By Chet Yarbrough
Written by: Dr. Atul Gawande
Lecture by: Robert Petkoff
“Being Mortal” is about life’s last chapter. Atul Gawande is an American surgeon and experienced author who is well qualified to write about human mortality; i.e. Gawande’s exceptional qualification is from a Stanford and Harvard education, and personal family’ experience. As a doctor, he understands the medical profession. As a son of a father that dies from complications of cancer and old age, Gawande experiences firsthand the complex nature of decision-making when one’s life is nearing its end.
Gawande admits to an early ignorance of appropriate medical practice when dealing with terminal patients. “Being Mortal” reveals the critical importance of understanding the desire of medical service customers when death is courting or firmly wedded to life. As death is a partner in life, it begins with belief that life, like marriage, lasts forever; neither is believed to end, until it does. Modern medical treatments focus on treating the ravages of fatal disease and old age as though they can be defeated. That focus is warranted by the medical profession but it does not address customer’s fears, desires, and needs. Gawande notes physician’ focus on medical treatment rather than medical customer’ concern is often counterproductive. If an operation or medical treatment threatens a core desire of a medical customer’s quality of life, decisions must come through collaboration.
Gawande explains that doctors are principally trained to treat symptoms and causes of disease. “Being Mortal” suggests a medical customer’s desire at the end of life is as important as medical treatment. Gawande suggests modern medicine, by training, education, and experience, is frequently biased toward treatment rather than quality-of-life issues. Quality-of-life is a big part of the conscious and subconscious concern of terminal patients. Gawande argues that medical treatment for terminal patient’s is often too narrowly focused. If medical treatment only offers misery and pain from disease or old age, continuation of life should be a collaborative decision between doctor, patient, and family.
Gawande gives examples of medical customers ranging from professional’ to blue-collar’ workers who are treated for terminal conditions without conscious consideration of what options are available, based on patient choice. Often, a medical customer’s choice is subverted by families that choose nursing home’ security over complications of independent living. Gawande argues that medical customer’s wishes should be clearly understood by doctors and families before decisions are made for treatment.
Gawande offers a history of treatment of the elderly and terminally ill. In the past, extended families often (particularly in countries other than the U.S.), took care of aging parents, and terminally ill relations until their death. As old age became more common in the world and hospital’ beds became more available, extended-family care of the elderly and terminally ill diminished. Care of the elderly by extended families morphed into retirement community’, nursing home’, assisted living’, and hospice’ industries. These industries took over management of older and terminally ill people; in part, because dependent adults (patients) did not want to be burdens to their families.
However, Gawande suggests institutionalization isolates the elderly and terminally ill; i.e. institutionalization encourages medical treatment by professionals based on symptoms rather than quality-of-life’ concerns. Because families are less involved in care of the terminally ill, and largely relieved of its consequent burdens, doctors and families fail to ask medical customers about their needs, fears, and concerns. Gawande hastens to explain that it is not because doctors or families do not care. Doctor’s focus is on physical conditions and medical treatment while families are principally concerned about loved one’s safety; often at the expense of quality of life.
Gawande brings his explanation of medical treatment for the elderly and terminally ill full circle. A complete physical is not complete without a careful examination of an elderly person’s feet. Despite the aches and pains of old age, one of the biggest threats to elderly quality of life is physical instability; i.e. the threat of falling and breaking bones. Patients with terminally ill disease know what a good day means in their remaining days. Medical treatment becomes more focused on what increases good days; rather than palliative treatment for illness or old age.
Doctors and institutions are now more likely to ask questions about quality-of-life issues with terminally ill patients. Independent living communities have added quality of life services that provide people more independence, based on different levels of bodily health. Hospice home care is a rising industry that allows elderly and the terminally ill to stay in their homes longer. Doctors question the terminally ill about what is most important for them to enjoy the remaining days of their lives. Treatment is focused on treating maladies that diminish a terminally ill patient’s joy in life. Treatment is customized to fit the reality of one’s mortality with an eye to what makes life worth living. Medical treatment emphasis is on patients living in the good moments of their remaining lives. Happiness is center stage when determining what medical treatment is required. If pain is the most inhibiting quality of a medical service customer’s enjoyment of life, than treatment of pain is the priority.
Gawande suggests medical treatment should be customized to increase the number of moment to moment enjoyments that make life worth living for the elderly and terminally ill.
There is no cure for death.