The book is a chastisement of Dr Atul Gawande’s fellow doctors who often “focus on prolongation of the life of their patients, while failing to recognize they may have higher or different priorities beyond merely being safe and living longer.” In that mission, he seems to have succeeded – Picture courtesy Goodreads

 

Confronting Human Mortality
By Dr Syed Amir
Bethesda, MD

 

In his best-selling book, Being Mortal--Medicine and What Matters in the End, Dr Atul Gawande, a professor and surgeon at Harvard Medical School in Boston, noted that while medical school taught him a lot of things, it failed to teach him how to deal with human mortality and death, existential issues that he confronted daily. Since the days of Hippocrates (Al Boqrat), the celebrated Greek physician who lived 2,500 years ago, practitioners of medicine have pledged to help save lives and do nothing to hasten death. Dealing with issues of death and mortality, however, has not been their purview.

Yet, occasionally, the prohibition against facilitating the end has not been followed literally. In 1936, King George V of Britain, who had been sick, comatose, and near death was administered high doses of morphine and cocaine by his doctor, Lord Dawson, to ensure a painless end. There was another consideration as well. The King’s death was advanced by a few hours to meet the news deadline for London’s morning papers. Death announcement in the evening papers was not considered sufficiently dignified, especially for the King-Emperor.

The process of dying and how to demystify it has been the subject of several recent books and treatises. Gawande, whose parents emigrated from India, contends in his book that although we avoid thinking or talking about it, dying remains an ineluctable part of life’s normal progression and should be faced with serenity. His book set off a flurry of lively debate in the news media, and the author became a familiar figure on the US talk shows. His book became one of the most popular books on the subject that have come out in recent years, swiftly climbing to the best-seller list.

The book focuses on a phenomenon of relatively recent origin. The human lifespan has been rising steadily since the days when peripatetic Greek physicians and philosophers taught medicine to their pupil. In the Middle Ages, people rarely lived to what we call a ripe old age, as infectious diseases and rampant pestilences took millions of lives, while childhood maladies killed many in infancy. During the reign of Abbasid Caliph Harun ur-Rashid in the eighth century, the average human lifespan was 40-45 years, and the fabled Caliph himself lived only for 46 years. In today’s Pakistan, the average life expectancy has climbed to 66 years; while in rich countries, Canada and Japan, people on the average live 80 years or beyond.

Human longevity has not been an unmitigated blessing. The final years of life are often marked with chronic, debilitating diseases, such as Alzheimer’s and Parkinson’s, which make people hopelessly dependent on others for day-to-day needs, leading to a sharp decline in the quality of their lives. As a physician, Gawande records his first-hand observation: “The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions--nursing homes and intensive care units--where regimented, anonymous routines cut us off from all the things that matter to us in life.”

Some three decades ago, another noted American surgeon and author, Dr Sherwin Nuland, now dead, made similar remarks in his much admired book, “How We Die.” Deriding the arrogance of modern physicians who with an arsenal of new diagnostic tools and powerful drugs at their disposal, believe that they can fight off death or at least keep it at bay for a while, Nuland remorsefully confessed that “on more than one occasion he had persuaded dying patients to accept aggressive treatments that intensified their suffering and robbed them of an easier death.”

During the past half century or so, the practice of medicine has changed radically in important respects. In the good old times, doctors were viewed as authority figures, their diagnosis and mode of operation were beyond question. The perception allowed no input from the patient in managing his own care, but paradoxically, it also freed him from the burden of making any decisions or choices, fostering the comforting belief that the doctor knew best. The system worked well as often patients, especially the aged with serious illnesses, did not last long. There were no life-support systems, no miracle drugs that could keep them alive for many months or years. Therefore, no one needed to ask whether the prolongation of life, largely valueless, was also the priority of the patient.

Being Mortal  is a compendium of anecdotes, many emotive even touching, based on the first-hand experience of the author. In many cases, he writes about geriatric patients who were terminally ill, with no hope of recovery. Nevertheless, their physicians continued their heroic effort to keep them alive, connecting them to ventilators, feeding tubes and administering cardiopulmonary resuscitations and heavy doses of painkillers, knowing well that it was all futile. Even when living on artificial life support was not the choice of the patient, the children would not agree to permit the parent a dignified exit. A dignified, peaceful death is not the only issue. In the United States, the cost of medical care is spiraling out of control. The expense of care of just five percent of patients in the last two months of their lives consumes one-quarter of the total budget allocated for the care of elderly. The pity is that the ultra-costly treatments rarely provided lasting benefit to the patient.

The most moving story in the book relates to the death of the author’s father who was a successful urologist. In his early seventies, he led a vigorous life, playing tennis, running a busy medical practice and was active socially. When he started complaining of neck pain, the symptoms were dismissed as part of the normal aging process. However, as the problem worsened, more extensive diagnostic tests revealed a tumor growing in his spinal cord, a finding much more serious than originally thought. The author gives a detailed account of the progression of the malignancy, the course of treatment and the emotional roller coaster his family went through.

The father went through an invasive surgical procedure that brought only temporary relief. The radiation treatment that followed caused miserable side effects and no remission from pain. Fed up with both the malady and the treatment, he refused to countenance any further treatment that would have condemned him to a miserable existence, with no ability to enjoy things he valued. He insisted that his oxygen supply and antibiotic drugs be withdrawn. He was finally taken back to his house as he desired, and there he peacefully passed away without much suffering.

Dr Gawande, a master storyteller, has produced a highly readable book, but it is not designed to unravel the mysteries of death or dying or to offer any insights into either. In fact, the book is a chastisement of his fellow doctors who often “focus on prolongation of the life of their patients, while failing to recognize they may have higher or different priorities beyond merely being safe and living longer.” In that mission, he seems to have succeeded.

(Dr Syed Amir is a former Assistant Professor, Harvard Medical School, and a health science administrator, US National Institutes of Health)