Atul Gawande: End-of-life counseling improves — and even extends — lives

End-of-life planning is not only difficult for patients, it’s difficult for doctors as well. One physician who’s given it a great deal of thought is Atul Gawande,  a much respected surgeon who’s also a writer for The New Yorker. Dr. Gawande wrote “Letting Go: What Should Medicine Do When It Can’t Save Your Life?” Correspondent Shoshana Guy traveled to Boston to sit down with him. They also discussed efforts to lower health care costs in a web-exclusive interview.

 
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  • Richard Gelb

    Fortunately, my wife, diagnosed w/ stage 4 transitional cell carcenoma in her kidney, decided after surgery, chemo, radiation, and surgery, decided to stop tx and do hospice. It was she who opened the discussion w/ her oncologist and his team, about ended cancer treatment (it was amazing to see the look of relief on their faces when she told them she wanted to end treatment and do hospice). She also got her wish to die at home! For which I am forever grateful!

  • Kirk W

    This was a very interesting progam, however both Dr. Atul Gawande and the PBS Need
    To Know Interviewer skirted around the truth of what REALLY drives Doctors,
    Hospitals, and the Republican/Democratic politicans who support their
    Medical Associations’ End of Life lobby initiatives. Once again it is lust for money, BIG money,
    that drives/encourages the useless/wasteful medical procedures inflicted on a dying
    patient during their final 4-6 months of life.

    It is well known that corporate/public Hospitals and the Doctors who own and work in those hospitals, build into their financial forecasting the increased dollars that flow
    directly from the useless procedures ordered by Doctors; and inflicted on their
    patients during the final months of their lives. They also Hippocratically rationalize to themselves
    that the patient MUST have wanted the procedures, because the patient did not
    opt for/enact End of Life instructions for hospice/pallative care, with its compassion and very effective pain control. Tis a crying shame that business is so damn unethical. Caveat Emptor! (In everyday language: Let the Buyer Beware!)

    The Doctors and Corporate/Public Hospital Board Executives also rationalize that THEIR Hospital
    system would not be what it is without those huge End of Life profits. It doesn’t take a
    brain surgeon (actually it does) to conclude that funding for End of Life Counseling
    would dramatically reduce End of Life Gouging by the Medical/Hospital Industry.

    Dr. Atul Gawande mentioned the statistic that each year “25% of Medicare Funding is
    spent on the 5% of patients that die.” If commonsense and compassionate End of
    Life Counseling prevailed, not only would the patient benefit by living longer with
    less pain, but the 25% might be reduced to 10% which would be good for taxpayers.
    It would also enable a dying patient to pass on a significant chunk of their life savings
    to their family, and keep it OUT of the pockets of Hospital Execs, Doctors and Health
    Care Lobbyists.

    Unfortunately, the corporate, medical and political leeches have their suckers firmly
    planted into the veins of the End of Life System; and they want the money/funding
    spigots turned all the way on. It is indeed a cruel world!

  • Jfc1220

    The article about President Regan’s smoozing the American People and encouraging them to forget Carter’s warning about the need to make sacrifices and face that we need to renounce oil dependency was very bold and very important.. The issue is one that we badly need to see and come to grips with now in a national conversation about what real democracy is and whether it requires sacrifice for the good of the whole or whether it supports the ideal of individual’s right to unfettered wealth

  • C B

    Kirk W, Do you mean Corporate/Private hospitals-not “Public” hospitals?

  • Fred Pauser

    Kirk, you and I watched the same program and came away with different conclusions. No one “skirted around the truth.” (Sure there’s more to the issue, but they had only 10 minutes.)
    If patients do not provide specific orders in regard to, at what point they want the doctors/hospitals to cease efforts to extend their lives, then medical people are both morally and legally bound to do whatever is feasibly possible for as long as it takes. Although there may be some unscrupulous doctors and hospital administrators, overall, this issue has little to do with greed or lack of ethics therein. Take a look at Richard Gelb’s response as a partial example of what I am saying. I think doctors and hospital staff in general are relieved when they are not obligated to take ridiculous measures to extend a patient’s life, knowing that doing such is likely to just extend suffering.
    Good doctors are in demand — why would they be concerned about money for unnecessary or harmful procedures? Hospital administrators, however, may be under pressure to make ends meet, satisfy investors, etc. They might favor the status quo and desire to maintain inertia. But is there EVIDENCE that a hospital lobby tried to defeat the end-of-life provisions in the Health Care bill? (I don’t know.)
    We agree that the end-of-life counseling provision of the bill would have been a good thing. It seems to me that it was defeated due to Conservatives drumming up opposition to it based upon talk of “death panels,” the ignorant notion that the government would be making life and death decisions, and “pulling the plug on grandma.” The conservatives succeeded. But was it conservative ideology and unethical steps taken by them in their desire to not allow Obama to make political points that defeated the provision? Even if hospital lobby money was involved, it would have been unethical for politicians to allow any lobby to sway them toward their ridiculous death panel argument, although that may be a part of what happened. Primarily I blame conservative politicians.

