US surgeon Dr Atul Gawande questions modern medicine's treatment of dying patients

Outbackjack
Outbackjack: Dr Atul Gawande has been making life and death decisions for a decade, but only in the past few years has the Boston-based surgeon questioned whether medicine gives people what they really want at the end of their lives.

It was one case in particular that helped him find some answers.

Sarah was in her thirties and pregnant when she was diagnosed with terminal lung cancer.

She did not want to die in a hospital but she did not want to leave her little girl when she was born.

Sarah underwent four different kinds of chemotherapy.

"I think the issue there was that I never asked those questions; I never asked her what she was really worried about," Dr Atul told The World Today from his home in Boston.
Audio: Do doctors and medical technology really give us what we want? (The World Today)

"One fear was that she wouldn't be there for her daughter. I mean here she was – she was in a wheelchair; she was on oxygen; she'd gotten so weak she literally could not hold her child. [The other fear] along the way was that she would not be able to hold her child.

"We didn't see it as one of our priorities that she have the capability in her last weeks of life to literally hold her own baby. And that's just a failure."

Dr Gawande, who was Sarah's surgeon, said he would have done things differently if he could, particularly because she was not responding well to the medical treatments.
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Outbackjack
Outbackjack: "What I could have said – and more importantly what I could have done with her oncologist – ... I think we together could have said, 'Sarah, we talked a few months ago. You had a couple of priorities that were really important to you – being able to hold your baby, being at home more than in the hospital,'" he said.

"'And if we go to this fourth round, it is likely going to take that away from you. It's a roll of the dice, it's a lottery ticket. Would you want to go for that knowing you'd be giving up those last steps in the time you have?

"And I would probably go further and say, 'Knowing what's important to you, I wouldn't recommend it.' I'd give her permission to say, 'No, I'm going to take my last time with my daughter and my family.' And I think she would have taken that."
People 'want more in the end'

Dr Gawande said many people want more from life at the end.

"We assume that there is little to salvage in these experiences and there is much more there – people have loyalties in their life," he said.

"And by loyalties I mean things that they live for that are bigger than just themselves. They can be more satisfying I think than we've understood."

In a new book called Being Mortal: Medicine and What Matters in the End, Dr Gawande said most people today die institutionalised in nursing homes or hospitals and are often unhappy.

He questioned whether doctors and modern medicine should approach people differently to give them what they really need before they die.

Dr Gawande said he felt "terrible" and thought he was a "failure" the first time one of his patients died.

"Part of this book comes out of more than a decade now as a surgeon, recognising that we're very good in medicine at dealing with the fixable problems, but when we have unfixable problems we are not so good," he said.

"Part of it is that you don't feel very competent except to know how to offer that extra last ditch effort to buy more time. You know, we're very good in medicine at sacrificing your time and quality of life now for the sake of time later."

Dr Gawande said medicine needs to understand there are more important things than extending life, such as giving patients options and support to make sure they have what matters to them most when they are approaching death.

"The most critical thing is those vary from person to person. For some people, depending on their phase in life, they just want to know that they are getting help so they're able to be at home more than in a hospital," he said.

"Or that they have some ability to be with their family or to walk a dog or to finish their own personal life project or get to a wedding that's really important to them. The most reliable way of learning what people's priorities are is simply to ask. And we don't ask in medicine."

It is a difficult conversation, Dr Gawande admits, and one he had to face when his own father was dying from cancer.

"The way we relate and connect right now is often poor, often leaves people suffering or feeling abandoned, or we are failing to help people through the anxieties of this experience which is very common and easy to make worse," he said.
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lori100
lori100: Many doctors simply are not good at treating people...they might be good at medicating an illness, though. They are uncomfortable with death and don't want to have to talk about it. At least they now are better at relieving pain for the patient. They need training in just learning how to talk to people.
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SillySally8
SillySally8: palliative care is the most important part of a dying persons journey imo...medically supervised/pain management and compassion towards the dying person is key, remembering that every persons journey is different
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