooth decay. It's important to know who is at risk of mucositis and prevent complications to help improve quality of life and make the most of your cancer therapy.

These risk factors include radiation to the head and neck, high dose chemotherapy, bone marrow transplantation, certain single agent and anti-cancer drugs, or a combination of these. Symptoms of mucositis should be treated as soon as they appear. It's important to be educated about proper nutrition and oral hygiene to help prevent or lessen these symptoms.

Once you're aware of proper nutrition, you'll be able to maintain adequate hydration, maintain your immunity, and help prevent nausea as well as protecting your teeth. Prevention will not stop mucositis from occurring, but it can help lessen some pain and reduce some of the side effects and symptoms of mucositis. The first step in prevention is to see if your health care practitioner can recommend a dentist that works with people living with cancer.

You'll need to have your teeth and gums evaluated and if you wear dentures to make sure that they fit properly. If any work is needed, like teeth extractions or refitting of dentures, it should be completed at least one month prior to starting therapy to help make sure your mouth has completely healed and prevent damage to your existing teeth, gums, or jawbones. The next step to taking care of your mouth is proper brushing techniques and oral hygiene.

If you smoke, it's extremely important that you stop smoking. Your health care practitioner can refer you to smoking cessation programs. You should use a soft bristle toothbrush and brush your teeth two to three times daily after eating.

If necessary, due to sensitivity or mouth sores, you may need to use a foam toothbrush with an antibacterial rinse. You should use mild-tasting toothpaste with fluoride, for example Provident, which is made by Colgate, and there's some coupons in your show notes. Some flavorings of toothpaste may irritate your mouth.

If your toothpaste is still too irritating, you can use a solution made of one teaspoon of salt dissolved in four cups of water. You should gently floss your teeth once daily, and if you have open mouth sores, don't floss. If you develop mucositis or it worsens, you will need to increase brushing to every four hours and at bedtime.

This will help keep your mouth moisturized and help prevent any infections. It's important to brush and floss very gently. If you want to rinse your mouth frequently to prevent cavities with antiseptic mouth rinses, ask your health care practitioner for recommendations for products to use, for example Paradex or Periogart.

You can make your own rinse by mixing one teaspoon of baking soda in eight ounces of water or half a teaspoon of salt and two tablespoons of baking soda dissolved in four cups of water. If you're being treated with high-dose chemotherapy or have had a bone marrow transplant, your health care practitioner can give you some medication that can prevent or shorten the duration of mucositis. Your mouth may become dry and you'll want to keep it moisturized.

This can be due to a decrease in your spit production or the mucositis directly. Some easy remedies include chewing ice chips, chewing sugarless gum, or sucking tart candy. If these do not work, there are artificial saliva products that your physician could prescribe for you, or there's some over-the-counter products that are available like oral balance.

Since your saliva barrier is compromised, it's been disrupted because of the treatment, you should avoid drinking or eating products containing sugar to prevent cavities. Pain is also a very serious complication of mucositis. Aspirin-containing products and non-steroidal anti-inflammatory products like Motrin or Naproxen should be avoided due to their effect on platelets, which can increase the risk of bleeding.

You can also use topical products like OraGel or some prescription products like viscous lidocaine or a product called GelClear. If the pain becomes more severe, you may need your doctor to prescribe you something stronger like Vicodin or Percocet or Tylenol with codeine. To help clean oral sores, you can rinse with a solution consisting of one part 3% hydrogen peroxide and two parts salt water, which is a teaspoon of salt mixed in four cups of water.

Saliva helps protect the mouth and the gums from infection. These infections can be bacterial, fungal, or viral in nature. For mild fungal infections, topical oral suspensions or dissolving tablets can be prescribed.

You'll need to swish or dissolve the medicine in your mouth and, depending on your healthcare practitioner's directions, either swallow or spit out the medicine. But what's important is to hold the solution in your mouth as long as possible. It's important not to use any medicine containing alcohol because it's going to burn your mouth, as well as drinking alcohol.

That will burn your mouth too and it's going to make your mucositis worse. For worsening fungal, bacterial, and viral infections, your healthcare practitioner will need to prescribe oral medication such as antibiotics to treat them. You should also remove any dentures or dental appliances and soak them in antiseptic solutions like Listerine or Paradox.

And actually, if you're wearing dentures and you have these mouth sores, it's probably a really good idea just not to wear them. I know that that's hard, but it'll make your mouth heal that much quicker. So here are some things you can do to help feel more comfortable if you have mucositis.

Sip water or sugarless drinks that do not contain caffeine. Suck on, do not chew, ice chips. Apply lanolin-based lip balm often.

Keep it in your pocket. Use it regularly. Use sugar-free chewing gum or sugar-free candy to stimulate saliva production.

If you use a mouth rinse, choose one that is alcohol-free. If you use a mouth rinse, choose one that is alcohol-free. Use a humidifier at night because that'll keep a lot of moisture in the air, which will help your mouth.

Avoid salty or spicy foods. Limit or don't use alcoholic beverages. And stop using any tobacco.

In our third half, Charlie has some nutrition facts to help you through your cancer treatment. So Charlie, have any questions about mucositis? Yeah, you lost me when you mentioned no alcohol. That's just a personal thing with me.

Gosh, it's, gosh, there's so much there. Okay, well, okay, so let me ask you. If someone can't swallow, what happens? Well, it depends on sort of their health before it all started and how long it's been going on.

If necessary, they can go into their ER or at their cancer center, get an IV. Small sips of water might be able to, you know, get past that pain. Or I mentioned viscous of lidocaine, which you swallow and it sort of anesthetizes the back of your throat so you don't feel the pain.

