Friday, July 30, 2010

Letting Go

Atul Gawande has a great piece in the New Yorker this week about the difficult and complex management of end stage disease in terminal patients. (See, I don't always criticize the guy. He writes good stuff.) What happens when we reach the point where further treatment is futile, when death gathers momentum, threatens to overwhelm at any moment? What do we do with these brittle, emaciated, broken human beings, bodies riddled with cancer, when all the latest toxic chemotherapy options have been exhausted and there's no more surgery to offer? What do we do when these patients don't want to hear about "palliative care" and "hospice", when they get angry or accuse you of abandonment when you tell the truth about their prognoses? There has to be something else, they plead, some new trial, some miracle cure. That faint sliver of light is what they grasp for when the darkness begins overtake them. Gawande:

There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

It's a great weekend read.


rlbates said...

Very nice read!

Christian Sinclair said...

Thanks for featuring this article. It is nice to see it being spread around the medical community and the general public. While long it is really telling of our struggles with the medical tipping point when our treatments no longer extend life.

For some takes on how the palliative medicine field is thinking about the article, check out Pallimed or Geripal (Yeah when I put those two together it sounds kind of silly, but hey that's those are the names.)

Anonymous said...

His name is pronounced "a tool" for a reason. Pedantic and self-important writing

Gary M. Levin said...

More than a nice read. Atul is so articulate and literate. I usually have to use my dictionary to feret out all he says. A nice juxtaposition for me from taking out cataracts!! It made me feel like more of a doctor.

Anonymous said...

I don't know why we can't treat terminally ill humans like my Dad used to do when our dogs got sick and old.
He'd take em to live at my Uncle Jocephus's farm down in South Georgia.
Not really sure why he took that shotgun, or how he drove 300 miles in 25 minutes, cause thats when he'd be back, counting on my ADHD not to put together 2+2..
Of course this year's the shoe's on the other foot, it'd be much more financially sound for him to die this year, when the estate tax is "0"% than next year when its 50%.
and he's sort of like the dogs, sits around sleeping all day, farts, and occasionally takes a dump on the front porch.
and just like our dogs, when he see's a shotgun he runs and hides and won't show back up for a week.

Frank "Euthanize em all and let God sort em out" Drackman

doc said...

End of life issues are always complex and tough to deal with for every party involved. On the medical side, sometimes you wonder if "playing God" or the perception thereof is involved.