Atul Gawande鈥檚 latest gem: Hospice care and our end-of-life wishes

piece about end-of-life care in the is听another gem听by the surgeon-writer-health policy wonk and staff member at Harvard-affialiated Brigham and Women鈥檚 Hospital in Boston.

In an online听chat听after the article was published, Gawande said he had the usual听preconceived notions about hospice before he听started researching the article:

Telling a patient that you鈥檇 like them to consider hospice now seems to people like you鈥檙e telling them that you want to 鈥済ive up鈥�. 鈥淗ospice鈥�=鈥漨orphine drip鈥� to many people. It more or less did to me, until I actually had a chance to see what hospice was.

Gawande听finds out, of course,听that hospice is neither听the morphine drip nor听withdrawal of care but听care with different goals. And he听refers to research showing that听hospice听actually extends the lives of some people (remember听).听听A nice line from the article:

The lesson seems almost听Zen: you live longer only when you stop trying to live longer.

He听follows听several听patients through their illness and eventual death.听The story of a young mother with lung cancer听is the most affecting, and it听shows that,听despite听everybody鈥檚听best intentions, some听people in the last stages of an illness听endure听the ordeal of tests, more tests, and听treatment after treatment, all of it听accomplishing little.

But Gawande doesn鈥檛 oversimplify.听With听another patient story he听illustrates the difficulty of coming听to terms with听illness or, perhaps more precisely, with听death鈥攅ven after receiving hospice care.听When a听woman听with congestive heart failure and pulmonary fibrosis suffers cardiac arrest, her family calls 911, not the hospice service, because that is what she wanted.听Emergency medical technicians rush in, shock her heart and intubate her (put a tube down her throat in attempt to get more air into her lungs),听to no avail.

Looking for solutions to the 鈥渟eemingly unstoppable momentum of medical treatment,鈥澨鼼awande pays a visit to La Crosse, Wisconsin,听 because of its low听end-of-life hospital costs. 听A听there听 has听encouraged听doctors and patients to discuss end-of-life issues. When听something similar was proposed in the federal health-care reform legislation, opponents characterized it as promoting the creation of 鈥渄eath panels,鈥� and it was removed from the bill.

He also talks to ,听an expert in听end-of-life care at his hospital about how听doctors should talk to patients who are facing a terminal illness.听Talk is part of the problem:听Gwande finds out from his colleague that听doctors do too much of it.听 Part of听Block鈥檚 advice is to sit down, take time, and not focus so much on expounding on treatment X vs. Y but on learning what鈥檚 important to patients.听Gawande writes:

This requires as much listening as talking. If you are talking more than half of the time, Block says, you鈥檙e talking too much.

Of course,听conversations about end-of-life wishes听are not limited to doctors and patients. They also happen鈥攐r don鈥檛 but should鈥攁mong families and loved ones.听This is not听easy terrain. There鈥檚 uncertainty, a welter of medical technicalities, and, as听Block points out, the acceptance of mortality. Now add in all the听swirling emotions and complexities听of family and love relationships鈥攚ell, little听wonder听we struggle to have such听converations.

Gawande ends the听the听on-line chat听by talking about his father, who is also a surgeon, and the treatment choices he was facing for a spinal cord tumor. Gawande鈥檚 father听started to develop early signs of quadriplegia as the tumor grew, but听an operation to create more space for the tumor had a 20% chance of quadriplegia. Gwande says:

I remember, we sat in the living room and I simply began by saying that it would help me if I understood some things about his priorities and wishes. And then I ran through some of Susan Block鈥檚 list: if things get bad, what is he willing to go through to stay alive? If options become limited, what is the way he wants to spend his time? What鈥檚 most important to him, knowing the tumor is eventually not curable? Those kinds of incredibly hard questions. Some he was ready to answer. Some not.

There鈥檚 the strong suggestion that听Gawande鈥檚 father听decided not to have the听operation.

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