Putting focus on good days
Published 7:44 am Monday, August 9, 2010
“What should medicine do when it can’t save your life?” I find this question critical, profound, and almost existential. It is raised by Atul Gawande, a general surgeon, who doesn’t profess to have a complete and final answer, but he contributes essential observations and valid suggestions.
I think I understand this: When we can no longer make people live longer, we must listen to them for what will make them live better in the short time they do have.
Dr. Gawande practices in Boston’s Brigham and Woman’s Hospital as well as teaching at both at Harvard’s medical school and its school of public health.
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I wish it were medical insight or human compassion that drives the question to the forefront of current issues. What does, however, is economics. A quarter of Medicare costs are for the 5 percent of covered people who are in their final year of life. Moreover, most of this is incurred in the last couple of months — and with little apparent benefit. The last six months of the average cancer patient costs $63,000. Chemotherapy requires $8,000 a month. intensive care is $3,000 daily, and surgery is $5,000 an hour.
While we need to address these costs, patients have more immediate concerns, e.g., avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others.
For most of our history, life-threatening ailments and death were a matter of but days or weeks; now people can suffer dying for years before they actually do. In its valiant effort to solve problems, modern medicine has created others with which we are much less prepared to deal. For many, death is certain but its timing is not.
Dr. Gawande observes: “In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.”
I see the conceptualization and practice of medicine undergoing a revolution. As a health educator years ago, I had lectured we need to get away from treating symptoms and focus on causes; as a member of medical centers’ staffs, we practiced this. We so succeeded we created a different kind of patient: those who are beyond healing, beyond what traditional medicine can accomplish.
Happily, a new medical discipline is developing called palliative care, and the hospice movement is its most common expression. “Palliative,” of course, means “soothing anxieties or other intense emotions.” Applied to medicine, it is, ironically, treating symptoms when we can do nothing about causes.
When my great, great grandfather and his son practiced medicine, they knew little science and relied on the art of medicine and achieved not much more than palliative results. Within my lifetime, we moved into the science of medicine with tremendous achievements, and my lifetime is now longer than my parents’. Sadly, many health care providers have all but forgotten the art of medicine rather than adding the science to it. Dr. Gawande and his colleagues are recovering the art.
Recent medical practice has been too obsessed with freedom from pain and discomfort. The concern should be not just how to live longer, but how to live better. The hospice movement has learned, “You live longer when you stop trying to live longer.”
Hospice nurse Sarah Creed asserts she has five seconds to make a patient trust her. “I do not come in saying, ‘I’m so sorry.’ Instead, it’s: ‘I’m the hospice nurse, and here’s what I have to offer you to make your life better. And I know we don’t have a lot of time to waste.’”
Some of the current problem comes from physicians who nervously over-estimate time remaining. Giving reasonable hope is one thing; failing to prepare for reality is another. Recent research, however, shows: “People who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation, and to spare their family anguish.”
Dr. Gregory Thompson, a critical-care specialist at La Crosse’ Gunderson Lutheran Hospital, has taught area physicians to ask their patients very early a series of “Do you want…” questions. By 1996, they had increased advance medical directives from fifteen to eighty-five percent of the patients. While their approach was human compassion, cost savings followed. La Crosse’s end-of-life costs are now less than half the national average.
Dr. Gawande summarizes: “Our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw upon. they need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come….”
Dr. Susan Block, a palliative-care specialist who works with Gawande, learned much when her own father agreed to additional treatment if it would enable him to watch football on television and have chocolate ice cream every day. He got both the football and chocolate ice cream. Not many days followed, but they were good days.