Being Mortal by Atul Gawande (February 2018)
I recently reread Atul Gawande’s Being Mortal, an exploration of how the medical profession is meeting the challenge of advising aging patients as they begin to consider the many options available to them for end-of-life care. As I recalled from my first read, it was a comprehensive account of the many factors involved when physicians are challenged to make the best decisions for patients and their families in situations where fixing or healing the patient is no longer the obvious course of care.
The uncomfortable question medicine will always grapple with is how to know it is time to stop recommending additional treatment. In a rich country such as the USA, there will always be one more round of care available through an extravagant option such as an experimental treatment or a last-ditch surgery. Gawande suggests that doctors often struggle at this stage with the reality of a disease and are more comfortable discussing the pros and cons of the remaining treatment options than they are discussing whether or not to stop treatment. This is a fair enough point, I think, but it does make me wonder if there are hidden reasons why it is implied that doctors are less capable of discussing ‘non-treatment’ options with their patients.
The strongest possibility I could come up with is that doctors understand the realities of non-treatment options and simply do not think they represent the best decision in most circumstances. This makes sense given the poor reputations boasted by certain nursing homes or assisted living facilities. The reality of this perception is perhaps reflected in the way these facilities are setup to appeal not just to prospective residents but also to caregivers and primary decision makers. Those concerned with how doctors are advising their patients on end-of-life options should remember that the better the non-treatment options are, the more likely it will be that doctors will recommend these options to their patients.
In some cases, the non-treatment options are very limited in their scope. The illness is simply too advanced in these cases and palliative measures may not be good enough to keep the terminal patient comfortable. The idea of ‘assisted suicide’ is becoming a more common option for these situations. In general, society battles against suicide because we understand most suffering to be temporary. This is perhaps especially true of the suffering brought on by mental or emotional health challenges. In the case of certain illnesses, however, we understand that suffering is NOT temporary but rather a permanent condition that will only worsen as the patient continues a long, steady decline. If a patient wishes to end such a life on his or her own terms, who is another person to intervene?
The idea of this option makes sense to me and I think its increasing acceptance around the world foreshadows its (eventual) full adoption here in the USA. Already, there are simple examples – like removing a breathing apparatus or feeding tube – that essentially are forms of assisted suicide. However, there is something unsettling to me about assisted suicide, especially if those in the medical profession are enlisted to help carry out these decisions. I don't think the response to my discomfort, though, is to rail against progress or look for ways to bolster ‘slippery slope’ arguments that I would use to debate against the idea.
Instead, I’m brought back to the earlier thought about doctors advising their patients – a good way to discourage one option is to make the alternative better. Options such as assisted living are challenging because they are hard. But if done correctly, the possibilities are significant for patients and their families. As Gawande points out in Being Mortal, assisted living is harder than assisted suicide because its possibilities are greater. I’ve been privileged to witness many wonderful moments firsthand through my volunteer work with hospice. The opportunity to experience these moments with friends and loved ones should be extended to as many patients as possible, I feel, but it will take a lot of work to build up our network of non-treatment options to provide the support and care every patient needs to live each remaining day to the fullest.
