Authors: Atul Gawande
The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end.
More often, these days, medicine seems to supply neither Custers nor Lees. We are increasingly the generals who march the soldiers onward, saying all the while, “You let me know when you want to stop.” All-out treatment, we tell the incurably ill, is a train you can get off at any time—just say when. But for most patients and their families we are asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. Our responsibility,
in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw on. They 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—and escape a warehoused oblivion that few really want.
SARA MONOPOLI HAD
had enough discussions to let her family and her oncologist know that she did not want hospitals or ICUs at the end—but not enough to have learned how to achieve her goal. From the moment she arrived in the emergency room that Friday morning in February, the train of events ran against a peaceful ending. There was one person who was disturbed by this, though, and who finally decided to intercede—Chuck Morris, her primary care physician. As her illness had progressed through the previous year, he had left the decision making largely to Sara, her family, and the oncology team. Still, he had seen her and her husband regularly and listened to their concerns. That desperate morning, Morris was the one person Rich called before getting into the ambulance. He headed to the emergency room and met Sara and Rich when they arrived.
Morris said that the pneumonia might be treatable. But he told Rich, “I’m worried this is it. I’m really worried about her.” And he told him to let the family know that he said so.
Upstairs in her hospital room, Morris talked with Sara and Rich about the ways in which the cancer had been weakening her, making it hard for her body to fight off infection. Even if the antibiotics halted the infection, he said, he wanted them to remember that there was nothing that would stop the cancer.
Sara looked ghastly, Morris told me. “She was so short of
breath. It was uncomfortable to watch. I still remember the attending”—the covering oncologist who admitted her for the pneumonia treatment. “He was actually kind of rattled about the whole case, and for him to be rattled is saying something.”
After her parents arrived, Morris talked with them too, and when they were finished Sara and her family agreed on a plan. The medical team would continue the antibiotics. But if things got worse, they would not put her on a breathing machine. They also let him call the palliative care team to visit. The team prescribed a small dose of morphine, which immediately eased her breathing. Her family saw how much her suffering diminished, and suddenly they didn’t want any more suffering. The next morning, they were the ones to hold back the medical team.
“They wanted to put a catheter in her, do this other stuff to her,” her mother, Dawn, told me. “I said, ‘No. You aren’t going to do anything to her.’ I didn’t care if she wet her bed. They wanted to do lab tests, blood pressure measurements, finger sticks. I was very uninterested in their bookkeeping. I went over to see the head nurse and told them to stop.”
In the previous three months, almost nothing we’d done to Sara—none of the scans or tests or radiation or extra rounds of chemotherapy—had likely achieved anything except to make her worse. She may well have lived longer without any of it. At least she was spared at the very end.
That day, Sara fell into unconsciousness as her body continued to fail. Through the next night, Rich recalled, “there was this awful groaning.” There is no prettifying death. “Whether it was with inhaling or exhaling, I don’t remember, but it was horrible, horrible, horrible to listen to.”
Her father and her sister still thought that she might rally. But when the others had stepped out of the room, Rich knelt down
weeping beside Sara and whispered in her ear. “It’s okay to let go,” he said. “You don’t have to fight anymore. I will see you soon.”
Later that morning, her breathing changed, slowing. Rich said, “Sara just kind of startled. She let a long breath out. Then she just stopped.”
T
raveling abroad sometime afterward, I fell into a conversation with two doctors from Uganda and a writer from South Africa. I told them about Sara’s case and asked what they thought should have been done for her. To their eyes, the choices we offered her seemed extravagant. Most people with terminal illness in their countries would never have come to the hospital, they said. Those who did would neither expect nor tolerate the extremes of multiple chemotherapy regimens, last-ditch surgical procedures, experimental therapies—when the problem’s ultimate outcome was so dismally clear. And the health system wouldn’t have the money for it.
But then they couldn’t help but talk about their own experiences, and their tales sounded familiar: a grandparent put on life support against his wishes, a relative with incurable liver cancer who died in the hospital on an experimental treatment, a brother-in-law with a terminal brain tumor who nonetheless endured endless cycles of chemotherapy that had no effect except to cut him down further and further. “Each round was more horrible than the last,” the South African writer told me. “I
saw the medicine eat his flesh. The children are still traumatized. He could never let go.”
Their countries were changing.
Five of the ten fastest-growing economies in the world are in Africa.
By 2030, one-half to two-thirds of the global population will be middle class. Vast numbers of people are becoming able to afford consumer goods like televisions and cars—and health care.
Surveys in some African cities are finding, for example, that half of the elderly over eighty years old now die in the hospital and even higher percentages of those less than eighty years old do. These are numbers that actually exceed those in most developed countries today. Versions of Sara’s story are becoming global. As incomes rise, private sector health care is increasing rapidly, usually paid for in cash. Doctors everywhere become all too ready to offer false hopes,
leading families to empty bank accounts, sell their seed crops, and take money from their children’s education for futile treatments.
Yet at the same time, hospice programs are appearing everywhere from Kampala to Kinshasa, Lagos to Lesotho, not to mention Mumbai to Manila.
Scholars have posited three stages of medical development that countries go through, paralleling their economic development. In the first stage, when a country is in extreme poverty, most deaths occur in the home because people don’t have access to professional diagnosis and treatment. In the second stage, when a country’s economy develops and its people transition to higher income levels, the greater resources make medical capabilities more widely available. People turn to health care systems when they are ill. At the end of life, they often die in the hospital instead of the home. In the third stage, as a country’s income climbs to the highest levels, people have the means to become concerned about the quality of their lives, even in sickness, and deaths at home actually rise again.
This pattern seems to be what is happening in the United States. Whereas deaths in the home went from a clear majority in 1945 to just 17 percent in the late eighties, since the nineties the numbers have reversed direction.
