Tuesday, July 27, 2010

Atul Gawande New Yorker Article "Letting Go"

I want to draw people's attention to a fantastic new piece in the New Yorker by Atul Gawande titled, "Letting Go: What should medicine do when it can't save your life?"  The stories told are raw and emotional, and offer glimpses into the struggles of patients with life-threatening illnesses, family caregivers, nurses, and physicians.  The hospice nurse in the article is both empathetic and very direct at the same time, in a very Boston sort of way.   I was trained by the physicians mentioned in the story (Block, Marcoux, Morris, Nowak, and even Gawande for a day).  These are some of the best physicians in the world.  And yet these stellar physicians - including Susan Block, perhaps the world's foremost communication specialist - struggle to talk with patients and family members about the one clinical event everyone is 100% going to experience: death.  Gawande does an outstanding job weaving patient stories, research findings, and health policy with the inner perspectives of physicians and nurses.   He gives the richest and most heartfelt account I have seen of the current state of the national convesation on death, difficult conversations, costs of care at the end-of-life, and quality of life.  I recommend that everyone read it.  Please share your thoughts in the comments.

by: Alex Smith

5 comments:

Helen Chen said...

Thank you for the post, Alex. Gawande’s article is truly remarkable and richly expands the discussion re: dying in America.(We have a hard time with 'death' but we sure know a lot of euphemisms for it: http://community.nytimes.com/comments/schott.blogs.nytimes.com/2010/07/09/weekend-competition-kicking-the-bucket/?sort=oldest&offset=2&scp=2&sq=euphemisms%20for%20death&st=cse).

Isn’t it ironic that what people seem to want is what we often find difficult to give: the time, attention, and ability to have meaningful conversations about what really matters to them during critical stages of their lives? And it isn’t just the geripal community that needs to read this, learn this, and do this difficult and sometimes heartbreaking work-- I was so encouraged to read that one of the heroes of the piece was the primary care physician. First of all, he was willing to be there. (How many of us ‘primaries’ let the service attendings or the hospitalists handle these challenging conversations?) But most of all, he had the concern, the ability, and the courage to help the family face the fact that no amount of tertiary care was going to stop the cancer. Isn’t that the kind of physician we want in our room, irrespective of “specialty”, when our own time comes?

Wendy S. Harpham, MD said...

As a physician/survivor, I encourage everyone not to let the length of Gawande's article dissuade them from reading it.

Dr. Gawande offers us useful insights on the highly complex and emotionally charged topic of end-of-life.

In one article, he brings together important truths, such as the notion that "doing everything" can - and often does - impair patients' quality of life in dramatic ways. And although it may nourish hope of lengthening life, in reality it often shortens life.

Gawande also helps us see why and how clinicians often encourage patients and their families to keep "fighting" death in ways that are not liken to help and are surely going to interfere with quality end-of-life care.

Here are links to short articles on (1) negotiating the difficult transition to hospice care and on (2) balancing hope and acceptance at the end-of-life. I hope your readers find them useful:

http://tinyurl.com/OT-071006

http://tinyurl.com/OT-122506

With hope, Wendy

Alex Smith said...

Thanks Helen and Wendy. I would like to see more about the role of the primary care physician. Would be great if the New Yorker picked a primary care doc next (Jerome Grupman is a neurologist, and Atul Gawande is a surgeon).

For those of you interested in hearing more from Atul Gawande on this subject, he will be interviewed by Terri Gross today (Thursday). For those in the Bay area listening to KQED, it will air at 1pm and 7pm.

sei said...

As usual, excellent reading from Dr Gawande. One thing that struck me was how young patients were. The firefighter was 42. The primary character Sara was in her 30's. Ms Cox was the only one who was older at 72. Clearly not a representative sample of the dying folks in America.

I'm not sure what to think about this. It could be random, it could be Dr Gawande's practice. It could be that stories of dying young people are much more...poignant? compelling? But it seems important to note for this community.

Jan Henderson said...

In the live exchange at the New Yorker site a few days after the article, Gawande wrote: (http://tinyurl.com/2aqan74)

“Telling a patient that you’d like them to consider hospice now seems to people like you’re telling them that you want to ‘give up’. ‘Hospice’=’morphine drip’ to many people. It more or less did to me, until I actually had a chance to see what hospice was. So now we talk about “palliative care” as a way of not talking about hospice—or death for that matter.”

I was wondering if people here think that’s a fair and accurate statement.

Then he says: “But already that’s beginning to change.”

I thought he was going to say “Now we’re able to talk about hospice as distinct from palliative care.” But he gives this example.

“I was just recently called in to provide surgical consultation on a patient in the hospital with a metastatic cancer that is at end stage. She is getting sicker by the day and I’m not sure she’ll be able to leave. Her medical team asked if they could get palliative care involved. She was adamantly against it. ‘I’m not ready to give up,’ she argued.”

I was surprised to see such a stark equation of palliative care with end-of-life. I’m sure this is an issue you’ve discussed here many time before.

I wonder how people learn about palliative care. From personal experience with friends and family? From news media? I assume there’s no one out there purposely creating misinformation (like death panels), so where does this idea come from? When I first learned about palliative care through the Internet it was very clear that it included the relief of pain and suffering during non-terminal illnesses.

Perhaps the Gawande example is not typical, and thus it’s misleading when it suggests how the perception of palliative care is changing. This woman, consciously or not, is dealing with the nearness of death. So for her, palliative care means giving up. A patient with a different prognosis may have a different understanding.

A friend of mine died last year after living with a diagnosis of leukemia for a year and a half. I watched her oscillate between strongly fighting the disease and wanting to make peace with her death. It was a roller coaster. I assume patients with a terminal illness would have different attitudes towards palliative care depending on their state of mind.