Winter 2018

Life and Death

Lessons from writer and surgeon Atul Gawande.

By Courtney Hollands

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Rachel Reindorf, M21, meets Atul Gawande after his lecture. Photo: Anna Miller

How can doctors help their patients better prepare for end of life? It’s a question that Atul Gawande grappled with in his 2014 New York Times best seller, Being Mortal, and explored during his Dr. Maurice Segal Lecture at the Sackler Center on September 15. Being Mortal was the Common Reading Book Program selection for all incoming medical students this fall.

In addition to being a surgeon at Brigham and Women’s Hospital and a staff writer for The New Yorker, Gawande is cochair of the Massachusetts Coalition for Serious Illness Care, which seeks to ensure that medical treatment aligns with patient “goals, values, and preferences at all stages of life and in all steps of their care.” The group has reached out to School of Medicine Dean Harris Berman and the state’s other medical school deans to collaborate on curriculum changes around these issues. Here are a few things we learned from Gawande’s talk.

THE GOAL IS NOT A GOOD DEATH; THE GOAL IS A GOOD LIFE TO THE VERY END With Being Mortal, “I thought I would be writing about the dying process and the choices at the very end about what kind of death you really want,” Gawande said. But as he talked to more than 200 patients and their family members, plus scores of geriatricians and other clinicians, he found that “people have priorities that they want us to help them with serving—priorities besides just living longer. They have reasons they want to be alive and things they are alive for.”

TALK IS POWERFUL Gawande cited a 2010 study led by Jennifer Temel from Massachusetts General Hospital that followed two groups of stage IV lung cancer patients. In one group, the patients received usual oncology care, while the other received usual oncology care plus visits with a palliative care clinician. The patients who spoke to a palliative care clinician chose to stop their chemotherapy earlier and had a better quality of life. In addition, Gawande said, they spent more time at home, underwent fewer surgical procedures, and spent less time in the ICU. “And the kicker was that they lived 25 percent longer,” he said.

CLINICIANS AS COUSELORS Starting in the 1980s, medical professionals focused on being as informative as possible, Gawande said: “We wanted to give people clarity about what the facts were in their situations and what their options were.” But conversations Gawande had made it evident that there’s another role: counselor. “The counselor gets really clear with you what your goals are, what your priorities are, what you’re willing to sacrifice and not willing to sacrifice,” he said. “And then, yes, we talk about the options and make a recommendation based on our experience about what is most likely to succeed in achieving what matters to you.”

AUTONOMY MATTERS Gawande interviewed nursing home residents who were miserable because every aspect of their lives—bedtime, mealtime, medication time—was tightly regulated. As one person running a home told him, it was the adult children who, fearing for their parents’ safety, usually made the decision to place their parents in nursing homes. “Safety is what we want for those we love, and autonomy is what we want for ourselves,” Gawande said. “Well-being is bigger than safety and survival. Our role as counselors … is not just to make our case for what the longer-term well-being of people is, but to enable autonomy for those choices along the way.”

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