Monday, 13 June 2016

"Being Mortal" by Atul Gawande: The End Matters

Dr. Atul Gawande is a surgeon, researcher and dilettante but also a writer as he describes himself in his twitter account. Dr. Gawande is also known in the field of clinical safety for his previous book "The Checklist Manifesto". The author of "Being Mortal" masterfully explains that life can also be valuable as we get older, frail and defenceless and that there comes a time when we can no longer fend for ourselves. The end matters, as sports enthusiasts know it so well, when pushing your luck at the last minute can lose the whole game strategy.

In his book, Dr. Gawande reflects on the end of life stage of many people from his experience as a doctor, to the extent that one of the best documented cases is that of his own father. In the video that I have chosen for you, you will see how he and his mother talk about it.

Lengthening life as the only objective

The medicine practiced in modern hospitals aims to achieve new levels of survival. In conversations with patients, doctors always find a place for another round of chemotherapy or another surgery venture. Instead, people in the final stage of life when they manage to regain their personal vision after so much medical enlightening, surveys found that patients are not opposed to living longer but they would also like to explain to the doctors, if that would be possible, that they would like to avoid suffering unnecessarily, they would like to have time to close ongoing issues with loved ones so they’d prefer to keep their mind awake as long as possible, they are concerned about being a burden to their family, etc. But rarely do these life issues fit in with the overloaded schedule of consultations and therapeutic alternatives. "Many patients are letting themselves be led by the fighter’s dynamic, says the author, and end up believing that they have to try everything until the doctor tells them that there is nothing more to do. But this latter revelation rarely occurs, because many doctors delight in having a “saviour” up their sleeve at all times.

Shared clinical decision – a middle way

Shared clinical decision is a movement that promotes the practice of a middle way between paternalism ("If I was your mother, what would you do doctor?") and the delegation of responsibilities ("I tell all the possibilities and you decide"). Shared clinical decision adopts an interpretative methodology starting from two basic questions, two approaches to the way of seeing things of each patient: a) What is most important to you? and b) What worries you most? After these two concepts have been clarified, the author says, it’s very easy to choose between the blue pill or the red, without underestimating the waiting options.

The calm conversation

The family meeting to discuss end of life process is a procedure that, according to Dr. Gawande, requires as many skills as to those that a surgeon is required to observe, because there is always a lot of anxiety, concerns and, often, plain panic when patients are faced with a pessimistic prognosis.

I have extracted 5 key questions from the book that the author believes are essential for the implementation of shared clinical decision within a calm conversation about the end of life process:
  1. What have you understood from what you have been told about the prognosis process?
  2. If I tell you that you have very little time left, what are you mostly concerned about? What do you think you have left to do?
  3. What is nonnegotiable for you in this upcoming process? What would you be willing to negotiate?
  4. If, for example, your condition worsens, what is your priority?
  5. Who would you like to take decisions in your name, in case there will be a time when you can no longer decide for yourself?
This is a conversation that doctors and nurses have not been prepared for. But the time has come to do it, and if we succeed, we will give meaning to the final process of the people we serve, and incidentally we protect them from the risks of disproportionate action.

I want to thank Dr. Atul Gawande for writing Being Mortal, an essential reflection for those who appreciate good medicine. And, as he explains, if the bone marrow of life is to be the authors of our own story, it wouldn’t do us any good to spoil a good game with a bad end.

Jordi Varela

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