End of the Road

Like a lot of baby boomers, I’ve become distressingly familiar with hospital intensive care units in recent years: the constant contrast between banal routine and live-and-death drama, the dangerous rituals of a shift change, the gradual turnover in patients as some quietly die, the realization that recovery has become remote, the infuriating wait for “rounds” and the information you feel sure you are being denied. While some hospitals are undoubtedly better places than others from which to leave this life, it’s all part of a system that seems to revolve around denial of what it happening. And so I was very interested to read Phillip Longman’s review of a book about that culture of denial in American health care and American culture, and wish now I coud have read Atul Gawande’s Being Mortal: American Medicine and What Matters in the End several years ago.

We have a system for dealing with end-of-live events, says Gawande, a surgeon, in which those god-like figures whose “rounds” we await, the physicians, are poorly equipped to handle:

Doctors today know how to treat, if not cure, many specific conditions, such as colon cancer, high blood pressure, or an arthritic knee. But, writes Gawande, “give us an elderly woman with high blood pressure, arthritic knees, and various other ailments besides—an elderly woman at risk of losing the life she enjoys—and we hardly know what to do and often only make matters worse.”

Most doctors have not received any training that specifically prepares them to treat the kind of patients who are overwhelmingly becoming the most common. These are people who, had they been born even a few decades before they actually were, would have likely died from childhood infections or midlife coronaries, but who under modern conditions have survived long enough to be afflicted by multiple chronic conditions such as cancer and Alzheimer’s disease.

Yes, hospitals are increasingly utilizing “palliative care” teams that take over for the helpless docs, but often long after unnecessary pain (not to mention expense) has been imposed on dying patients and suffering family members–and that’s just with the patients lucky enough to have family members around to monitor care. As Gawande and Longman say, we need a system change.

One of the major contributions of this book is that Gawande manages to reframe end-of-life issues outside the normal, puerile terms of debate. He does not concentrate on the financial costs of heroic, high-tech treatments that only marginally extend life expectancy, though those costs are extensive. Nor does he engage directly with those calling for, or decrying, various forms of “rationing.” Rather, Gawande quite rightly shows how for the vast majority of us the real issue is entirely different: just how—in the face of a health care delivery system acculturated to and profiting from the overtreatment of its sickest, most vulnerable patients—do we and our loved ones get through to the end of life while avoiding painful, expensive, futile care we don’t want.

It’s really hard to imagine an issue that’s more certainly waiting for most of us at some point down the road.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.