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A Conversation With Atul Gawande, MD: Living a Good Life All the Way to the End

Posted on Apr 12, 2016 in Community News

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“When should we try to fix and when should we not?” asks Atul Gawande, M.D., MPH, in his latest bestselling book, Being Mortal: Medicine and What Matters in the End. Dr. Gawande is a practicing surgeon at Brigham and Women’s Hospital in Boston, a professor at Harvard Medical School and the Harvard School of Public Health, a staff writer for The New Yorker and executive director of Ariadne Labs, a global health care innovation center.

Being Mortal is his fourth bestselling book. It’s a physician’s personal journey toward a better understanding of aging, serious illness and what it means to balance prolonging life with preserving the treasured priorities that mean the most to each human being as that life draws to a close.

Dr. Gawande is also the featured speaker at Mills-Peninsula’s Community Health Dinner and Lecture and the annual Mills-Peninsula Luncheon and Lecture in April 2016, benefiting the Mills-Peninsula Palliative Care Program and breast health programs.

In anticipation of his April visit to speak at our Mills-Peninsula events, we asked Dr. Gawande to share his insights about how doctors, patients and family members can partner together to help loved ones live a life that is meaningful to them all the way to the end of life.

Q: What were the key takeaways you learned from researching and writing Being Mortal?
DR. GAWANDE: I ended up interviewing more than 200 patients and family members about their experiences with serious illness and infirmity. I also interviewed scores of clinicians including palliative care physicians, hospice teams, nursing home aides and directors. The people who were really great at what they were doing had learned several key things.

First was that people have priorities for their lives that they want their health care providers to serve besides just living longer. We all have purposes larger than ourselves. The most reliable way to learn about a patient’s priorities is to ask…and we don’t ask. When we don’t ask, we end up in a situation where the care that we give is often out of alignment with what people’s priorities actually are for their lives.

Suffering comes from finding out that the medical evasion of mortality results in a focus on disease, instead of a focus on you, the patient, and what matters most in your life no matter how long or short it is.

So what I was able to learn was how to change that story by asking the right questions.

Q: How has this new awareness changed how you practice medicine now?
DR. GAWANDE: Up to this point, my thinking was that being good at managing difficult conversations about a patient’s end of life meant being really direct about the facts and options. “There are options A, B and C. Here are the benefits and here are the risks of each of them. Now, what do you want to do?”

One of my palliative care colleagues said to me, “You know what your problem is? You’re an explainaholic.”

The point he was making was that people come to better decisions by being able to tell you what matters most to them. And to put in their own words their understanding of where they are with their illnesses.

So the practical thing I learned was how to ask questions like: “What’s your understanding of where you are with your illness at this time? What are your fears and worries for the future? What are your goals if time is short? What are you willing to sacrifice and what are you not willing to sacrifice for the sake of more time?”

Q: What did that look like in practice?
DR. GAWANDE: I have a colleague whose father told her when she asked these questions, “I’m willing to go through a lot as long as I can still watch football on television and eat chocolate ice cream.”

So when my dad became ill, I told him that story. He said, “No way.” Football and ice cream were not what mattered to him. My dad was willing to go through a lot as long as he could be at home, sit at the family dinner table, and enjoy his food and the company and interaction of other people. “If that’s no longer possible,” he said, “just give me the pain medicine and let me go.”

My conversations with my patients used to be, “Well, you can do nothing or we can try something.” Now my questions have shifted to, “Tell me what really matters most in your life, what you’re willing to go through and what you’re not willing to go through for the sake of more time. And then, based on what is important to you, I can recommend to you what’s our best shot at getting that or tell you if it’s not really on the table.”

I feel like that’s what I learned and it was transformative.

Q: What is the most important advice you would give to patients facing end-of-life decisions?
DR. GAWANDE: As soon as people need help in their lives, whether they need a wheelchair or a home care worker, it’s important for them to be clear right from the beginning about what really matters to them. And the only way to do that is to talk about it before the crisis ever comes.

These questions are not ones that only clinicians can ask. It’s the conversation I had with my dad. What are your biggest fears and worries if your health worsens? If your health declines, what does living a good life mean to you? What is a life still worth living? And how do we make sure we preserve that?

One person I wrote about said to me, “Safety is what we want for those we love. Autonomy is what we want for ourselves.” And I think for those of us who have aging parents or people going through serious illness around us, we want them to survive and be safe above all. But for ourselves? There are things we live for that are bigger than ourselves and that’s where we get our purpose in life. And recognizing that the people we love also have their own purpose in life, that’s the trick.

This blog post was excerpted from a Mills-Peninsula interview with Dr. Gawande in Mills-Peninsula’s “healthpoint” magazine.