Negotiating life’s thresholds

In an article in the Aug. 2 issue of the New Yorker, the surgeon/writer Atul Gawande MD considers Americans' ars moriendi, the art of dying — or rather our lack of one. There are some interesting parallels with birth, such as our society's propensity to throw technology at situations that often might be better left to nature, taking its course in its own time.

What I found fascinating was the honesty with which Gawande writes about his own discomfort with talking with patients who are looking to him to guide them through a fundamentally human experience, one his skills as a surgeon don't equip him to handle.

Of the team of physicians treating Sara Monopoli, a young mother dying of lung cancer, Gawande writes:

You’d think doctors would be well equipped to navigate the shoals here, but at least two things get in the way. First, our own views may be unrealistic. A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than forty per cent of oncologists report offering treatments that they believe are unlikely to work. In an era in which the relationship between patient and doctor is increasingly miscast in retail terms—“the customer is always right”—doctors are especially hesitant to trample on a patient’s expectations. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught. When you have a patient like Sara Monopoli, the last thing you want to do is grapple with the truth. I know, because [Monopoli's oncologist, Dr. Paul] Marcoux wasn’t the only one avoiding that conversation with her. I was, too.

Gawande had been called in to talk with Monopoli about surgery on a secondary, treatable thyroid cancer. Though he thought she would die long before the thyroid cancer became a serious problem, Gawande relates miserably dancing around the subject of death with her.

Determined to be more honest in talking with patients with a poor prognosis, Gawande tried to communicate the stark truth as he saw it to a woman with advanced colon cancer. After she went on to have a better-than-expected recovery,  she told Gawande that their early conversation had made her feel "as if I'd dropped her off a cliff."

In a long section on the importance and nuance of effective communication, Gawande concludes that "the words you use matter."

It appears that conversation — just words — during a terminal illness might help people avoid medical interventions. Gawande cites a 2004 initiative by Aetna insurance company that allowed terminal patients to proceed with aggressive medical treatment, while at the same time using the emotional supports of a hospice facility. (The two approaches are not typically used together.) The patients' hospital stays decreased by more than two-thirds, and the cost of their care went down nearly a quarter.

"The program’s leaders had the impression that they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough—just talking," Dr. Gawande writes.

He writes,

We pay doctors to give chemotherapy and to do surgery, but not to take the time required to sort out when doing so is unwise.... But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.

My apologies to Gawande for shoehorning his thoughts on death into this ongoing discussion of birth, but I think his honest consideration of a doctor's role in helping people negotiate life's last major threshold is worth thinking about relative to the first.