  • Andy

    There are crooks in every business. Certainly there are unscrupulous doctors that will try to perform billable procedures on people who have nothing to gain from them, but the bigger psychopathology in effect is ego. It’s hard to admit personal defeat to your client in your chosen profession, whether you’re a plumber or a surgeon.

    A little financial incentive to the general practitioner might motivate them to have this conversation with a patient, sick or healthy, before the “high pressure sales pitch” comes for that next round of chemo or the next surgery.

    I say this both as a surgeon and as one who recently lost their mother to cancer, after she decided to make peace with the disease and to die at home, comfortable and surrounded by those who loved her.

  • Fred Pauser

    Kirk, you and I watched the same program and came away with different conclusions. No one “skirted around the truth.” (Sure there’s more to the issue, but they had only 10 minutes.)

    If patients do not provide specific orders in regard to, at what point they want the doctors/hospitals to cease efforts to extend their lives, then medical people are both morally and legally bound to do whatever is feasibly possible for as long as it takes. Although there may be some unscrupulous doctors and hospital administrators, overall, this issue has little to do with greed or lack of ethics therein. Take a look at Richard Gelb’s response as a partial example of what I am saying. I think doctors and hospital staff in general are relieved when they are not obligated to take ridiculous measures to extend a patient’s life, knowing that doing such is likely to just extend suffering.

    Good doctors are in demand — why would they be concerned about money for unnecessary or harmful procedures? Hospital administrators, however, may be under pressure to make ends meet, satisfy investors, etc. They might favor the status quo and desire to maintain inertia. But is there EVIDENCE that a hospital lobby tried to defeat the end-of-life provisions in the Health Care bill? (I don’t know.)

    We agree that the end-of-life counseling provision of the bill would have been a good thing. It seems to me that it was defeated due to Conservatives drumming up opposition to it based upon talk of “death panels,” the ignorant notion that the government would be making life and death decisions, and “pulling the plug on grandma.” The conservatives succeeded. But was it conservative ideology and unethical steps taken by them in their desire to not allow Obama to make political points that defeated the provision? Even if hospital lobby money was involved, it would have been unethical for politicians to allow any lobby to sway them toward their ridiculous death panel argument, although that may be a part of what happened. Primarily I blame conservative politicians.

  • Kirk W

    Fred Pauser 5 minutes ago in reply to Kirk W

    Fred, Thanks for your comment. In your final paragraph, most of which I agree with, you wrote this:

    “Even if hospital lobby money was involved, it would have been unethical for politicians to allow any lobby to sway them toward their ridiculous death panel argument, although that may be a part of what happened. Primarily I blame conservative politicians.”

    Hospital lobby money was involved, federal politicans are unethical, and they stopped the funding for End of Life Counseling. Both the politicans and their corporate bosses know that profits would nosedive, if there were a broad funded effort for responsible doctors and non-profit organizations to explain to the unaware masses that they would suffer much less and probably live longer as a hospice patient during the last 6 months of their lives vs vegetating in a hospital’s ICU. No matter who is to blame, the bottom line is that the vast majority of Americans are the ultimate losers, because the entities that insist on profit before people have been successful at denying them the funding needed for one to one End of Life Counseling by their own doctors.

    Having said the above, I would encourage you to read the following articles on this subject:

    Greedy Doctors Are The Same As Wall Street Bankers (with quotes by Dr. Atul Gawande)
    Posted on July 30, 2009 by thoughtbasket – 14 Comments
    http://thoughtbasket.com/2009/07/30/greedy-doctors-are-the-same-as-wall-street-bankers/

    Should Doctors Own Hospitals? Controversy builds over a fast-growing, profit-driven business
    http://www.businessweek.com/magazine/content/06_08/b3972088.htm

    DOCTORS, HOSPITALS DUKE IT OUT. Doctor-owned facilities sue hospitals on alleged antitrust violations.
    Sheri Qualters / Staff reporter
    http://www.stuevesiegel.com/CM/Press/Doctors-Hospitals.asp

    Letting Go: What should medicine do when it can’t save your life? by Atul Gawande
    http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all

    Regard,
    Kirk

  • Sue

    I can’t help but wonder if Obama was diagnosed with something incurable,suddenly how important it would be for HIM to discuss life goals with his doctor?

