I’m a great admirer of the thoughtful, literary style of Atul Gawande. He writes sincerely and movingly about the trials and tribulations of modern medicine. It’s when he tries to extrapolate public-policy recommendations from these stories that he falls flat, kind of like a Steinway piano whose middle C is badly out of tune.
His most recent article, titled “Letting Go” and published in the August 2 issue of The New Yorker, is exemplary of his work. In the article, Gawande tells the stories of several patients, young and old, who are dying — typically of cancer — and how doctors, nurses, patients, and their families struggle with the challenge of facing death.
As he notes, end-of-life care was a prominent element of the Obamacare debate. “Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.” Why is this a matter of concern? Because Medicare is a taxpayer-funded entitlement, spawned by Congress 45 years ago today. But Gawande thinks that certain politicians have got it all wrong:
The subject seems to reach national awareness mainly as a question of who should “win” when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we can’t afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But they’re debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper.
By “deeper,” Gawande means that patients and their caregivers aren’t trained to face death; instead they’re trained to fight on, adding more and more treatments, even if many of those treatments are futile. Of course, these problems are rare in other parts of the world. In Britain’s National Health Service, for example, terminally ill patients are incorrectly classified as “close to death” so as to allow the withdrawal of expensive life support.
But there is something to be said for dying with dignity and for making considered decisions about how much medical intervention is enough. What Gawande doesn’t get — what he calls “demagoguery” — is the understandable fear that Americans have that, in a state-run system, those decisions won’t be theirs. We only have to look across the pond to see how that could play out.
Gawande believes, as we all do, that the practice of medicine would benefit from patients’ thinking ahead about end-of-life care. He cites the example of La Crosse, Wisc., where, since 1991, anyone admitted to a hospital, nursing home, or assisted-living facility was required to fill out a form asking: “Do you want to be resuscitated if your heart stops? Do you want aggressive treatments such as intubation and mechanical ventilation? Do you want antibiotics? Do you want tube or intravenous feeding if you can’t eat on your own?” Gawande notes that the mere act of asking patients to think about these questions in advance led to more humane, and more effective, treatment later on. It’s a good idea, one that other hospitals could learn from.