Authors: Atul Gawande
Two months on, in June, I flew home from Boston not only to see him but also to give the graduation address for Ohio University. My father had been excited about attending the convocation from the moment I had been invited a year before. He was proud, and I had envisioned both my parents being there. Little is more gratifying than actually being wanted back in your hometown. For a while, however, I feared my father might not survive long enough. In the last few weeks, it became apparent he would, and the planning turned to logistics.
The ceremony was to take place in the university’s basketball arena with the graduates in folding chairs on the parquet and their families up in the stands. We worked out a plan to bring my father up the outside ramp by golf cart, transfer him to a wheelchair, and seat him on the periphery of the floor to watch.
But when the day came and the cart brought him to the arena doors, he was adamant that he would walk and not sit in a wheelchair on the floor.
I helped him to stand. He took my arm. And he began walking. I’d not seen him make it farther than across a living room in half a year. But walking slowly, his feet shuffling, he went the length of a basketball floor and then up a flight of twenty concrete steps to join the families in the stands. I was almost overcome just witnessing it. Here is what a different kind of care—a different kind of medicine—makes possible, I thought to myself. Here is what having a hard conversation can do.
I
n 380
BC
,
Plato wrote a dialogue, the
Laches
, in which Socrates and two Athenian generals seek to answer a seemingly simple question: What is courage? The generals, Laches and Nicias, had gone to Socrates to resolve a dispute between them over whether boys undergoing military training should be taught to fight in armor. Nicias thinks they should. Laches thinks they shouldn’t.
Well, what’s the ultimate purpose of the training? Socrates asks.
To instill courage, they decide.
So then, “What is courage?”
Courage, Laches responds, “is a certain endurance of the soul.”
Socrates is skeptical. He points out that there are times when the courageous thing to do is not to persevere but to retreat or even flee. Can there not be foolish endurance?
Laches agrees but tries again. Perhaps courage is “wise endurance.”
This definition seems more apt. But Socrates questions whether courage is necessarily so tightly joined to wisdom. Don’t we admire courage in the pursuit of an unwise cause, he asks?
Well, yes, Laches admits.
Now Nicias steps in. Courage, he argues, is simply “knowledge of what is to be feared or hoped, either in war or in anything else.” But Socrates finds fault here, too. For one can have courage without perfect knowledge of the future. Indeed, one often must.
The generals are stumped. The story ends with them coming to no final definition. But the reader comes to a possible one: Courage is
strength
in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength.
At least two kinds of courage are required in aging and sickness. The first is the courage to confront the reality of mortality—the courage to seek out the truth of what is to be feared and what is to be hoped. Such courage is difficult enough. We have many reasons to shrink from it. But even more daunting is the second kind of courage—the courage to act on the truth we find. The problem is that the wise course is so frequently unclear. For a long while, I thought that this was simply because of uncertainty. When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to decide whether one’s fears or one’s hopes are what should matter most.
I HAD RETURNED
to Boston from Ohio, and to my work at the hospital, when I got a late-night page: Jewel Douglass was back, unable to hold food down again. Her cancer was progressing. She’d made it three and a half months—longer than I’d thought she’d have, but shorter than she’d expected. For a week, the symptoms had mounted: they started with bloating, became waves of crampy abdominal pain, then nausea, and progressed to vomiting. Her oncologist sent her to the hospital. A scan
showed her ovarian cancer had multiplied, grown, and partly obstructed her intestine again. Her abdomen had also filled with fluid, a new problem for her. The deposits of tumor had stuffed up her lymphatic system, which serves as a kind of storm drain for the lubricating fluids that the body’s internal linings secrete. When the system is blocked, the fluid has nowhere to go. When that happens above the diaphragm, as it did with Sara Monopoli’s lung cancer, the chest fills up like a ribbed bottle until you have trouble breathing. If the system gets blocked up below the diaphragm, as it did with Douglass, the belly fills up like a rubber ball until you feel as if you will burst.