  • Lamott

    As a woman who discovered she had breast cancer at 40, I have long read about and been interested in death and dying issues. I am now 57. I ma very interested in talking to family, friends and doctors about what ‘quality of life’ means to each individual. I think Obama is helping this country and I think his interest in end of life discussions is on track with helping people with quality of life. It happens to save money when a person uses Hospice services. I know because of discussions we had with my mom and dad when we found he had melanoma which spread to his brain. He was able to stay in his own house for the last three months of his life though he was failing. Hospice was essential to his well being and ours. We had an emergency kit in the refrigerator for pain which was never used. He died the way he wanted to die. It was very peaceful. If my doctor cannot talk to me when I need to have such discussion I would call Hospice or even hire a psychologist to help me decide what I want to do. I am a realist. None of us gets out alive. Why don’t we plan for it like we plan a family or plan for retirement? That makes sense to me.

  • Anonymous

    I am a physician assistant who has worked with infected in-patients for 12 years. An indiscriminant cross section of all patients, from all races, with all diseases get infected. On a daily basis I attempt to help patients and their families make better end of life decisions, and I try to actively engage these discussions. I held my grandfather’s hand when he died, I often sit with dying patients when there is no one else there (and you would not believe how often this happens to patients with families who know that they are dying) simply to give some presence. I watched my husband’s best friend walk into a hospital and die 6 WEEKS later from a horribly aggressive brain tumor and promised to help care for his wife and son; my husband tried to help him prepare to die (at 38). Yes there are likely doctors who actively seek patients to increase their billing but 90% of those with whom I work would be thrilled NOT to have to start hemodialysis on a 90 man in an ICU bed, NOT to surgically clean out the pressure ulcer on the non-verbal, bed bound patient with a feeding tube. Why do we do it?? Mostly because as a society, we have not yet said “no”. Just because we can does not mean we should and the combination of culture (my in-laws have yet at 75 spoken about their end-of-life wishes with one another), skill (we can ‘non-invasively’ do almost anything), and legal backdrop make it very hard to say, we can do hemodialysis but we will not offer it. I appreciate this dialogue and hope that it continues. I would say that on any given day 20-40% of the patients that I round on have a quality of life that 98% of Americans would agree was not worth their suffering nor the money spent to keep them alive. But yet despite all of my talks and begging, patients families demand that I plod on. I would love to have any politician round with me and see what we are doing; how crazy it is.

  • http://raisingspirits.michaelgoldbergonline.com Rabbi Michael Goldberg, PhD

    As a hospice and hospital ICU chaplain as well as a professional ethicist who has served on hospital ethics committees, I have witnessed the needless and pointless suffering that patients and their families have endured when they and their physicians have failed to have in-depth discussions about their wishes at the end of life.

    As Dr. Gawande and the studies he cites show, end-of-life counseling can not only ease suffering but at times extend life itself. In this light, ongoing, truthful dialogues between physicians, their patients, and where appropriate their patients’ loved ones, are nowhere near “death panels,” but might well be called “life panels” instead.

  • dying mom’s son

    Palliative Care only added to the misery!

    A Mount Sinai Palliative Care team ushered me into a room to tell me that after many hospital stays in the past two years my semi-conscious mom’s cancer-ridden body had reached THE END – she was doomed.

    This news wasn’t bad enough, oh my God, Palliative Care were determined to “””help””” (How could they possibly) by hastening my nervous breakdown interrogating about my violent alcoholic father and AWOL sibling-rivalry-gone-psycho sister.

    Drained by another hospital stay at my mom’s bedside I arrived home to find a Palliative Care member had phoned my drunken father to poison his already alcohol-fueled mind, “What’s wrong with your son?” (The only responsible family member to this point holding things together!)

    One week ahead of her death the hospital kicked Mom out to rehab, which, the very next morning sent her right back to a hospital. Rather than malpractice, Palliative Care might have prepared me for watching her week-long comatose gasping for breath.