But it can be dangerous for some people because they can choke because they can't feel their throat. So it's prevention, as always, is the best thing. Even if you're taking chemotherapy while it's being infused, you could hold ice in your mouth to help keep the mouth protected from the chemo getting into those tissues.

But I think what's important with any of our podcasts is that forewarned is forearmed, is that the saying? Where if you know that this can happen, you say, okay, here's the things I'm doing so that I can prevent this from happening. And you might still get it, but it won't be as bad if you follow some of these guidelines. And I put a lot of resources in the show notes for additional things that you can read about this.

But, you know, do your best to try to prevent it and you'll feel a lot better. And, okay, so just as a quick recap, what are some of the things to prevent it? Well, you can hold ice chips in your mouth while you're getting treatment, making sure that your mouth stays moist, keep that moisture barrier going by sipping water or sugarless drinks that don't have caffeine in them. Use a lanolin-based lip balm to keep your lips nice and moist.

You can chew sugarless gum or sugar-free candy to keep the saliva production going so that you keep your mouth nice and wet. Use humidifier at night, avoid salty or spicy foods, limit alcohol, and stop using tobacco. And brush your teeth.

Oh, great, now I have to brush my teeth on top of it. No, no, of course you do, yeah. And be gentle, be gentle.

Don't go in there like gangbusters and, you know, you want to be gentle with those tissues and just keep them clean and moisturized. Ah, okay. No, no, thank you for that checklist because, I mean, you always have such, you know, great information.

Sometimes for me, I just need to narrow it down to, okay, here's one, two, three, four, and five, so thank you for that. And there's also, like I said, in the resources, there's lots of other, you know, like even if you need to make your own checklist of, okay, check off, put a star next to every time you brush your teeth or whatever. Yeah, that's true because, I mean, a couple of times, I mean, I've been very lucky.

I don't get sick that often, but yeah, when a doctor has told me, okay, you need to do A, B, and C for the next, I don't know, you know, two or three weeks, Charlie, I don't, you know what, I just realized, I do that. On a post-it, I'll put, you know, the three or four, you know, a list of the three or four things I need to do, and I stick it in my bathroom mirror. Thankfully, I have not have had to do that very often, but yeah, there it is right there in black and white, and it just reminds me to do this because better, you know, the old saying about an ounce of prevention is worth a pound of cure.

Right. Yep. Our third half begins with nutritional tips, which will help if you are experiencing dehydration, taste changes, decreased appetite, or pain with eating.

Number one, eat small frequent meals throughout the day. Two, try to have a balanced diet to maintain energy and your immunity. Three, avoid spicy, hot, or cold foods if it is painful to eat or if you're having nausea.

Eat food that is a little bland and at room temperature. Four, drink lots of fluid, broth, or drinks like Gatorade. This will keep you hydrated.

Five, eat food high in calories and protein to maintain weight and nutrition. Take vitamins and minerals recommended by your healthcare practitioner. Six, if your mouth is too sore, eat soft or blended foods like ice cream, pudding, soup, and applesauce.

Seven, zinc supplements may help with taste changes. Talk to your healthcare practitioner about this. Eight, prescription medications are available to help increase appetite.

Again, ask your healthcare practitioner about this. Nine, avoid your favorite foods when you are receiving chemotherapy. You may develop a taste dislike to them and not want to eat them when you're feeling better.

Ten, use mild spices or flavoring to make your food taste better. Eat whatever you can tolerate to maintain weight. And finally, Holly Butcher posted her advice to the world 24 hours before she died of cancer.

This was her message. It's a strange thing to come to terms with your own mortality at 26. We go through life expecting tomorrow, planning for the future, and imagining growing old.

I dreamed of a life filled with love, children, and laughter. Cancer had other plans. Now I see how fragile and precious life is.

Every day is a gift, not a guarantee. I didn't write this to make anyone fear death, but to remind you not to sweat the small stuff. Appreciate the now.

Be grateful for your body. Move it, feed it well, and don't waste energy hating it. Stop fixating on flaws that won't matter in the end.

Instead, breathe in fresh air, soak in nature, and take in the beauty of simply being alive. Spend your time on experiences, not things. Don't miss a beach trip because you bought another dress.

Hook a meal for a friend. Write them a heartfelt note and say, I love you. Often.

Wine less, help more. Give generously. It brings more joy than anything money can buy.

And value people's time. Show up, be present, and put down your phone. You don't need a perfect body, a high-paying job, or an Instagram-worthy life.

Do what makes your heart happy. Say no to things that drain you. And if something makes you miserable, change it.

And please, donate blood. It gave me another year with my loved ones, a year filled with some of the best memories of my life. That gift meant everything.

Till we meet again. That caps the end to this week's episode. Please stay tuned for the continuing saga of Everyone Dies, and thank you for listening.

This is Charlie Navarrete, and from actor Cillian Murphy about his character Peaky Blinders, he's not afraid of death. So, no, I can do anything I want. And I'm Marian Matzo, and we'll see you next week.

Remember, every day is a gift. This podcast does not provide medical advice. All discussion on this podcast, such as treatments, dosages, outcomes, charts, patient profiles, advice, messages, and any other discussion are for informational purposes only, and are not a substitute for professional medical advice or treatment.

Always seek the advice of your primary care practitioner or other qualified health providers with any questions that you may have regarding your health. Never disregard professional medical advice or delay in seeking it because of something you have heard from this podcast. If you think you may have a medical emergency, call your doctor or 911 immediately.

Everyone Dies does not recommend or endorse any specific tests, practitioners, products, procedures, opinions, or other information that may be mentioned in this podcast. Reliance on any information provided in this podcast by persons appearing on this podcast at the invitation of Everyone Dies or by other members is solely at your own risk.