Gawande discusses problems of 'medicalized' mortality in the U.S.

The medical industry’s typical approach to end-of-life care is to trade quality of life in the short term for longer life in the future, but the trade-off isn’t always a good one, the author and surgeon said.

Atul Gawande

Author and surgeon Atul Gawande, MD, MPH, described how witnessing the untimely and inevitable passing of patients, friends and his father revealed to him the shortcomings of the American medical system’s and society’s approach to dying.

 “I learned about a lot of things in medical school, but mortality wasn’t one of them,” he said, addressing an overflow crowd March 2 in Berg Hall, at the Li Ka Shing Center for Learning and Knowledge.

The medical industry’s typical approach is to trade quality of life in the short term for longer life in the future, but the trade-off isn’t always a good one, he said.

Gawande, who earned a bachelor’s degree from Stanford in 1987, addressed end-of-life issues — the topic of his best-selling book Being Mortal — in delivering the eighth annual Cynthia and Alexander Tseng, Jr., MD, Memorial Lecture. Gawande received his medical degree from Harvard Medical School in 1995. He also earned a master’s degree in public health from Harvard in 1999.

In the highly personal talk, Gawande discussed how decades of modern medical advances have changed our attitudes about dying and death. As fewer diseases and injuries pose life-threatening risks, because of vastly improved medications and therapies, people simply expect to live longer. Well-being has become synonymous with longer and more robust life, supported at every stage by effective medical interventions, including a growing market of “lifestyle” rather than lifesaving treatments.

Living longer, not always better

Gawande argued that while advances in health care are positive, one consequence is that we have “medicalized our mortality” to the point that even terminally ill patients and their families look to their doctors for lifesaving answers.

He said he became inspired to “pick up my journalist’s pen” and explore questions about life and mortality that his elite medical education hadn’t equipped him to remedy.

For example, aggressive cancer treatment can be debilitating and painful, and often fails to prolong life, merely making the end of life miserable for patients.

If palliative doctors were a drug, the FDA would approve them.

In contrast, the goal of palliative care is to create the best possible day for patients today, regardless of what it means for the future. Studies show that for terminally ill patients, palliative care improves quality of life, he said. Palliative care practices can reduce unwanted medical procedures, as well as costs, and have been shown to actually increase life span — by 25 percent in one study of late-stage lung cancer patients.

“If palliative doctors were a drug, the FDA would approve them,” said Gawande.

Gawande is currently heading up a clinical trial that is gathering evidence on the effectiveness of better end-of-life discussions through an organization he founded called Ariadne Labs. (The company is named for Ariadne, the Greek goddess who showed Theseus the way out of the Minotaur’s maze using a thread.)

Ariadne Labs aims to provide simple directions to help patients, doctors and families through critical moments in their lives. The backbone of this program is the “Serious Illness Conversation Guide,” which offers seven questions to facilitate meaningful conversation among physicians, patients and families. It focuses on optimizing quality of life for patients based on what matters most to them. 

Gawande stressed the need for better communication with patients and families facing end-of-life decisions, particularly that doctors listen to the needs and desires of their patients. He said doctors tend to be “explain-aholics,” and rarely take the time to ask their patients about their values and priorities for the time they have left. When they do, chances are that patients will want to forego complex, inpatient procedures in favor of technology and treatments that enable them to spend more — and more comfortable — time at home, he said.

“We should be able to deploy modern medicine to best meet the goals and desires of patients,” Gawande said.

The Cynthia and Alexander Tseng, Jr., MD, Memorial Lecture is co-sponsored by the Tseng Lectureship Endowment Fund in the Stanford Cancer Institute and by the Stanford Center on Longevity.


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