“It’s really long, and it will make you cry” doesn’t sound like much of an endorsement. (It is, and it will.) But Atul Gawande’s article, Letting Go, is a profoundly moving exploration of end-of-life questions that we all need to consider.
When battling a terminal illness, at what point should treatment shift from staving off death to, instead, making the remaining days as rich and fulfilling as possible?
Most terminal patients and their families choose, quite understandably, to continue aggressive (oftentimes experimental) courses of treatment, regardless of how remote the chances of success or how debilitating the side effects. We hope against hope that our loved one will, in effect, win the lottery and become the outlier on the life expectancy charts.
This is human nature. It’s also modern medicine doing precisely what it was intended to: prolong life. But it isn’t a palliative approach (taking into account not only physical but also social, emotional and spiritual conditions), and it eventually comes into conflict with the thing we value most of all, which is to prolong living. Having lucid, heartfelt conversations with the people we love. Being outdoors and feeling the sunshine and breeze on our skin. Going out to dinner with friends. Eating chocolate ice cream.
There’s a common misconception that hospice care hastens death, a waving of the white flag as the patient forgoes further treatment in favor of higher doses of pain relief. In fact, studies show that the opposite may be true.
“In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer.”
When patients enter into a hospice program, they begin to confront—together with family, doctors and caregivers—the painful but necessary questions about how to prioritize their time left. They talk about how they want to live. And how they want to die. And it’s the act of talking about it that seems to make all the difference. In a study by the national Coping with Cancer project, two-thirds of terminal-cancer patients had no discussions with their doctors about their goals for end-of-life care. But the third who did:
“[W]ere far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive-care unit. Two-thirds enrolled in hospice. These patients suffered less, were physically more capable, and were better able, for a longer period, to interact with others. Moreover, six months after the patients died their family members were much less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation, and to spare their family anguish.”
Swedish doctors refer to this as the “breakpoint discussion,” a series of conversations that help determine when to “switch from fighting for time to fighting for the other things that people value.”
I confess that I write this as someone who has yet to confront these decisions. It’s easy for me to advocate Gawande’s approach; I’m not faced with the prospect of losing somebody I desperately want to keep with me. But my dad turned 80 this past year, and my mom, who’s struggled with numerous health issues, is only slightly younger. Theory will become reality before too long.
When it does, I hope we have the courage to value living, not just life.
Photo credit: Kevin Rawlings
