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the need for higher level care placement by 40 percent – similar to the effect of having outpatient multidisciplinary geriatric teams – “we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart.” So why are only 300 residents a year becoming geriatricians? Why are geriatric departments being shut down? All this in a country where our elderly population is going to double between the years 2010 and 2030? Bonkers! Gawande is not overly sentimental, and he lets the experiences speak for themselves. But there are moments in this book that will jerk your tears and make you reflect on your loved ones who have passed or almost passed. As he details his father’s slow demise with cancer, I found myself thinking of my own father’s near death at Kaiser South San Francisco three years ago. Heart attack, atrial fibrillation, on pressors and BiPap, cath lab one hour away at the downtown facility. I would have done anything at that moment for a chance to pull him through, whatever the cost! I wanted everything done! He got great care, not perfect care (can it ever be so to a physician family member?), but great, and he pulled through. I contrast this with my yearly trips to Nicaragua where many of the dying people just straight up don’t get advanced treatments because they aren’t available or are too expensive. This is rationing, and developed countries are eventually going to feel it more as our proverbial medical snake-on-the-staff swallows more of the GDP pie. If you take away nothing else from Gawande’s book, remember these four questions to ask your patients and loved ones who are ill: “What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the tradeoffs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?” A condensed version of this is, “If time becomes short, what is most important to you?” As a family physician who has had many

end-of-life discussions with patients and their families, I know I have made missteps, and I have already found these four questions extremely helpful. Within days of reading this book, this approach helped me uncover that a middleaged lady with metastatic lung cancer who kept returning to the ED was most fearful of falling at home and not of dying. Our focus became that. When rounding with the residents on a young man dying from an untreatable GI malignancy, it became clear that he wanted a feeding tube to allow him to go on a two-week road trip he had been planning for a long time with an old friend. After that, he wanted to pursue hospice. That road trip became our goal. Gawande quotes a palliative care specialist as saying, “A family meeting is a procedure, and it requires no less skill than performing an operation.” Many other pearls abound in this book. If you are talking more than 50 percent of the visit, you are talking too much. Don’t take away hope, but bring up the elephant in the room when it is clear a patient is dying. A good way to do this is by pushing the computer screen aside for a moment, looking right at the patient and family, and saying “I’m worried about you. I’m very worried” and then let the pregnant pause deliver the insight to them and follow their lead. Two doctors from different hospitals I have talked to recently about this book independently declared, “This book should be required reading in every medical school.” I have to agree. I think you will, too, after reading Being Mortal. I hope it touches you deeply, makes you question your own habits and approaches, and most importantly, motivates you to appreciate every fleeting moment of the rest of your life and the undying spirit of family. Books and their wisdom are immortal. Pass this gift on to others.

“For human beings, life is meaningful because it is a story.” – Atul Gawande, MD

hitzemn@sutterhealth.org

September/October 2015

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2015-Sep/Oct - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...

2015-Sep/Oct - SSV Medicine  

Sierra Sacramento Valley Medicine is the official journal of the Sierra Sacramento Valley Medical Society (SSVMS) and promotes the history,...