“Letting Go” by Dr. Atul Gawande

Over the weekend I read  “Letting Go” by Dr. Atul Gawande in the August 2, 2010 issue of The New Yorker.  Dr. Gawande is a surgeon at Brigham and Women’s Hospital in Boston.  The article focuses on the central problem he identifies not as the cost of end-of-life care but on “how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives.”  (p. 39).  Physicians often rely on patients to tell them when to stop curative treatment but patients and their families now have access to enormous amounts of medical research via the internet.  This new access fuels patients’ desires to keep fighting for a cure.  When physicians and patients are unwilling to give up hope for a cure, both may be surprised to find that the actual process of dying is filled with  much more medical intervention – ventilators, blood draws, feeding tubes, catheters – than anyone ever wanted.  The mystery of how to prevent this centers around the question of when the patient, doctor, and family should begin to accept that the process of dying has begun and cannot be stopped.

Dr. Gawande makes this point by talking about death as a war that no one wins.  He points out that this type of war should be led not by Custer, but by Robert E. Lee, “someone who understood that the damage is greatest if all you do is fight to the bitter end.” He argues that physicians should recognize that patients have no experience with end-of-life care and 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…” (p. 49).

It was a sad article with extended profiles of patients, both young and old, who received enormous amounts of unnecessary medical treatment at the end of their lives.  For these patients, there seemed to be no one willing to play the role of witness and companion, to help them accept that while hope for a cure was gone there was hope for comfort, less pain, and for meaningful time with family and friends.  As Dr. Susan Block, a palliative care expert, says in the article, this role is extremely important and very difficult.   She tells Dr. Gawande that a family meeting to discuss end-of-life issues “requires no less skill than performing an operation.”  (p. 47).  She goes on to describe her experience talking with her own father, who surprised her with his desire to remain alive as long as he was able to eat chocolate ice cream and watch football on TV.

When I was doing my research for Music at the End of Life: Easing the Pain and Preparing the Passage, I was surprised to find that many of the physicians I interviewed were quite transparent about the limits of medicine in caring for dying patients.  Several of them described the relief they feel when they are able to offer music-thanatology as an additional support once curative treatment has ended.  They know that music will provide something when medication and medical intervention cannot.  Gawande discusses the ways in which hospice has helped to “negotiate an ars moriendi for our age.”  (p. 42).  I am hopeful that this modern art of dying will rely heavily on the arts and on spiritual and pastoral care to provide courage to patients and physicians as well as a new kind of hope.

Dr. Gawande was also recently on NPR’s Fresh Air.

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