LTC Bullet:  Being Morbid

Friday, February 13, 2015

Seattle—

LTC Comment:  We’ll review Dr. Atul Gawande’s new book Being Mortal about the modern American way of dying after the ***news.***

*** Attention documentary fans:  Regarding the topic of today’s LTC Bullet, also of interest is this article “Atul Gawande on why doctors often fail their dying patients” in The Washington PostFrom the article:

Atul Gawande brought his best-selling book on end-of-life care, ‘Being Mortal,’ to the small screen Tuesday night in an hour-long documentary providing a deeply intimate look at patients in their final days, their families, and the doctors wrestling with patients' expectations — as well as their own. The consistent thread in the PBS ‘Frontline’ documentary is just how hard it is for doctors to have honest conversations with their patients about end-of-life care. ***

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LTC BULLET:  BEING MORBID

LTC Comment:  Morbidity scares me a lot more than mortality.  The unbearable pain and suffering come first.  Death is just the final release from all that and  

The heart-ache and the thousand natural shocks
That flesh is heir to; ‘tis a consummation
Devoutly to be wished.  (Hamlet

So I think Dr. Atul Gawande’s new book Being Mortal: Medicine and What Matters in the End focuses on the right topic:  how we die, the process of dying.  Instead of helping the terminally ill live the best life possible as long as possible, our medical system emphasizes heroic, often poisonous and painful, measures to sustain life regardless of quality.

Don’t misunderstand.  Dr. Gawande does not advocate euthanasia.  In fact, he criticizes its creeping (and creepy) advance in parts of Europe.  He writes with passion and authority, often from deeply personal examples, about needless end-of-life misery and ways we might better help individuals reach the end with dignity and fulfillment.

One problem.  I listened to the audio version of the book so I don’t have a hard copy from which to craft a review with quotes and illustrations.  Luckily several excellent reviews of Being Mortal have been published in the national media.  Some quotes from those and links to them follow.  For my part, suffice it to say I recommend the book.

First, Gawande’s own website has this to say here:

Medicine has triumphed in modern times, transforming the dangers of childbirth, injury, and disease from harrowing to manageable. But when it comes to the inescapable realities of aging and death, what medicine can do often runs counter to what it should.  Through eye-opening research and gripping stories of his own patients and family, Gawande reveals the suffering this dynamic has produced. Nursing homes, devoted above all to safety, battle with residents over the food they are allowed to eat and the choices they are allowed to make. Doctors, uncomfortable discussing patients’ anxieties about death, fall back on false hopes and treatments that are actually shortening lives instead of improving them. And families go along with all of it.

My favorite of the independent reviews is The Guardian’s available here.  It begins by recounting the myth of Tithonus whom the goddess Eos made immortal but, alas, neglected to ensure his health.  He withered away with age but couldn’t die.  The review summarizes: 

If the first half of his book concerns nursing homes and how we can age with self-respect, the second half concerns palliative care and how we can die with grace. The stunning victories of medical science over the last century have, according to some critics, left too many doctors arrogant and unwilling to concede defeat (the militaristic clichés are essential to this vision of medicine and the body). We’re waking up to that mistake now: hospice and palliative care are at last receiving the attention and the funding they deserve; helping our patients through a good death is increasingly acknowledged to be as important as helping them flourish while alive. Much of the second half of the book concerns the health system of the US where Gawande practises, and where the hospice movement and the provision of community palliative care are relatively undeveloped compared to those in the UK.

The New York Times’ review by Timothy Egan, available here, focuses on Dr. Gawande’s development as a surgeon and the evolution of his ideas about death and dying.  It concludes:

But patients who receive good geriatric care stay happier and healthier, just as old people who can remain at home and aren’t forced into nursing homes are better able to enjoy their lives. This book makes a thorough inquiry into how the idea of the assisted-living facility arose as a supposed improvement on regimented nursing homes but has often become a disheartening place for independent-minded people to have to go. The all-important quality-of-life issue that is used to market such places, Dr. Gawande maintains, is directed more toward the people planning to leave Mom than toward Mom herself. But he sees a lot of hope in the group living concept, if it is overseen with the residents’ happiness in mind.

Reason magazine has a different take here

If Gawande had been willing to address the systemic causes of medicalized death, he could have had to face a difficult question: How can we reconcile his hope for personalized end-of-life care with the large, centralized institutions (Medicare and private insurers) that are the system's actual customers? Gawande's whole point is that objectively "needed" care has little meaning when it involves a person who is dying. The course of treatment must be based on personal preferences, on finding the correct balance of treatment and life's objectives that he so eloquently prescribes. But how can a centralized payer—in this case Medicare—ever drive the correct set of incentives for a world of personalized care?  It can’t.

Whatever the cause of the current end-of-life medical malaise, every human being has a stake in resolving these problems.  For anyone interested in and concerned about the critical issues of death and dying, including the integral role of long-term care, Being Mortal is a book not to be missed.