Dr. Atul Gawande, a surgeon, Harvard professor and author, has offered another perspective on dying in a New York Times article. Its title, “The Best Possible Day,” hints at what is to come. [1]
He first expresses his frustration as a physician with dying patients he cannot fix and as a son whose father in his 70’s was having mounting difficulties. As a result, he conducted research by interviewing over 200 people about their experience with aging or serious illness.
The most fundamental discoveries of this research were two. “First, . . . we have failed to recognize that people have priorities that they need us to serve besides just living longer. Second, the best way to learn these priorities is to ask about them.”
For a physician like himself, he concluded that the most important questions to ask the patient to discover their priorities are these:
- “What is their understanding of their health or condition?”
- “What are their goals if their health worsens?”
- “What are their fears?”
- “What are the trade-offs they are willing to make and not willing to make?”
Gawande then offers the example of one of his patients, a woman in her early 60’s who had battled a rare pelvic cancer, but two years later developed a leukemia-like malignancy caused by her prior cancer treatment that was incurable by established means.
After having a conversation with Gawande about her goals and fears and priorities, she determined that her most important priorities were returning to her home from the hospital and resuming her beloved piano teaching. Making these two things happen “took planning and great expertise.” But it happened for the last six weeks of her life.
Her husband later said, “She was more alive running up to a [piano] lesson and for the days after.” She still had “some things she wanted . . . [her students] to know before she went. It was important to her to be able to say her goodbyes to her dear friends, to give her parting advice to her students.” At her last recital with the children, she had “taken each student away from the crowd to give a personal gift and say a few words.” She gave a book of music to Gawande’s daughter and whispered, “You’re special.” The dying woman made that day “the best possible day” for herself and for her students.
Gawande also reports that physicians need to know and remember that “[p]eople want to share memories, pass on wisdoms and keepsakes, connect with loved ones, and to make some last contributions to the world. These moments are among life’s most important, for both the dying and those left behind.”
Thank you, Dr. Gawande, for this important reminder to us all. I look forward to reading your new book, Being Mortal: Medicine and What Matters in the End, which sounds like a continuation and elaboration of your New York Times article.
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[1] Gawande’s essay is more profound than Dr. Ezekiel Emmanuel’s essay about wanting to die at age 75, which has provoked a lot of reactions.
Comment: Review of Dr. Atul Gawande’s “Being Mortal” Book
The review says the book reveals the impact on Dr. Gawande of “his grandfather’s extraordinarily long and atypically happy old age, his wife’s grandmother’s extremely long and typically unhappy old age, and his own father’s struggle with age and illness.” Indeed, according to the review, the book shows a physician “socked in the gut by age and infirmity unfolding in one’s own family — an experience that has to be the world’s finest postgraduate medical education.”
The reviews concludes that the book “is an acknowledgment that serenity and well-being actually cannot be dished up cafeteria-style — and that sometimes the only sure way to gain control is first to relinquish it, whether to a bad disease, a dying patient or the constraints of a finite life span.”
The author of the review is Dr. Abigail Zuger, an Associate Professor of Clinical Medicine at Columbia University College of Physicians and Surgeons and Senior Attending Physician at New York City’s St. Luke’s-Roosevelt Hospital Center. She is a board-certified internist and infectious disease specialist with particular interest and expertise in HIV infection. She also is a frequent contributor to the “Well” blog on the New York Times website and the author of a book about an HIV clinic.
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Dr. Abigail Zuger, Don’t Spoil the Ending: ‘Being Mortal’ Explores the Benefits of Setting Goals for Death, N.Y. Times (Oct. 7, 2014),http://www.nytimes.com/2014/10/07/health/being-mortal-explores-the-benefits-of-setting-goals-for-death.html?ref=health. Dr. Zuger’s biography, http://www.jwatch.org/editors/u030; Dr. Zugar’s book, http://www.amazon.com/Abigail-Zuger/e/B001KEAURI; Dr. Zuger’s blog contributions, http://well.blogs.nytimes.com/author/abigail-zuger-m-d/.
Comment: Another Review of “Being Mortal”
According to Dr. Paul McHugh, a professor of psychiatry at Johns Hopkins University, Atul Gawande’s Being Mortal “describes learning how to extend those limits [of the mortal body]—and discovering how to respect them, in the case of terminal illness, in ways that neither he nor his patients anticipated.”
In fact, Gawande “argues for the importance of palliative care for the terminally ill—especially the palliative services organized in a systematic fashion by hospice groups. He ardently believes that such services and treatments fall within the scope of the modern surgeon’s concern.” This is “a forceful case for palliative care and hospice services—with their capacity to sustain life’s quality out to the end.”
