Quality matters. It's not just quantity that counts towards the end of our lives, and in fact, most people would choose "good time" over "any time." Physicians know this but for many reasons we can't always help patients have the best life possible before death.
Dr. Atul Gawande recently did an interview with the Washington Post on the subject, and it felt authentic. While admire his work, I do not consider myself an unconditional devotee. However, this article is truly amazing.
It is a call to action. He graciously and decisively invalidates all the excuses that physicians create to not tackle end-of-life discussions with patients, confessing some of the challenges along the way.
Some of my favourite excerpts are here:
HP: One tough question. I watched your lecture today with some primary care physicians. Their reaction was to say, “Of course all this information about the need for conversation in end-of-life care was revelatory to you, Dr. Gawande. You’re a surgeon.” In your telling of the story, how much did the culture of specialty care fail to prepare you adequately for the challenges recounted in your book?
AG: Look I’m a surgeon--highly procedural, geared towards always being able to offer something more. It’s no surprise that this field did have prepared us formally for these kinds of conversations. Furthermore, I’m in an academic medical center, high-end Mecca. Many people come there because they want that experimental therapy, the last ditch maneuver against all odds.
. . . If these [end of life] conversations are so important--and people across other fields seem to know it--we’re still not having them. It’s not happening for two-thirds of people with advanced cancers for example. We have evidence that these conversations are even less likely to happen for other common things people die of: congestive heart failure, for example.
Maybe that’s because families and patients tend to move on to a specialist rather than the primary care doctor for these conversations, but I often find primary care doctors aren’t having them, either.
HP: Even if they had the skill to have the conversation, that’s not really who the patients are looking to for these conversations.
AG: If you look at the studies, they find that having a palliative care doctor or geriatrician more closely involved in care can lead people to forego aggressive therapy sooner and have better outcomes--not only less suffering but even improved survival. But we don’t have enough of these doctors to go around. Furthermore, there’s something wrong with the idea that you outsource this kind of decision-making and discussion.
HP: One of your book’s saddest quotes comes from a hospice patient, who says: “The oncologist and the heart doctor told me that there’s nothing more they can do for me.” It’s as if palliative care and hospice are the consolation prizes we give you when we really can’t do anything more.
AG: . . .
Even when we are needing to handoff, I’m involving someone who is going to have palliative care or hospice or primary care team. I’m not involving them because there’s nothing more I can do. I’m involving them because we require other people’s expertise to help us achieve what we’re trying to do.