Being Mortal: Medicine and What Matters in the End
Atul Gawande
Metropolitan Books (2014)

Invaluable insights that reveal and affirm the importance of the quality of death

It is impossible to calculate the number of lives that have been saved by a visionary pragmatist, Atul Gawande, M.D., and his passionate advocacy of using checklists to reduce (if not eliminate) mistakes during healthcare provision. For years, mechanics as well as pilots and their navigators have spent hours prior to each flight to ensure that there will be no problems with the given aircraft. Why not healthcare professionals? As they will readily concede, a hospital probably is the unhealthiest place to be when already ill.

“We have just two reasons that we may fail. The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude – because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about. For nearly all of history, people’s lives have been governed primarily by ignorance.”

With regard to healthcare provision, he adds, “At least 30 percent of patients with stroke receive incomplete or inappropriate care from their doctors, as do 45 percent of patients with asthma and 60 percent of patients with pneumonia. Getting the steps right is proving brutally hard, even if you know them.” Hence the importance of using checklists to improving the quality of care…and the quality of life.

I urge those who have not as yet read his book, The Checklist Manifesto, to do so as soon as possible.

There is almost universal agreement on what the meaning of the phrase “quality of Life” means but that is hardly true with regard to the meaning of the phrase “quality of death.” Perhaps the strongest disagreements and most heated exchanges involve those who support or oppose assisted death, counterpart and polar opposite of assisted living. Perhaps Being Mortal will help to resolve at least some of those differences and disagreements. More to the point, I hope it will alleviate the distress and anxiety of those who proceed through their final days.

I agree with Sarah Nelson’s observations that, “Through interviews with doctors, stories from and about health care providers (such as the woman who pioneered the notion of “assisted living” for the elderly)—and eventually, by way of the story of his own father’s dying, Gawande examines the cracks in the system of health care to the aged (i.e. 97 percent of medical students take no course in geriatrics) and to the seriously ill who might have different needs and expectations than the ones family members predict. (One striking example: the terminally ill former professor who told his daughter that “quality of life” for him meant the ongoing ability to enjoy chocolate ice cream and watch football on TV. If medical treatments might remove those pleasures, well, then, he wasn’t sure he would submit to such treatments.) Doctors don’t listen, Gawande suggests—or, more accurately, they don’t know what to listen for.”

Presumably an increasingly greater number of healthcare administrators are compiling a checklist of the checklists that are needed, identifying also those best-qualified to compile them so that the meaning of “assisted dying” is extended to include making every effort possible to ensure a quality of death that takes into full account what will respond effectively to the emotional and psychological as well as physical needs of patients. That is what they deserve and that is what their loved ones should expect of those to whom their loved ones’ care has been entrusted.

Again, it is impossible to calculate the number of people who will benefit from what Atul Gawande recommends in his latest book. Having lived as long as I have, and given my own experience during the last days of family members and friends, I think those of us who cared for them did our best to make them comfortable, to manage their pain (if that’s really possible), and to treat them with proper respect. Only by reading this book did I realize, however, what more — and less — could have been done, with greater sensitivity.

The review of Being Mortal by “Helping Hands” in The Economist concludes, “Many people fear that a doctor who does not try everything possible has abandoned his patients, and they will die earlier as a result. Surprisingly, however, the try-everything approach appears not even to offer a longer life. Multiple studies have shown that patients entering hospice care, which usually means abandoning attempts at a cure, live at least as long as those receiving traditional care. A startling study in 2010 found that patients with advanced lung cancer who saw a specialist in palliative care as well as receiving the usual oncological treatment stopped chemotherapy sooner, entered a hospice earlier, suffered less—and lived 25% longer than comparable patients who received only the standard care. ‘If end-of-life discussions were an experimental drug, the FDA [an American regulatory body] would approve it,’ says Dr Gawande. In life, as in all stories, he writes, ‘endings matter.'”

Anyone who questions that should ask those now close to end-of-life.