McHugh, Going Gently Into the Night, W.S. J. (Oct. 17, 2014), http://online.wsj.com/articles/book-review-being-mortal-by-atul-gawande-1413501104
Comment: Yet Another Review of “Being Mortal”
Paula Span gives a favorable review to Dr. Atul Gawande’s “Being Mortal,” although she says other books and articles have covered the issues discussed in the book. Yet because of Gawande’s deserved reputation as an excellent writer already has made it # 3 in the New York Times list of best selling hardcover nonfiction and the subject of a public television “Frontline” documentary to air in January 2015.
Span, A Doctor Discovers Dying, N.Y. Times (Oct. 21, 2014), http://newoldage.blogs.nytimes.com/2014/10/17/a-doctor-discovers-dying/?ref=health; Don’t Spoil the Ending, N. Y. Times (Oct. 6, 2014), http://www.nytimes.com/2014/10/07/health/being-mortal-explores-the-benefits-of-setting-goals-for-death.html?_r=0; A Prescription for Life’s Final Stretch, N.Y. Times (Oct. 16, 2014), http://www.nytimes.com/2014/10/17/arts/being-mortal-by-atul-gawande.html?src=me.
Comment: Interview of Atul Gawande
Dr. Atul Gawande is interviewed in the print version of the October 26th New York Times Book Review about what books he currently is reading, his favorite doctor in fiction, books that influenced his decision to become a doctor, the best self-help books and what author he would like to write about Atul’s own life.
Online is an expanded version of the interview in which he talks about books he is embarrassed not to have read (“War and Peace”); and what he plans to read next.
Most interesting for me was his following identification of books he would recommend to an aspiring doctor:
• “Tolstoy’s ‘The Death of Ivan Ilyich.’ It’s the best portrayal of sickness and suffering I have ever read — minutely observed, difficult and still true a century and a quarter later.
• “Great writing on illness and mortality extends vastly beyond works by doctors, and I can’t let the opportunity go without mentioning at least a few more of my non-doctor favorites: There’s Anatole Broyard’s amazing memoir of his own dying, ‘Intoxicated by My Illness,’ Anne Fadiman’s ‘The Spirit Catches You and You Fall Down’ and Joan Didion’s ‘The Year of Magical Thinking. Oh, and Sylvia Plath’s ‘The Bell Jar,’ Ken Kesey’s ‘One Flew Over the Cuckoo’s Nest’ and William Styron’s ‘Darkness Visible.’ And I can’t leave out Thomas Mann’s ‘The Magic Mountain’ or Virginia Woolf’s ‘On Being Ill.’ These all deserve readers of any kind. . . . [Those] of us work in health care . . . have a particular responsibility to understand what people experience when their body or mind fails them. Our textbooks and manuals aren’t enough for that task.”
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By the Book: Atul Gawande, N. Y. Times Book Review (Oct. 26, 2014), http://www.nytimes.com/2014/10/26/books/review/atul-gawande-by-the-book.html?ref=books.
Comment: Dr. Gawande’s Conversation with Charlie Rose
On October 27, 2014, Dr. Atul Gawande was interviewed on the “Charlie Rose Show,” http://www.charlierose.com.
Comment: Research about Hospice Care
An article by Paula Span starts, “Helping dying patients have the best possible remaining life, followed by a good death, is really the purpose [of hospice care].”
A new study by Brigham and Women’s Hospital in Boston concludes that hospice care is also less expensive than nonhospice care. “It matched two groups, each containing more than 18,000 older Americans with metastatic cancer, comparing patients who enrolled in hospice with those who had the same poor prognosis but didn’t use hospice. The researchers tracked participants in both groups until their deaths.”
“The hospice patients had far fewer hospitalizations and less than half as many intensive care unit stays . . . . They endured half as many invasive procedures. They were five times less likely to die in a hospital or nursing home. [The result,]“care in the last year of their lives cost an average of about $8,700 less than for the nonhospice patients. Costs for patients in the nonhospice group were $71,517 on average in the last year of life, compared with $62,819 for those in hospice.”
Echoing Dr. Gawande’s copmments in the main post, Dr. Ziad Obermeyer, an emergency physician and health policy specialist at Harvard Medical School and the author of the study, referred to his own experiences in a busy urban emergency room. “We see so many people with end-stage diseases, and they’re still getting very aggressive treatment. I’m often the first person to discuss end-of-life care with them, even though they’ve seen a whole list of doctors.”
“Such conversations often prove difficult, but they’re particularly tough in an emergency room, he pointed out, when ‘you might have a five-minute window in which to make an important decision’ — like whether to put a patient on a ventilator.”
“People who opt for hospice are different from those who decline it, Dr. Obermeyer acknowledged: “Hospice is the way people express their preferences about what kind of care they get.”
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Span, An Easier Death, and Less Costly Too, N.Y. Times (Nov. 20, 2014), http://newoldage.blogs.nytimes.com/2014/11/20/an-easier-death-and-less-costly-too/?ref=health.