Walking into Douglass’s hospital room, I’d never have known she was as sick as she was if I hadn’t seen the scan. “Well, look who’s here!” she said, as if I’d just arrived at a cocktail party. “How are you, doctor?”
“I think I’m supposed to ask you that,” I said.
She smiled brightly and pointed around the room. “This is my husband, Arthur, whom you know, and my son, Brett.” She got me grinning. Here it was eleven o’clock at night, she couldn’t hold down an ounce of water, and still she had her lipstick on, her silver hair brushed straight, and she was insisting on making introductions. She wasn’t oblivious to her predicament. She just hated being a patient and the grimness of it all.
I talked to her about what the scan showed. She had no unwillingness to face the facts. But what to do about them was another matter. Like my father’s doctors, the oncologist and I had a menu of options. There was a whole range of new chemotherapy regimens that could be tried to shrink the tumor burden. I had a few surgical options for dealing with her situation, as well. With surgery, I told her, I wouldn’t be able to remove the intestinal blockage, but I might be able to bypass it. I’d either connect an obstructed loop to an unobstructed one or I’d
disconnect the bowel above the blockage and give her an ileostomy, which she’d have to live with. I’d also put in a couple drainage catheters—permanent spigots that could be opened to release the fluids from her blocked-up drainage ducts or intestines when necessary. Surgery risked serious complications—wound breakdown, leakage of bowel into her abdomen, infections—but it offered her the only way she could regain her ability to eat. I also told her that we did not have to do either chemo or surgery. We could provide medications to control her pain and nausea and arrange for hospice at home.
The options overwhelmed her. They all sounded terrifying. She didn’t know what to do. I realized, with shame, that I’d reverted to being Dr. Informative—here are the facts and figures; what do you want to do? So I stepped back and asked the questions I’d asked my father: What were her biggest fears and concerns? What goals were most important to her? What trade-offs was she willing to make, and what ones was she not?
Not everyone is able to answer such questions, but she did. She said she wanted to be without pain, nausea, or vomiting. She wanted to eat. Most of all, she wanted to get back on her feet. Her biggest fear was that she wouldn’t be able to live life again and enjoy it—that she wouldn’t be able to return home and be with the people she loved.
As for what trade-offs she was willing to make, what sacrifices she was willing to endure now for the possibility of more time later, “Not a lot,” she said. Her perspective on time was shifting, focusing her on the present and those closest to her. She told me that uppermost in her mind was a wedding that weekend that she was desperate not to miss. “Arthur’s brother is marrying my best friend,” she said. She’d set them up on their first date. Now the wedding was just two days away, on Saturday at 1:00 p.m. “It’s just the
best
thing,” she said. Her husband was
going to be the ring bearer. She was supposed to be a bridesmaid. She was willing to do anything to be there, she said.
The direction suddenly became clear. Chemotherapy had only a slim chance of improving her current situation and it came at substantial cost to the time she had now. An operation would never let her get to the wedding, either. So we made a plan to see if we could get her there. We’d have her come back afterward to decide on the next steps.
With a long needle, we tapped a liter of tea-colored fluid from her abdomen, which made her feel at least temporarily better. We gave her medication to control her nausea. And she was able to drink enough liquids to stay hydrated. At three o’clock Friday afternoon, we discharged her with instructions to drink nothing thicker than apple juice and return to see me after the wedding.
She didn’t make it. She came back to the hospital that same night. Just the car ride, with all its swaying and bumps, set her vomiting again. The crampy attacks returned. Things only got worse at home.
We agreed surgery was the best course now and scheduled her for it the next day. I would focus on restoring her ability to eat and putting drainage tubes in. Afterward, she could decide if she wanted more chemotherapy or to go on hospice. She was as clear as I’ve seen anyone be about her goals and what she wanted to do to achieve them.
Yet still she was in doubt. The following morning, she told me to cancel the operation.
“I’m afraid,” she said. She didn’t think she had the courage to go ahead with the procedure. She’d tossed all night thinking about it. She imagined the pain, the tubes, the indignities of the possible ileostomy, and then there were the incomprehensible horrors of the complications she could face. “I don’t want to take risky chances,” she said.
