“Modern medicine is good at staving off death with aggressive interventions — and bad at knowing when to focus, instead, on improving the days that terminal patients have left.”
–Dr. Atul Gawande, “Letting Go,” The New Yorker, Aug. 2, 2010
I remember reading this article almost six years ago as nothing more than a mere medical school hopeful. Was it powerful? Absolutely. Gripping? Definitely. Well written? Completely. But for me personally, what it contained in literary value, it lacked in authenticity. What did I know about medicine? Not much, as it turns out. I read the article as an outsider and a layperson: a college junior with an affinity for the sciences trying to gain some perspective. I wanted to familiarize myself with aspects of the field, such as death and dying, that didn’t require a prerequisite anatomy, physiology or pathology course. Six years later, as my third-year clinical rotations come to a close, I revisit this topic of death and dying with a vengeance, and much more perspective.
In today’s America, it is well documented that each year, more of our GDP is being devoted to health care spending, and a disproportionate amount of that health care spending is towards end-of-life care. According to a 2013 report from The Medicare NewsGroup, Medicare spending reached about $554 billion in 2011. This was 21 percent of the total spent on health care in the United States that year. About 28 percent of that $554 billion — $170 billion — was spent on patients’ last six months of life.
In the setting of a financially overburdened health care system, it is this disproportionate spending in the last six months of life that has spurned the hotly debated topic of end-of-life care. This debate has come about, at least in part, due to the advent of modern medical technology. Cutting-edge imaging techniques and dialysis machines, for example, have afforded patients extra life that their parents and grandparents did not have the fortune of experiencing. But at what cost? This is a question that should not be answered solely in a dollar amount. There are anecdotes from hospitals across America with the story of irreversibly ill patients ridden with bed sores, catheter infections and aspiration pneumonias, as physicians subject them to debridements, antibiotics, feeding tubes, breathing tubes and CT scans. Why is this? Is it the doctors’ fault for throwing the proverbial kitchen sink at the patient for fear of being sued? Is it the patients’ families fault for staunchly denying the mortality of their loved one? These are difficult questions to answer, and until I stepped foot in the hospital as a third year student, I was naïve to the debate.
As a third-year medical student, I am the lowest rung on the hospital ladder, but alas, this badge of inferiority has afforded me experiences only unique to a position as lowly as a third year. When patients see my face every day at 5 a.m. for pre-rounds, and again in the morning for rounds, and again for afternoon rounds for weeks on end, the third-year student’s face becomes a sense of familiarity among the foreign landscape of the hospital. We tend to spend more time with our patients than a resident or attending. We are responsible for fewer patients, and as a result, we get to know our patients better. We talk to our patients. We know their favorite meal and we know which professional athletes they hate. We know which sister hasn’t come to visit yet and which grandson just made the honor roll.
On my medicine clerkship, I was fortunate enough to take care of a man who I saw every day for four straight weeks; I’ll call him Mr. P. Mr. P was a 93-year-old gentleman who had lived a “full life,” as he called it, and now was succumbing to advanced congestive heart failure. He had pitting edema up to his mid-thigh, and a jugular venous pulse visible from across the room. Every morning I would ask him how his breathing was and every morning he would give me the same reply. “I feel great,” he would slyly say before catching his breath. “Now stop badgering me and let’s talk some baseball.” The crackles in his lungs were prominent and worsening by the end of the day, despite maximal diuretic therapy. Mr. P and I became close. He told me he was ready to die, and he was not scared. He stated his wish to leave the hospital and live out the rest of his days surrounded by the comfort and familiarity of the home he lived in for the past 53 years. Two weeks and endless blood draws later, he was still in the hospital. It infuriated him, and it infuriated me. I’ll never forget it.
In Letting Go, Dr. Gawande talks about the hardships that families go through when a loved one has a terminal illness. Almost uniformly, families of patients who opted for hospice care had an easier time dealing with the death of their loved one. There was a true sense of closure: a “goodbye” untainted by the beeping machines of an ICU and the clouded mind of a heavily medicated patient. Dr. Gawande also writes about how patients who have end-of-life conversations prior to their death end up spending less time in ICUs, are more physically capable for longer periods of time, and after their death, are less likely to have family members with prolonged periods of depression. In a 2014 article published in JAMA, Obermeyer et al. enrolled over 86,000 patients with poor prognosis cancers in a cohort study of patients in hospice and non-hospice care. The period between hospice enrollment and death for hospice beneficiaries was matched to the equivalent period of non-hospice care before death for non-hospice patients. The results showed that while enrolled in hospice care, beneficiaries were hospitalized less, received less intensive care, underwent fewer procedures and were less likely to die in hospitals and skilled nursing facilities.
Over similar periods before death, most non-hospice beneficiaries were admitted to hospitals and ICUs for acute conditions not directly related to their poor-prognosis cancer. Obermeyer concludes that such care is unlikely to fit with the preferences of most patients. These findings, mashed up against today’s expense-driven health care issues, underscore the need for the medical community to reflect on the dying process. Medical technology will only continue to improve, and this is undoubtedly great for society. Amidst the improvements however, rather than always fighting to keep a human body alive, we must not forget the person who lives in that body. End-of-life patients should be treated as more than just a slim possibility of a marginally prolonged survival time. Gawande adds,
“There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets — and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win.”
As my first full year of hospital clerkships comes to an end, I realized that the paradigm of death, if reanalyzed, might go a long way in relieving the financial stresses of our health care system. Human life is precious, but it is not mutually exclusive to truly believe in that statement while also being pragmatic and honest about death and dying. Near the end of Letting Go, Dr. Gawande posits:
“The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.”
Six years ago when I first read the article, I knew human life was precious, but this knowledge was just superficial. I have realized that as the new generation of physicians comes along, we owe our end-of-life patients more than unrelenting care for the sake of providing care. It is for this reason that I firmly believe end-of-life care should be a mandated part of the medical school curriculum. The implications of instituting a formal course on the dying patient for the next generation of physicians are, from a cultural and economic standpoint, hard to understate. End-of-life education at the medical school level could aid the next generation of doctors in maintaining their responsibility as healers while also treating the human spirit and in turn, facilitating more economic use of health care resources. Gawande finishes:
“People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come — and to escape a warehoused oblivion that few really want.”