suffering should be given the option that they could have an assisted death. In Oregon or Washington, it’s done with a careful procedure that has led to just 1 percent of the population choosing to have that kind of a prescription. Only half end up using it. But the option is there on your shelf and the relief of knowing that there is a pathway if your suffering becomes unbearable. Where it gets complicated is that I think that the percentage of people who end up choosing assisted suicide should be regarded as a failure of the health system. Those are people [for] whom we have failed to relieve their burden of suffering. I’m alarmed by the idea that a goal is a good death. I don’t think our goal is a good death. I think our goal is a good life all the way to the very end. There are consequences if we think about it as a good death. In the Netherlands, the first country to have adopted this approach, the percentage of people at death who end up choosing this pathway is closing in at about 4 percent. The most common reason is that they say that they want to take this path because they don’t want to be a burden on others. That worries me. It worries me even more that the Netherlands was one of the late countries to develop a hospice and palliative care system to allow people more options for being able to have something other than suffering at the end of life. This debate is going on very intensively in India about assisted death. In India, cancer patients are not given narcotics at the end of life. I saw surgery patients there that were only given Tylenol for orthopedic surgery or for abdominal surgery. So if you had a terminal cancer – you’re in terrible pain and no one’s doing anything about it – wouldn’t you want assisted death? Something to put you out of your misery? But each one of those is a failure of the health system. So I am supportive of assisted death, but it’s with the understanding that assisted living is harder than assisted death, and each death chosen for that pathway is our failure to have developed capabilities that relieve people of suffering or to deploy the known capabilities to relieve people of that suffering. CHEN: Roughly 8,000 [people] turn 65 daily. At the same time, geriatrics may be the only specialty where you make less the more you train. The number of geriatricians has dropped by 25 percent in recent years.
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Clearly these trends are not in alignment. GAWANDE: I had the geriatrics clinic on the first floor right below my surgical clinic. I went in one day and I said, “I’m writing a book, can I follow you around?” They were like, “Yeah, sure.” The geriatrician is the one who is willing and able to deal with all of the range of problems that an elderly person has, many of which you cannot fix, but you can sometimes manage. An example that really struck me was a person in her 80s who [came into the office.] As I looked at her, I thought the biggest risk that she faced was that there was a chest X-ray that showed a possible lung nodule; that she’d had polyps in the past and should she have a colonoscopy or not might be a discussion that we needed to have; and her arthritis was really acting up and maybe
“I ’m alarmed that a goal is a good death. I don’t think our goal is a good death. I think our goal is a good life all the way to the very end.” there’s some medication for that. We should pick one of those and work on it. What [the geriatrician] zeroed in on was the fact that she was at tremendous risk of falling, that in talking to her, [he’d learned that] she had been having some falls and that was the most dangerous thing for her quality of life, for what she cared about in her life, which was living in her apartment independently for as long as she could. He knew the risk factors, which I didn’t know, things like being on four drugs or more or having weakness. He paid more attention to her feet than anywhere else and showed me how to examine the feet and then made a plan for her that addressed each of those issues: reduced her medications, worked on nutrition for her, got a podiatrist to work on the sores on her feet. A year later, I talked to her and she’d had no more falls since that visit and was still living independently in that apartment, and her risks had been very high for a falling in six months. Those are the kinds of capabilities we’re talking about. CHEN: What are some of the things that
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you actually see work in end-of-life planning? GAWANDE: At the first level, what comes has been powerful in Oregon, Wisconsin and other communities that have been able to make this work is being willing to talk to your own family member about “What are your fears and worries? What are your goals? What kind of life is worth living for you and what kind of life isn’t worth living?” Because more often than not, 70 percent of us will come to that moment and need someone else to speak for us, because we can’t. Those people are rarely equipped with the information. CHEN: The Institute of Medicine just released a report entitled Dying in America: Improving the Quality and Honoring Individual Preferences near the End of Life. Is there anything that is missing in that report or that you would want to highlight? GAWANDE: It’s a 507-page compendium of all of the evidence about the ways in which we’re failing at the end of life. What’s great is that it was a much more comprehensive overview of the science than I ever managed to get to, because the 500 pages distills tens of thousands of pages of information. We were fortunately aligned in all the same ways. What I hoped to do was tell the stories behind the data of what it’s like to try to use that kind of information and apply it in dayto-day life, whether as a doctor or as a family member, and also what it’s like when you don’t have that kind of information. The parts that are missing are a little bit of “How do I do that?” Conversations are powerful, but what kinds of conversation, and what are the words? A lot of what I was looking for was how do I get the words to talk to my father, to talk to my patient? Do I really have to break bad news for him? Some of those skills and lessons that people have are really powerful, like learning to not just give people the data about survival rates and so on but instead to be able to use words like “I’m worried. I’m worried about what this means.” It conveys that you care, that you’re not certain that they’re going to die in six months, but that you’re worried and that leaves open many possibilities, but also some direction for going forward. That report was phenomenally important and part of a wave of [a] variety of information that suggests we are way beyond death panels now and willing to engage at a national level with transforming our institutions to work better for us.