When Atul Gawande, MD, MPH, witnessed the untimely and inevitable passing of patients, friends and his father, the shortcomings of our medical system’s approach to dying were revealed to him. As the noted author and surgeon told an overflow crowd at Stanford’s medical school earlier this week, he became inspired to “pick up my journalist’s pen” and explore questions about life and mortality that his elite medical education hadn’t equipped him to remedy.
Headlining the eighth annual Cynthia and Alexander Tseng, Jr., MD, Memorial Lecture, the former Stanford undergrad introduced his talk on end-of-life issues with the observation that begins his New York Times #1 book, Being Mortal: “I learned about a lot of things in medical school, but mortality wasn’t one of them.”
In a highly personal, and at times moving, talk, Gawande went on to discuss how decades of modern medical advances have changed our attitudes about dying and death. As fewer diseases and injuries pose life-threatening risks due to vastly improved medications and therapies, people simply expect to live longer. Well-being has become synonymous with longer and more robust life, supported at every stage by effective medical interventions, including a growing market of “lifestyle” rather than life-saving treatments.
Gawande argued that while health and medicine advances are of course positive, one consequence is that we have “medicalized our mortality” to the point where even terminally ill patients and their families look to their doctors for life-saving answers.
“Well, I didn’t [have the answers],” Gawande said.
Gawande said that medicine’s typical approach is to trade time and quality of life in the short term for longer life in the future, but the trade-off isn’t always a good one. For example, aggressive cancer treatment can be debilitating and painful, and often fails to prolong life, merely making the end of life miserable for patients.
In contrast, the goal of palliative care is to create the best possible day for patients today, regardless of what it means for the future. Studies show that for terminally ill patients palliative care improves quality of life, including people’s sense of control and empowerment over their lives. While these positive attitudes may be expected, palliative care practices reduce unwanted medical procedures (as well as costs) and have been shown to actually increase life span - by 25 percent in one study of late-stage lung cancer patients.
“If palliative doctors were a drug, the FDA would approve them,” Gawande told the audience.
Gawande is currently heading up a clinical trial that is gathering evidence on the effectiveness of better end-of-life discussions, through an organization he founded called Ariadne Labs. (The company is named for Ariadne, the Greek goddess who showed Theseus the way out of the Minotaur’s maze using a thread.)
Ariadne Labs aims to provide simple directions to help patients, doctors and families through critical moments in their lives. The backbone of this program is the “Serious Illness Conversation Guide,” which offers seven questions to facilitate meaningful conversation among physicians, patients and families. It focuses on optimizing quality of life for patients based on what matters most to them.
To do so Gawande stressed the need for better communication with patients and families facing end-of-life decisions, and called for doctors to listen to the needs and desires of their patients. He said that doctors tend to be “explain-aholics” and rarely take the time to ask their patients about their values and priorities for the time they have left. When they do, chances are that patients will want to forgo complex in-patient procedures in favor of technology and treatments that enable them to spend more - and more comfortable - time at home.
“We should be able to deploy modern medicine to best meet the goals and desires of patients,” Gawande said.
Michael Claeys is the senior communications manager for the Stanford Cancer Institute. Kris Newby provided additional reporting for the story.
Previously: "Stop skipping dessert:" A Stanford neurosurgeon and cancer patient discusses facing terminal illness, No one wants to talk about dying, but we all need to, On a mission to transform end-of-life care, Atul Gawande on "letting go" at life's end and In commencement address, Atul Gawande calls for innovation around "entire packages of care"
Photo by Norbert von der Groeben