On mortality and frailty

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Atul Gawande explores the limitations of modern medicine

Photo: Prudence Upton

Dr Atul Gawande’s latest book, Being Mortal, attempts to understand human fragility beyond the medical viewpoint. It offers a deep insight into how medical advances with an “urge to fiddle and fix” have lost sight of some key questions about the meaning of life. Gawande, a surgeon from Boston, author of four books and a staff writer for The New Yorker, was at the recent Sydney Writers Festival, speaking to a packed auditorium at the Sydney Opera House. He spoke about dying, what courage means in the face of mortality and about dying with dignity.

As we grow older and are made aware of our fragility, our priorities change. We want to shape our life story even towards the end, but unfortunately, Gawande admits frankly, the medical profession is yet to recognise this.

“People have priorities than just living longer and you need to tailor medical options to help them meet these priorities,” he says.

Asking some key questions early on in treatment, can help the patient can live a meaningful life to the end.

Gawande gives the example of his father who developed a spine tumour and became a quadriplegic. More than anything, his father wanted the ability to have interactions with family and friends over the dinner table at least once a week. This defined his medical treatment. When chemotherapy started taking over his ability to interact, he wanted it stopped. This is the change in the care paradigm that Atul Gawande wants to see.

Gawande asks some curly questions concerning his profession and how society treats the aged.

With the unceasing pace of medical innovation, we live longer. This is great- when we have our independence, but sooner or later, it becomes impossible to live on our own. As elders grow infirm we want them to be safely housed in a nursing home to receive the best possible care, but it has been found that depression increases when a person is institutionalised.

“Why is it that we want safety for those we love and autonomy for ourselves?” Gawande questions. Home is a place where you get the freedom to make the choices. “Can we go to the fridge in the nursing home and take out food when we want? Can you choose your room-mate in the nursing home? Taking away choices from the aged is what matters most to them.”

Gawande advocates the need to change the way we design and run nursing homes.

Photo: Tim Llewellyn

What matters the most at the end of life is different for different people, and doctors and carers of the aged have to acknowledge this.

Giving his personal example, Gawande says he would be “happy to be a Stephen Hawking” as long as he could interact with others and have a sharp mind, but his wife expressed her wish that she wanted to be kept alive only so long as she “looked happy”.

Dr Atul Gawande is scathing about the present state of affairs where many medical interventions are pointless. Over-treatment and over-diagnosis has increased.

“Spinal surgeries for back pain have more than tripled and yet the disability levels have not changed at all. More than half the population ends up with a CT or MRI scan,” he points out.

When asked by an audience member what he thought about euthanasia as a patient’s choice, Gawande replied that not offering this option to some people can certainly be cruel, but often the motive behind people wanting to die is due to causes we can alleviate. Patients in severe pain in poorer countries, without basic narcotics, often prefer death to pain. It is also an alarming situation when an elderly woman wants to die because she feels she is a burden.

“Our goal should not be offering a good death, but a good life, until the very end,” says this thoughtful doctor.

What a doctor needs to ask a fatally ill patient

This open discussion should inform the treatment

> What is your understanding of your current health or condition?

> If your current condition worsens, what are your goals?

> What are your fears?

> Are there any trade-offs you are willing to make or not?

> (And later) What would a good day be like?

 

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Jyoti Shankar is a freelance writer and sustainability professional, who is passionate about nature
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