The writing of this Boston general surgeon has been widely praised by people I admire such as the late Oliver Sacks, and for good reason. His writing is informative and straightforward, delivering a sober second opinion on issues in modern medicine and American society, opinions that often challenge ‘conventional wisdom’.
The subtitle of this book, Medicine and What Matters in the End, gives the reader a hint- it is all about dying and the failure of modern medicine and modern society to adequately prepare the elderly, the infirm, and the obviously terminal for the inevitable, and to take into account their priorities and wishes. That is not exactly a fun topic to read about but is an important one to think about. Calling up personal experiences with his patients and his family, he documents the inadequacies of the usual approaches in modern medicine and the harm that often results from denial, unrealistic prognostication, and over-treatment, particularly in the oncology field. A strong advocate for the specialty of geriatrics, hospice care, and allowing the dying to remain at home, he shows by example the harm that often comes from hospitalization, overly optimistic treatment recommendations and denial of the obvious by patients, physicians and families alike. This rings true with my own experience, not only with patients, but with colleagues and acquaintances. He correctly points out that for most of human history, death came unpredictably, usually rapidly, and without hospitalization. Only within the last few decades have we delegated the care of the elderly and the infirm to anyone outside of the home and the extended family. Growing up, it seemed natural that my frail grandfather lived with us rather than in a distant institution, and I have vague pleasant memories of him (and sometimes hid his dentures.)
The late Shep Nuland was one of the first in the era of modern medicine to discuss death in frank terms in his 1993 documentary book How We Die, breaking with the long-standing Western tradition of avoiding this unpleasant topic altogether, as shown by the late Ernest Becker’s Denial Of Death. But even the words ‘the late’ seem to me to be a form of euphemistic denial- they are both dead, not just late.
I have some reservations about this book. Surgeons came late and reluctantly to appreciation of the double-blind controlled trial as the gold standard of all kinds of treatment. Gawande cites only one controlled trail of care delivery, and that was designed and conducted by a geriatrician and predictably showed better outcomes for those cared for by geriatricians. Too many studies are designed to benefit those who design them. And even an old agnostic like me noticed the absence of any significant discussion of spiritual matters in palliative care, recognizing, as I do, that religious beliefs can be a very important source of comfort for the dying.
A couple of quotes. “We want autonomy for ourselves and safety for those we love. That remains the main problem and paradox for the frail.” “Assisted living is far harder than assisted death, but its possibilities are far greater as well.”
With all this discussion of dying, and with an unknown personal expiration mode and date, I am still ambivalent about dying at home, as I would prefer to have paid professionals doing the messy unpleasant work, rather than my family. And I dream of being shot dead by a jealous husband, but only if it was justified and not any time soon. Many relatives would be appalled, but even more would chuckle.
The Passionate Reader 