I had read his previous Complications about life as a surgeon several years ago, greatly impressed.
Both books have been highly praised, with the present book listed by the New York Times as among must reads of 2014.
As a surgeon at Massachusetts General Hospital, Gawande knows what he’s writing about.
And he writes well, often movingly, in layman’s language, of death scenarios with their accompanying challenges that need to be individualized, since we’re all different.
I suspect many readers will opt to avoid a seemingly morbid subject, but that’s a mistake, for mortality knows no exceptions and our best approach is one that, through knowledge, provides us with options.
And Gawande, a writer for the prestigious New Yorker as well as a physician, delivers–deftly, compassionately, and always with eloquence, on a difficult subject.
Moreover, his book preeminently addresses the medical community, often committed to treatment paradigms that work against the patient’s welfare.
Physicians are trained to see themselves as enhancers of health and survival. They are not taught how to handle lingering illness devoid of remedy:
…within a few years, when I came to experience surgical training and practice, I encountered patients forced to confront the realities of decline and mortality, and it did not take long to realize how unready I was to help them (3).
If your problem is fixable, we know just what to do. But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity, and extraordinary suffering (8).
What’s the point, anyway, of continuing chemotherapy, radiation, and surgery in terminal cases when such methodologies may involve great risk and, often, increase duress?
When, in short, should doctors, not just patients, let go?
Patients cling to hope and doctors knowingly feed into this, when frequently no regimen can procure that miracle of restoring health and dignity.
Or as Gawande vividly makes clear in his allusion to Tolstoy’s powerful tale, The Death of Ivan Ilyitch:
What tormented Ivan Ilyitch most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result (2).
The ultimate challenge for physicians is to accept the restraints of biology and assist their patients to come to terms when that moment arrives
Otherwise, they can inflict considerable, even barbaric, suffering.
Doctors need to be patient-centered, addressing the patient’s best interests, and sometimes the greatest kindness entails being candid..
Ultimately, it’s about providing patients with options that preserve dignity, lessen suffering, and are in accord with the patient’s priorities.
We’ve made some progress in the now universal acceptance of Advanced Directives, though initially contested. But what about options for the terminal patient, still conscious, who lingers, often in great pain, and with perhaps even greater to come?
Gawande says that there are two dominating physician protocols: the one patronizing (this is what you should do); the other, informative (here are your scenarios).
Doctors do better when they ask the right questions of their patients in such contexts:
Whenever serious sickness or injury strikes and your body breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make or not willing to make? And what is the course of action that best serves this understanding? (259)
Palliative care, for example, may well be a better option to further surgery, chemotherapy and radiation when the outcome may make matters worse.
On the other hand, indulging patient fantasy may invoke “a prolonged and terrible death” (4).
Gawande carries out what he advocates. For me, his account of his father’s lingering passage into mortality is deeply moving, which I think many of us can identify with in our own wrestlings with the demise of those we love.
In addition to all of you, I wish every medical practitioner would read this book.
Death isn’t an enemy, but the natural order of things.
How much better it would be in our final moments to have someone like Gawande attending–a physician, with compassion, listening and helping us discern those best options that enhance our dignity and lessen our suffering.