We all want to rely on our doctor to fix us, help us make medical decisions, and support us in stressful periods when our health, our partner’s health or our parent’s health is precarious. In Being Mortal, Atul Gwande, a practicing surgeon and author of three bestselling books, admits that doctors often don’t do these things, explains why, and offers ideas of how doctors could help patients facing end of life decisions. Gawande explains that doctors are taught to save lives, not how to help patients live until they die. Doctors use aggressive treatment to battle death, even when they know there is little chance of the treatment affecting the final outcome for the patient. He cites research and tells stories of his own patients and family which reveal the suffering that modern medicine can inflict on the dying process. Gawande admits that sometimes doctors try so hard to extend life that they end up shortening it and reducing quality of life.
After he follows a hospice nurse on her rounds, observes a geriatrician in his clinic, and learns about how nursing homes could innovate to individualize care, Gawande suggests conversations that doctors, nurses, caregivers, and family members should have with frail and or terminally ill people. Gawande knows that these conversations are no easier for doctors than for family members, but when he started having these conversations with patients, he knew he was doing better by them. A colleague of Gawande’s, a nationally recognized palliative care specialist, Susan Block, trains doctors to talk with their patients. She suggests that each time a treatment choice needs to be made with someone whose health is deteriorating, the following questions can clarify what treatment steps to take or not take:
- What is your understanding of your situation and its potential outcomes?
- What are your fears about what lies ahead? What are your hopes?
- What kinds of trade-offs are you willing or not willing to make if the worst happens to you?
- How do you want to spend your time if your health worsens?
- Who do you want to make decisions if you can’t?
Asking these questions can lead to what Swedish doctors refer to as a “breakthrough discussion,” conversations which help sort out when someone needs to switch from fighting for time to fighting for other things they value, like being with family or taking a last trip to a beloved place, or enjoying apple pie.
In my next blog, I will discuss another theme in Gawande’s Being Mortal, where are you going to live when you need health care support?