As we talked, it became clear that her difficulty wasn’t lack of courage to act in the face of risks. Her difficulty was in sorting out how to think about them. Her greatest fear was of suffering, she said. Although we were doing the operation in order to reduce her suffering, couldn’t the procedure make it worse rather than better?
Yes, I said. It could. Surgery offered her the possibility of being able to eat again and a very good likelihood of controlling her nausea, but it carried substantial risk of giving her only pain without improvement or adding yet new miseries. She had, I estimated for her, a 75 percent chance I’d make her future better, at least for a little while, and a 25 percent chance I’d make it worse.
So what then was the right thing for her to do? And why was the choice so agonizing? The choice, I realized, was far more complicated than a risk calculation. For how do you weigh relief from nausea, and the chances of being able to eat again, against the possibilities of pain, of infections, of having to live with stooling into a bag?
The brain gives us two ways to evaluate experiences like suffering—there is how we apprehend such experiences in the moment and how we look at them afterward—and the two ways are deeply contradictory. The Nobel Prize–winning researcher Daniel Kahneman illuminated what happens in a series of experiments he recounted in his seminal book
Thinking, Fast and Slow
. In one of them, he and University of Toronto physician Donald Redelmeier studied 287 patients undergoing colonoscopy and kidney stone procedures while awake. The researchers gave the patients a device that let them rate their pain every sixty seconds on a scale of one (no pain) to ten (intolerable pain), a system that provided a quantifiable measure of their moment-by-moment
experience of suffering. At the end, the patients were also asked to rate the total amount of pain they experienced during the procedure. The procedures lasted anywhere from four minutes to more than an hour. And the patients typically reported extended periods of low to moderate pain punctuated by moments of significant pain. A third of the colonoscopy patients and a quarter of the kidney stone patients reported a pain score of ten at least once during the procedure.
Our natural assumption is that the final ratings would represent something like the sum of the moment-by-moment ones. We believe that having a longer duration of pain is worse than a shorter duration and that having a greater average level of pain is worse than having a lower average level. But this wasn’t what the patients reported at all. Their final ratings largely ignored the duration of pain. Instead, the ratings were best predicted by what Kahneman termed the “Peak-End rule”: an average of the pain experienced at just two moments—the single worst moment of the procedure and the very end. The gastroenterologists conducting the procedures rated the level of pain they had inflicted very similarly to their patients, according to the level of pain at the moment of greatest intensity and the level at the end, not according to the total amount.
People seemed to have two different selves—an experiencing self who endures every moment equally and a remembering self who gives almost all the weight of judgment afterward to two single points in time, the worst moment and the last one. The remembering self seems to stick to the Peak-End rule even when the ending is an anomaly. Just a few minutes without pain at the end of their medical procedure dramatically reduced patients’ overall pain ratings even after they’d experienced more than half an hour of high level of pain. “That wasn’t so terrible,” they’d
reported afterward. A bad ending skewed the pain scores upward just as dramatically.
Studies in numerous settings have confirmed the Peak-End rule and our neglect of duration of suffering. Research has also shown that the phenomenon applies just as readily to the way people rate pleasurable experiences. Everyone knows the experience of watching sports when a team, having performed beautifully for nearly the entire game, blows it in the end. We feel that the ending ruins the whole experience. Yet there’s a contradiction at the root of that judgment. The experiencing self had whole hours of pleasure and just a moment of displeasure, but the remembering self sees no pleasure at all.
If the remembering self and the experiencing self can come to radically different opinions about the same experience, then the difficult question is which one to listen to. This was Jewel Douglass’s torment at bottom, and to a certain extent mine, if I was to help guide her. Should we listen to the remembering—or, in this case, anticipating—self that focuses on the worst things she might endure? Or should we listen to the experiencing self, which would likely have a lower average amount of suffering in the time to come if she underwent surgery rather than if she just went home—and might even get to eat for a while again?