Singer Johnny Paycheck once wrote that "there's no easy way to die." Paycheck was a bummed-out country singer lamenting a fizzled relationship, but his tossed-off line is full of existential import. In fact, Paycheck cut to the very heart of a modern medical crisis: the inability of doctors to prepare patients for their eventual deaths.
In his new book Being Mortal: Medicine and What Matters in the End, Dr. Atul Gawande explores the difficulty doctors, nurses and healthcare providers have in giving patients not what they want in their final days, but what they need. The book is rooted in Gawande's firsthand experience.
"As a resident I saw this man who came in, and my job was to get permission (...) for him to get to surgery. He had come in, he was becoming paralyzed from a tumor that had involved his spinal cord, and it was a metastatic cancer throughout his body. He wanted a chance to 'beat this,' as he put it," Gawande said on Boston Public Radio. "This was a guy who was emaciated. It was clear it was his last weeks."
Gawande said the patient was alarmed when he heard what his odds of survival were. "As soon as I talked about the risks and benefits, he said, 'There's a risk that I could die? (...) What are you talking about?' I said, I'm sorry, I'm sorry," Gawande said. "He never made it out."
Gawande said an entirely different approach occurred to him, one that required being straight with patients about prognoses, as well as knowing their final wishes to the letter. "We had not been talking about it with him (...) until he'd been at that crisis moment, beside himself with fear," Gawande said. "You can give [people] a better end-of-life."
Gawande said two imperatives occurred to him after his resident experience. The first was that a doctor must hear how the patient envisions his or her final days. "It may be that [they] want to be cognitively intact, (...) or to be home as much as possible." Gawande said the most reliable way of finding out is just to ask.
The second lesson Gawande took away was that the attitude about death — both patients' and doctors' attitudes — needed to change dramatically. Gawande said we talk about death "as a kind of failure. It's hard for us to feel that it is normal." He said incentives for doctors also need to be there. "I get paid to perform the operation. I get paid very little to have these [end-of-life] conversations," Gawande said.
Gawande said the same scenario he wrestled with as a medical resident has repeated itself many times in his work. His 13-year-old daughter's piano teacher had a recurrence of cancer, and the cancer wasn't responding to treatment. The piano teacher came to him for advice.
"She was now really in trouble," Gawande said. "What we recognized was, well, let's work with that. I think [many people] if given the option of 'death with dignity' in her situation would've taken that option."
Gawande said they worked to maximize the value of her remaining time. "What if we fought for, not longer time, but just for having a good day?" Doctors administered pain meds, and Gawande's daughter's teacher ended up with four weeks at the end of her life, during which time her students played a recital for her. "She got a kind of passing that, you know, in our obtuseness in medicine, we don't provide," Gawande said.
Gawande admitted it's a difficult conversation to have with a patient. "Denial is normal. There are people who all the way through do not" want to address their death. By having the conversation about death "you can harm people, that's one thing that comes across from the evidence. (...) It's really interesting. A palliative care expert or hospice, they treat the conversation the same way [I treat operations]," Gawande said.
Gawande summed up his new book in one sentence: "The goal is to have as good a life as possible, all the way to the very end."
>> To hear the entire interview with Dr. Atul Gawande, click the audio link above.
