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Sonoma Medicine

The magazine of the Sonoma County Medical Association

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CURRENT BOOKS
Breakpoint Discussion

Rick Flinders, MD, and Jessica Flinders, FNP

Being Mortal: Medicine and What Matters in the End,
Atul Gawande, MD, Metropolitan, 304 pages (2014).

 Atul Gawande has done it again. With his writer’s craft, he has directed a surgeon’s precision at yet another of the great maladies of his profession. Writing chiefly from The New Yorker since 1988, he has dissected, among other topics, the systemic malady of medical errors (Complications, 2002) and the high cost of medical care (“The Cost Conundrum,” 2009). Now, in Being Mortal, he tackles the burden of owning up to the often delusional stubbornness of our cultural persistence in denying the reality of death. Prolonging, at any cost, life of often dubious and miserable quality has become the modus operandi of a largely undirected and incoherent medical system. At the heart of the discussion is our own mortality. As the contemporary American poet Mary Oliver concludes in her memorable poem “On Blackwater Pond”:

To live in this world
you must be able
to do three things:
to love what is mortal;
to hold it
against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go.

Both of us (Rick and Jessica) practice in settings with considerable experience of the elderly. In addition, we are both old enough to take mortality personally: our patients’, our own, our  spouses, our parents, even our children. Gawande writes: “The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and ICUs—where regimented and anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully to the very end, we have allowed our fates to be controlled by the imperatives of medicine, technology and strangers.”

In Being Mortal, Gawande carefully and compellingly lays out the case for a more enlightened and compassionate approach to the care of our frail elderly. Like many in our profession, he is appalled by the increasingly excessive treatment of the terminally ill. Who among us has not witnessed our own best efforts to prolong life often succeed only in prolonging dying? We’ve all heard, from more than one patient: “I ain’t afraid of death, Doc. It’s the dying that scares me.”

Gawande is acutely aware of the danger of a physician, sworn to preserve life, writing about the inevitability of decline and death. “Mortality can be a treacherous subject,” he writes, “No matter how carefully you frame it, people are going to accuse you of fostering a society prepared to sacrifice its sick and aging.”

We all remember how the legitimate debate for incorporating the benefits of hospice care into the Affordable Care Act degenerated into the specter of “death panels.” But what if the sick and the aged are already being sacrificed, Gawande asks, “as victims of our collusive refusal to accept the inexorability of our own life cycle?”

A significant portion of Being Mortal examines evidence for better approaches to dying, with better outcomes, that Gawande says are “largely ignored, waiting to be recognized.” As in all his written work, Gawande’s timing and methodology are impeccable. He blends the facts of our aging epidemiology with stories of our elders’ fear of dying and their experience of getting old and sick. In the foreground is the story of his own father, also a physician, written in a direct and delicate voice. Gawande never stoops to melodrama, yet he tells the tale we are all living through as a people and a nation. According to him, the institutional care of our elderly is not only Dickensian in tone, it occurs in settings and inside walls that would fit into the chapters of the coldest and darkest Dickens.

While Gawande’s narrative is informative on the demographics and experience of aging, he also directs us to look past the external circumstances of illness. Listen and learn from the patient. In perhaps the best chapter of Being Mortal, Gawande writes about the “hard conversations” we have with patients. One of these he has come to call the “breakpoint discussion” and urges us to ask these four questions:

• What is your life like right now?
• What are your fears?
• What are your goals?
• What trade-offs are you willing to make in order to achieve your goals?

Gawande’s father, for example, was willing to live as a quadriplegic as long as he could eat chocolate ice cream and watch TV. Closer to home, an acquaintance of ours recently said that he would accept almost any quality of life as long as he was free of severe pain, could sustain his own nutrition, and both recognize and communicate with his loved ones. The answers for each person are unique, personal and unpredictable—and they change with time and experience. While the answers are important in themselves, they also provide a framework for the conversation and process to continue. If death is the last illness we still don’t speak about, the “breakpoint discussion” is a way of opening the conversation. 

Rick recently attended his 50th high school reunion. It was sweet and sobering. Sweet to see old friends, but in a sidebar on the invitation was a somber catalog of nearly 80 others who would not be attending the reunion—not because of travel distance, but because of the inconvenient truth of death. Among the old friends who did attend, the topic of conversation was not the prospect of dying, but rather the fear of going bankrupt from medical expenses trying to prevent death—as if the spiritual and existential issues surrounding our mortality weren’t enough.

Just as modern medicine medicalized childbirth a half century ago, it has now medicalized death and dying. These processes have been abducted from the cultural and social context that centuries of civilization developed for family and community.

Dr. Gayle Stephens, the recently deceased founding father of family medicine, feared becoming a patient more than dying. He asked:  

“Must death continue to be a tawdry, privatized, sanitized farce played out in institutional settings like so many crucifixions? Can not we as physicians, who collectively have contributed so much to the horror that makes everybody yearn for a quick and painless death, give some leadership in restoring death to the dignity of its communal roots, and help make it mean something again, not only for the dying but also for the living?”

This is strong language from a medical elder who earned, over a lifetime of practice and teaching, the right and credibility to be heard. At the age of 85, he had to negotiate, vigorously and contentiously, with his university doctors to be released to hospice care and go home to the care of his family.

The Declaration of Independence speaks of the “unalienable rights” of life, liberty and the pursuit of happiness. Given our current circumstances, as so compellingly depicted by Gawande, we may need to add to these the right to be allowed a natural death. ::

Dr. Flinders, who teaches hospital medicine at the Santa Rosa Family Medicine Residency, serves on the SCMA Editorial Board. Ms. Flinders is a family nurse practitioner at Northern California Medical Associates in Petaluma.

 
Emails: flinder@sutterhealth.org
rickjess@sbcglobal.net

SONOMA MEDICINE  |  Winter 2015  |  Sonoma County Medical Association

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