Use of hospice care has been growing steadily—to the point that, by 2010, 45 percent of Americans died in hospice. More than half of them received hospice care at home, and the remainder received it in an institution, usually an inpatient hospice facility for the dying or a nursing home. These are among the highest rates in the world.
A monumental transformation is occurring. In this country and across the globe, people increasingly have an alternative to withering in old age homes and dying in hospitals—and millions of them are seizing the opportunity. But this is an unsettled time. We’ve begun rejecting the institutionalized version of aging and death, but we’ve not yet established our new norm. We’re caught in a transitional phase. However miserable the old system has been, we are all experts at it. We know the dance moves. You agree to become a patient, and I, the clinician, agree to try to fix you, whatever the improbability, the misery, the damage, or the cost. With this new way, in which we together try to figure out how to face mortality and preserve the fiber of a meaningful life, with its loyalties and individuality, we are plodding novices. We are going through a societal learning curve, one person at a time. And that would include me, whether as a doctor or as simply a human being.
MY FATHER WAS
in his early seventies when I was forced to realize that he might not be immortal. He’d been as healthy as a Brahma bull, playing tennis three days a week, maintaining a busy urology practice, and serving as president of the local Rotary Club. He had tremendous energy. He did numerous
charity projects, including working with a rural Indian college he’d established, expanding it from a single building to a campus with some two thousand students. Whenever I came home, I’d bring my tennis rackets and we’d go out on the local courts. He played to win, and so did I. He’d drop shot me; I’d drop shot him. He’d lob me; I’d lob him. He had picked up a few old-man habits, like blowing his nose onto the court whenever he felt like it or making me chase down our errant tennis balls. But I took them to be the kinds of advantages a father takes with a son, rather than signs of age. In more than thirty years of medical practice, he’d not canceled his clinic or operating schedule for sickness once. So when he mentioned the development of a neck pain that shot down his left arm and caused tingling in the tips of his left fingers, neither one of us was inclined to think too much of it. An X-ray of his neck showed only arthritis. He took anti-inflammatory medication, underwent physical therapy, and took a break from using an overhead serve, which exacerbated the pain. Otherwise it was life as usual for him.
Over the next couple years, however, the neck pain progressed. It became difficult for him to sleep comfortably. The tingling in the tips of his left fingers became full-blown numbness and spread to his whole left hand. He found he had trouble feeling the thread when tying sutures during vasectomies. In the spring of 2006, his doctor ordered an MRI of his neck. The findings were a complete shock. The scan revealed a tumor growing inside his spinal cord.
That was the moment when we stepped through the looking glass. Nothing about my father’s life and expectations for it would remain the same. Our family was embarking on its own confrontation with the reality of mortality. The test for us as parents and children would be whether we could make the path go
any differently for my dad than I, as a doctor, had made it go for my patients. The No. 2 pencils had been handed out. The timer had been started. But we had not even registered that the test had begun.
My father sent me the images by e-mail, and we spoke by phone as we looked at them on our laptops. The mass was nauseating to behold. It filled the entire spinal canal, extending all the way up to the base of his brain and down to the level of his shoulder blades. It appeared to be obliterating his spinal cord. I was amazed that he wasn’t paralyzed, that all the thing had done so far was make his hand numb and his neck hurt. We didn’t talk about any of this, though. We had trouble finding anywhere safe for conversation to take purchase. I asked him what the radiologist’s report said the mass might be. Various benign and malignant tumors were listed, he said. Did it suggest any other possibilities besides a tumor? Not really, he said. Two surgeons, we puzzled over how a tumor like this could be removed. But there seemed no way, and we grew silent. Let’s talk to a neurosurgeon before jumping to any conclusions, I said.
Spinal cord tumors are rare, and few neurosurgeons have much experience with them. A dozen cases is a lot. Among the most experienced neurosurgeons was one at the Cleveland Clinic, which was two hundred miles from my parents’ home, and one at my hospital in Boston. We made appointments at both places.
Both surgeons offered surgery. They would open up the spinal cord—I didn’t even know that was possible—and remove as much of the tumor as they could. They’d only be able to remove part of it, though. The tumor’s primary source of damage was from its growth inside the confined space of the spinal canal—the beast was outgrowing its cage. The expansion of the mass was crushing the spinal cord against the vertebral bone, causing pain as well as destruction of the nerve fibers that make up the
cord. So both surgeons proposed also doing a procedure to expand the space for the tumor to grow. They’d decompress the tumor, by opening the back of the spinal column, and stabilize the vertebrae with rods. It’d be like taking the back wall off a tall building and replacing it with columns to hold up the floors.
The neurosurgeon at my hospital advocated operating right away. The situation was dangerous, he told my father. He could become quadriplegic in weeks. No other options existed—chemotherapy and radiation were not nearly as effective in stopping progression as surgery. The operation had risks, he said, but he wasn’t too worried about them. He was more concerned about the tumor. My father needed to act before it was too late.
The neurosurgeon at the Cleveland Clinic painted a more ambiguous picture. While he offered the same operation, he didn’t push to do it right away. He said that while some spinal cord tumors advance rapidly, he’d seen many take years to progress, and they did so in stages, not all at once. He didn’t think my father would go from a numb hand to total paralysis overnight. The question therefore was when to go in, and he believed that should be when the situation became intolerable enough for my father to want to attempt treatment. The surgeon was not as blithe about its risks as the other neurosurgeon. He thought it carried a one in four chance of itself causing quadriplegia or death. My father, he said, would “need to draw a line in the sand.” Were his symptoms already bad enough that he wanted surgery now? Would he want to wait until he started to feel hand symptoms that threatened his ability to do surgery? Would he want to wait until he couldn’t walk?