Dying and in denial: a new book offers a powerful dissection of contemporary end-of-life care, yet misses the underlying problem.

AuthorGoldhill, David
PositionBeing Mortal: Medicine and What Matters in the End - Book review

Being Mortal: Medicine and What Matters in the End, by Atul Gawande, Metropolitan Books, 304 pages, $26

THE NEAR-UNIVERSALITY of a slow death is a triumph of modern medicine. Our success in managing what had been rapidly fatal diseases has essentially created a new phase of life--a period of physical and mental decline that can last for many years. But as Dr. Atul Gawande argues in his new book Being Mortal, rather than take advantage of the possibilities of these bonus years, we've allowed them to be defined by the ultimately futile struggle merely to survive. We've turned over the last years of our lives to the medical profession, which has, in Gawande's phrase, "almost no view at all ... of what makes life significant."

Being Mortal traces Gawande's evolving realization that the default values of his profession conflict with the needs of his dying patients. At the core of this disconnect is mutual denial--both the patient's (or her loved ones') difficulty accepting that death is inevitable and the physician's difficulty accepting that his skills can't defeat this ultimate foe.

Mutual denial leads directly to excessive treatment, as physicians try anything to maintain the patient's--and their own--hope that they are effectively battling disease.

Gawande describes end-of-life care as the equivalent of distributing very low-odds lottery tickets on survival at massive cost. "The waning days of our lives," he writes, "are given over to treatments that addle our brains and sap our bodies for a sliver's chance of benefit." Often, treatment fails even this low standard. For example, the widespread use of multiple prescription drugs by seniors substantially increases their risk of catastrophic falls.

Gawande contends that in our age of "informed consent" and "shared decision-making," a doctor can hide from true candor through accurate disclosure--by becoming "Dr. Informative." What is needed instead is an emotionally honest conversation with a dying patient about what she wants for her remaining time. Such conversations require physicians to see that medicine's purpose is broader well-being, not just physical health. This requires the emotional sensitivity to know when a patient and her family are ready to have that conversation, a skill peripheral at best to prevailing medical culture.

At the core of Being Mortal is the poignant story of the decline and death of the author's own father. A proud and accomplished man, Gawande's dad is determined that his cancer not interfere with his career, his charitable projects, his civic activities, or even his tennis game. As Atmaram Gawande's cancer slowly spreads, and as the associated incapacities and embarrassments grow, the author struggles to have the very discussion with his father that his book urges physicians to have with their dying patients. "We had trouble finding anywhere safe for conversation to take purchase."

This is despite Gawande's father and mother both being practicing physicians. All three know exactly what is happening physically, but if anything, that makes candid discussion more awkward. Ultimately, Gawande senior's irrepressible energy drives the correct balance of treatment and capacity: He still has too much to do to settle for being merely kept alive.

This highly personal example best illustrates Gawande's central point. The approach of mortality isn't essentially a medical challenge. It's a highly personal one, centering on individual choice and priorities. The...

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