Health Column: Dysfunctional Dying in America
MOHLER’S MEDICATION MAXIMS
Free Press Health Columnist
In polite company, I was taught that one does not discuss sex, politics or religion. Atul Gawande, a practicing Harvard general surgeon and author, in his opening paragraph of “Being Mortal, Medicine and What Matters in the End” would add “dying.” He says, “I learned a lot of things in medical school, but mortality wasn’t one of them.”
Later he comments that the closer we all get to death, the less we discuss dying. Initially I was put off that this book was another doctor/medicine-bashing diatribe, but 10 pages in I changed my mind. This is a deeply personal, passionate, (and compassionate) call to arms about our current dysfunctional, medicalized approach to the processes of getting older, sicker, and dying.
“Being Mortal” is filled with cold, hard facts: “Falling is our biggest risk as we get older;” “physicians consistently over-estimate how long their dying patients will live;” and “40 percent of oncologists admit offering treatments that they believe are unlikely to work.” The real strengths of this book, however, are the true stories that Dr. Gawande relates about his patients and his own family members who get old, sick, and die.
A recurrent theme in these patients’ stories is that the physicians (he includes himself) are often unable to have the “difficult discussion” with their declining patient. Doctors are unable to have the dialogue that points out the futility of the fifth cancer drug, another course of radiation or a trip to the operating room. We physicians are impotent to initiate discussions that will help prepare the patient for what is to come.
Dr. Gawande suggests, “We’ve created a multi-trillion-dollar edifice for dispensing the medical equivalent of lottery tickets — and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win.” As medical advances have progressed, it is almost always possible to offer some form of treatment, Gawande writes, but the question that all too often is overlooked is whether treatment will lead to a better life. Frequently, the late-in-the-story-of-life interventions not only do not “help” the patient, but cause harm.
Dr. Gawande’s military analogy rings true. “The simple view is that medicine exists to fight death and disease. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war you cannot win, you don’t want a general that fights to the point of annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end.”
GAWANDE ON NURSING HOMES
“Nursing homes were never created to help people facing dependency in old age. They were created to clear out hospital beds.” “The three plagues of nursing homes: boredom, loneliness and helplessness.”
GAWANDE ON THE NEEDS OF THE OLD & FRAIL
“People, readily demonstrate a willingness to sacrifice their safety and survival for something beyond themselves such as family, country, or justice.” “ … Older people interact with fewer people …” “They focus on being rather than doing and on the present rather than the future.”
GAWANDE’S ADVICE TO PHYSICIANS
“As people’s capacities wane, whether through age or ill health, making their lives better requires curbing our purely medical imperatives. We must resist the urge to fiddle and fix and control.”
“Being Mortal” finishes on a poignant, optimistic note, as Gawande tells the story of the final days of his own dying father, who is now fully engaged with a hospice program. Both father and son have found some peace, his dad having achieved some acceptance of what is to come.
In my view, this book should be required reading for all physicians and for anyone else who expects to die.
Free Press health columnist Dr. Mohler has practiced family medicine in Grand Junction for 39 years. He has a particular interest in pharmaceutical education. Phil works part-time for Rocky Mountain Health Plans. Email him at firstname.lastname@example.org
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