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Atul Gawande on "letting go" at life's end

Medical innovations have enabled us to wring a few more days, or months, out of life for the terminally ill; and anyone who's lost a loved one knows the outsize value of an extra hour.

But as Atul Gawande, MD, works out in a heart-breaking New Yorker piece, aggressive end-of-life intervention often comes at great cost: We spend thousands of dollars on chemotherapy, surgery and intensive care stays, often depriving patients of the chance to be with family, enjoy physical touch and stay mentally aware as they approach death:

The hard question we face, then, is not how we can afford this system's expense. It is how we can build a health-care system that will actually help dying patients achieve what's most important to them at the end of their lives.

In "a war you can't win," Gawande says, "you don't want a general who fights to the point of total annihilation." So why do many doctors try to beat back the inevitable with medicine's heavy artillery?

[M]any people argue that the key problem has been the financial incentives: we pay doctors to give chemotherapy and to do surgery, but not to take the time required to sort out when doing so is unwise. This certainly is a factor. (The new health-reform act was to have added Medicare coverage for these conversations, until it was deemed funding for "death panels" and stripped out of the legislation.) But the issue isn't merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is-what, in other words, we should and should not be paying for doctors to do.

Rather than attempting a summary of the essay, I'll only say, go read it. At the risk of sounding macabre, it's an issue we all have to confront at one point or another.

Related: In commencement address, Atul Gawande calls for innovation around "entire packages of care", The high-cost capital: Key to health reform? and Facing mortality

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