"Practicing doctors are a tough group to try and train," he told me. "That's what we've been trying to do for the past 10 years, and we've barely moved the needle. I have much more faith in patients bringing this conversation to doctors than waiting for doctors."
And so he makes it straightforward, telling people exactly what a good Conversation should involve: How important is it to you to live as long as possible, even if it means that you would experience pain and suffering? Would you want to avoid pain at all costs, even if you might not be able to interact with others? How important is it to you to be at home when you die?
"When you ask most people where they want to die," Volandes said—referring, of course, to people who have some context for the nature of the question—"most people say, I want to die outside of the hospital, in my home, in comfort."
Nearly 80 percent of Americans, in fact, say that. And yet, close to 55 percent of older adults die in a hospital or nursing home. Fewer than one in four manage to die at home. Why does this discrepancy persist?
* * *
The American approach to death in the past century has followed an arc not unlike our approach to food. One of the most common pieces of advice given by nutrition experts today was coined by Michael Pollan: "Eat food. Not too much. Mostly plants." But amid war and scarcity in the early and mid nineteenth century, producers flaunted triumphs science in food processing and preservation—in their capacity for synthetic tastes, bright colors, and infinite shelf lives. Wonder Bread, Tang, Spam, Velveeta, perfection salad, and Twinkies were created not because they should have been created, but because they could be created. They were cheap and delicious; God bless the land of plenty.
It was decades later that the the "real food" movement supplanted the virtue of processed foods, favoring anything natural (or at least appearing to be of nature). Part of that shift was due to advances in agriculture and transportation making natural-food access possible, but an even larger part was consciousness of nutrition and health. For many people, the central questions of consuming food shifted away from "Can we?" and toward "Should we?" Nearly in step, those were the questions facing doctors in a culture that tended to pursue invasive measures by default, for patients near the end of their natural lives.
As Gawande tells the story, in the 1940s, almost everyone died at home. But by the late 1980s, a mere 17 percent of people did. That shift was partly due to tremendous scientific advances that transformed the hospital from a place of very few effective treatments, to a place that had intravenous antibiotics, heart surgery, and kidney transplantation. By the latter part of the century, a doctor could do something for almost anyone (or rather, almost any medical condition), and hospitals became places not of resignation, but of hope. In 1946, the Hill-Burton Act provided government funding for widespread hospital construction. For the moderately and seriously ill, going to a hospital became the default.