Book Review
Atul Gawande. Being Mortal.
Medicine and what matters in the end.
In the introduction the author describes
an early patient of his patient he calls Mr Lazaroff. Mr Lazaroff had widely metastasised prostate
cancer. He was dying and dying imminently. However he was offered a palliative
surgery that might have the effect of slowing the progress of the disease, but
only marginally, and which might also help relieve his pain. However, the
downside was a highly invasive surgery from which it was vanishingly unlikely
that the patient would recover.
The patient chose the surgery. And the
expected outcome occurred. The patient
did not recover well and died within a couple of weeks. The author says: “I
believed then that Mr Lazaroff had chosen badly and I still believe this.” He chose badly not because of all the
dangers, but because the operation didn't stand a chance of giving him back
what he really wanted, his continence and the strength of the life he had
previously known. He was pursuing little
more than a fantasy at the risk of a prolonged and terrible death, which was
precisely what he got.
This book is about trying to avoid Mr
Lazaroff's fate. The author believes that modern medicine has got dying wrong,
that it has changed the way we die and medicalised it without really
understanding what was happening. The result is that far too many people pursue
completely unrealistic hopes at the end of their lives and end up missing out
on what the author calls the “dying role.” He also argues that this problem is
compounded by medicine that the practice of medicine end is complicit in this
travesty of death and dying.
It used to be that people would be
relatively well then get sick and then die quite quickly. The pattern has
changed. Now it is more likely that a person will become progressively
debilitated. The person will have a series of small crises, each one leaving
him or her less well-off, less mobile, less active, than he or she was before.
In addition there is the inexorable course of ageing. We do just wear out. The
combination of these factors is that more and more people are living longer and
longer in worse and worse condition. Add to that the shift in demographics
which means that people now live alone after their children have left home for,
potentially, decades. Decades where they
are independent and self- directed. That
loss of independence that comes with aging comes hard.
The fundamental changes in the nature of
medical care that occurred over the last 50 to 70 years have meant the
proliferation of hospitals and our ability to do far more and to extend the
lives of far more people. However the problems of poverty and the problems of
lack of family connection are not solved by increased medical care in
hospitals. Hence the arrival of long-term care facilities. They are the
repositories of people who do not have the capacity to live alone and whose
families are unable or unwilling to take them in. Or indeed where the resident is unwilling to
be cared for by a family member.
There are changes in long-term care,
changes away from an institutional warehouse model which seems in many cases
just a way of caring for people’s bodies.
There is a shift towards methods of “assisted living.” This approach
requires, in the first place asking people what they want. There is evidence
that if you ask people what they want their answers vary depending upon their
circumstances and, of course, the stage of life that they are at. This means
that the hopes and expectations of elderly people, the desires that they have
for their own lives, are completely different from the desires that they might
have had as younger people. Horizons
contract and the realm of the possible become smaller. But this need not be a
bad thing if we can reconfigure the structures we create to match the things
they want. If so, there is the potential
for people to live rich and full lives in the way that they choose for longer
and longer.
We have lost the ability to die. In the
frantic rush to extend life, to find another cure, to keep going to keep
'fighting' we have missed the point
where it is possible to say goodbye to say what you want, to play the dying
role. This means that people are not able to put their houses in order. They
are not able to say the last things that need or want saying, instead they are
strive for an impossible goal. The result is a loss that everyone feels. And
this emphasis on an unattainable goal is fed and nurtured by the practice of
medicine. Physicians are sometimes, perhaps even often, unable or unwilling to
speak the truth. Many people find it very difficult to identify that this
really is the end.
There is evidence that patients also end
up accepting aggressive treatments, that perhaps they believe won't help, but
which they accept in order to please their families.
If one genuinely understands that a
person has reached the end, and understands that further aggressive treatment
will not only, not prolong life, but may indeed even shorten it, and accepts
even if the treatment does extend life it does so at a terrible price of
quality, then one is free to do something better, to spend that time in far
more worthwhile ways. An acceptance that
these things are true means that one is free to focus at that time in a
person's life on the things that are really important. Some families described
this time as the best time that they have ever experienced. Because now they
have time and indeed the necessity to concern themselves with the things that
they are really concerned about.
Gawande finishes by saying that physicians
have been wrong about the job of medicine. Physicians have imagined that the
function of medicine is to promote health and survival. But he says it is not.
It is really about encouraging well-being. And there I think is the question
for all of us who work in the field of health care. What is “well-being,” how
do we promote it, and how at the end of the person’s life do we ensure that
that life can finish well-lived?
