Quality of Death

I think this is the best piece yet by the ever-impressive Atul Gawande. He reports on cases -- one, in particular -- where almost hopeless efforts to prolong a life succeeded only in making death more miserable. The article is especially strong on the pressure every doctor feels to mislead dying patients about their prospects, keeping hope alive where there is no hope. They allow and even encourage patients and their families not to face reality. As a result, the last days are far more dreadful than they need to be.

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.

More often, these days, medicine seems to supply neither Custers nor Lees. We are increasingly the generals who march the soldiers onward, saying all the while, "You let me know when you want to stop." All-out treatment, we tell the terminally ill, is a train you can get off at any time--just say when. But for most patients and their families this is asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. But our responsibility, in medicine, is to deal with human beings as they are. 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.

Well said. The money wasted on ill-advised end-of-life-care -- colossal though the sums may be -- ought not to be the main focus of discussion. It will have to be talked about, of course, but that framing of the issue is disturbing and divisive. Before we get to that, we should be talking about the patients' interests, as those interests would be judged by patients themselves, given all the facts.This is not about death panels. It is about patients' rights.

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