Monday, November 24, 2014

Atul Gawande on Being Mortal

Medical writer and surgeon Atul Gawande, author of Complications, Better and The Checklist Manifesto (yep, a book about checklists – which is an unexpectedly BRILLIANT read) just released Being Mortal.

This is not a book about veterinary science or veterinary practice but it is of interest to such an audience in the main because it deals with systematic problems with medicine – problems that will affect us all (if they don't/haven't already).

In this book he reflects on end-of-life care of human patients, including his own dad. 

BeingMortal takes aim at our fetish for medical intervention, right up to someone’s dying moments. It’s something as a vet I’ve come to appreciate. It is common, when I euthanase an animal, for the owner to tell me that they wish that a family member who recently died in hospital could have died at home, without all of the treatment that has become the norm for preserving human life – ventilators, antibiotics in the face of insurmountable infection, feeding tubes and so forth. Of course these technologies have a place, and have saved lives – but sometimes they simply prolong a life, which may not be a life the patient considers one worth living.

He is, as usual, very critical of his profession – in a constructive way. It takes guts to be critical of one’s profession, and I don’t imagine one publishes a book like this without copping inevitable flak. Gawande is also a physician with the maturity to admit and reflect on his mistakes. He recognises his own role in perpetuating the problem. Which makes for compelling reading.

Gawande astutely observes our fetish for intervention, and suggests that medical students may be set up for this early in their careers.

“You become a doctor for what you imagine to be the satisfaction of the work, and that turns out to be the satisfaction of competence. It is a deep satisfaction very much like the one that the carpenter experiences in restoring a fragile antique chest or that a science teacher experiences in bringing a fifth grader to that sudden, mind-shifting recognition of what atoms are. It comes partly from being helpful to others. But it also comes from being technically skilled and able to solve difficult, intricate problems. Your competence gives you a secure sense of identity. For a clinician, therefore, nothing is more threatening to who you think you are than a patient with a problem you cannot solve”.
Agreed. The problem of course is when attempts to do something – because we fear doing nothing- impact on the quality of life of patients.

Much of the discussion is around the care of the elderly, which – though improving in some areas – can be barbaric. Part of the issue is the obsession with safety which is prioritised over and above patient autonomy.

“Nursing homes have come a long way from the firetrap warehouses of neglect they used to be. But it seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.”
He well and truly argues against that conclusion, discussing palliative care and hospice in a way that I’ve not been exposed to prior. And it’s a conversation that all health care professionals – and those who will use their services - should be involved in.

“The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet- and this is the painful paradox – we have decided that they should be the ones who largely define how we live in our waning days. For more than half a century now, we have treated the trials of sickness, aging and mortality as medical concerns”.
The problem is that our population is aging. Now, more than ever, all of us need to consider the important question: when should we try to fix and when should we not? (One of the big revelations for me was the evidence in Gawande’s book that in opting to “not fix” there is still much we can do to improve quality of life).

Gawande argues that there is more to being old than simply being safe and living a bit longer, that the meaning in people’s lives is their ability to shape their own story, that we can ALL work to reshape our aged-care institutions – and even our culture – to improve the quality of everyone’s lives. I was in tears when I finished the book, but they were tears of hope. Gawande’s is a really positive message. This sort of reflection is what should lie at the heart of medicine.

“The battle of being mortal is the battle to maintain the integrity of one’s life – to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe that their job is not to confine people’s choices, in the name of safety, but to expand them, in the name of living a worthwhile life.”
Animals aren’t a big feature of the book – although the ability to keep an animal in a home, hospice or aged care facility definitely improved the quality of life of many – but the content is relevant to anyone, vets, vet students or otherwise. In fact, it’s a book I’d recommend to any mortal. And it’s one I hope my doctor reads!


Gawande, A (2014) Being Mortal: Medicine and What Matters in the End. Metropolitan Books.