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Atul Gawande on End-of-Life Care

By: 
Renee Despres
Wednesday, October 24, 2012 - 13:02

Atul Gawande tackles some of the most difficult questions in health-care in his recent article for the New Yorker titled "Letting Go": How do we die, and what role should health-care play in the final moments of our lives? When we become terminally ill (as we all will someday), should health-care providers focus on extending lives or on improving the quality of the time we have left?

Gawande, a general surgeon and prolific writer (not only is he a staff writer at the New Yorker, he’s authored three books and numerous other articles) offers a thoughtful exploration of the choices we make – and the choices that are made for us – at the end of our lives. He takes the subject of end-of-life care decisions out of the inane “death panel” debates that accompanied the discussions of health-care reform and puts it smack dab where it belongs: into a discussion of patient autonomy, dignity, and respect.

Reading Gawande’s article brought back one of my first experiences as a health-care provider. I was working in the emergency room at a small hospital in Pueblo, Colorado when the transport team brought in a man in his late 80s. He was unresponsive, barely breathing, frail, dehydrated. Even to my inexperienced eye, it was obvious that the life in him was sustained only by the multiple machines, medications, and tubes that were attached to or inserted in his body. As the rookie in the room, it fell to me to “bag” him – that is, manually squeeze oxygen into a tube in his lungs, using a device called a “bag-valve-mask” (BVM). I squeezed the bag in concert with his own feeble attempts to breathe for almost four hours while a respirator was procured from a nearby hospital and the on-call respiratory therapist summoned from her slumber.

I can’t remember all the procedures performed that night, more than 14 years ago, but I clearly remember the words of the nurse on the floor where we eventually transferred the patient. Naively, I asked what had precipitated the ambulance ride, the all-out efforts in the emergency room, and the ache in my wrists after four hours of squeezing the BVM. “Oh, he’s been like that for nearly two years now,” she said. “He just received about $40,000 in medical care, and he’s never going to wake up again. His daughter just can’t let him go.”

I remember feeling shocked at the nurse’s harsh appraisal of the care we had rendered that night in terms of cost – and at the same time wondering how many children could have been vaccinated for the price of that one night’s visit. Like my friend the nurse, Gawande doesn’t shy away from the harsh facts about the cost of health care for the terminally ill:

The soaring cost of health care is the greatest threat to the country’s long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.

Yet those costs, Gawande suggests, are only a symptom of the real problem. Few physicians (or other health-care professionals) have any idea how to provide high-quality care to people at the end of their lives, although many know how to treat their illnesses. Conversely, while many people may know what kind of care they’d like to receive at the end of their lives, few people how how to get that care.

Training health-care providers to help people make choices about their end-of-life care will in itself lead to cost savings — not as a goal, but as its own “side effect.” The most humane, ethical, and effective health-care measures for are are also cost-effective. Yet the work of hospice providers and palliative care physicians remains mysterious to too many other health-care providers. These dedicated crews help people focus on making what’s left of their lives better – getting out with friends, seeing family, visiting a favorite place for a last time. Innovative programs are cropping up here and there — like “Sentimental Voyage,” where hospice workers team up with ambulance service to provide “last ride” services to transport homebound, terminally ill people to the places they’d like to go. Most of the requests they receive aren’t grandiose. They range from Christmas shopping for family members in July, seeing a fireworks show, a granddaughter’s birthday party, and more.

Those requests reflect a core piece of human nature: We are social beings, even when we are terminally ill and reaching the last moments of our lives. When we focus on preserving our connections and relationships with others, we gain the path to a dignified death, and our survivors have a chance to let go. As Gawande writes:

People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding sufferinging with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives.

Almost two weeks after its publication, the article, titled “Letting Go,” remains in the “most popular” slot in the New Yorker’s online line-up. Let’s hope it stays there for a long while.