GUEST POST by N.R.Ramesh
For those who are not familiar with Atul Gawande, a short
introduction is probably in order. He is a surgeon, lives and works in the US
at Brigham and Women’s Hospital, and has been writing quite extensively. He is a
staff writer for the ‘The New Yorker’ magazine, and has published three books
earlier, ‘Complications’, ‘Better’ and ‘The Checklist Manifesto’. These books
deal with the challenges of practicing medicine, starting from the dilemmas
doctors face when they have to treat with incomplete information to running
hospitals better and how to make the medical practice safer.
In this book, Dr. Gawande has taken a critical look at how
modern society is dealing with the end of life care. He starts by emphasizing
that our bodies eventually start failing and the end eventually happens due to
the cumulative effects of all the changes due to ageing, starting with cellular
degeneration to structural changes to our anatomy. Next he traces a little bit
of history of how end of life care has changed from what were called the ‘poor
houses’ in the US to the modern day ‘nursing homes’. He also explores the
differences between different societies and finds that as the overall economic
situation improves, most societies around the globe follow a similar path in
terms of dealing with the evening of one’s life.
He vividly describes how the current average nursing home or
assisted living communities in the US, and probably in most other developed
economies are more designed to be places where one is kept “safe”, and
“medically alive” at the cost of everything else that may matter for the
resident. He has interviewed several residents, care givers, geriatricians and
finds that the routine in such homes are designed for the overall efficiency of
the staff and care givers and do not have any flexibility that the residents desire.
He highlights this to be one of the first things that people who move into such
places miss and makes them feel that they are no longer in their “homes”. The
regulations that govern such communities are also only focused on the physical
safety of the residents and hardly anything else. Regulations have certainly
helped to improve the general hygiene and comfort levels from the days of the
“poor houses”, but have not addressed the wholesome needs of the residents. He
also gives a good account of hospice care which is getting popular under which one
is able to maintain a decent quality of life staying in their own homes.
Dr. Gawande has also interviewed and visited some of the
communities that have been trying to fix this issue and have tried to make the
residents lives more meaningful. He talks about the community that tried to
collocate close to a school with kids visiting them during their breaks or
where the residents can watch the kids play, and another one where they tried
bringing in pets like birds to keep the residents engaged. It seems that having
something meaningful to do, however little it may be due to one’s physical
limitations does a world of good to the resident’s mental state and it rubs off
into their physical well-being as well.
He then talks about the difficult choices one has to make
when faced with terminal illnesses. He illustrates this with a few patients he
has followed, primarily those facing terminal cancers and the difficult choices
one has to make with respect to the treatment regimens, especially when the
outcomes predicted are not very rosy. Quality of life seems to be taking a big
hit for some who opt for these treatment regimens and the last few weeks of
their life is spent secluded in an Intensive Care Unit, away from their family
and friends, and often with multiple tubes into their bodies to keep them
“alive”. He suggests that when we know the end is inevitable and fairly close,
it may be worth considering what is really important for the individual and
allow them to make those choices. He also feels that the medical community,
especially Doctors need to be better trained to have these conversations when the
person is fully conscious and aware, and help them make the right choices. One
of the persons described is his own father who is diagnosed with cancer and how
he chose to decline some treatment options towards the end, and decided to stay
at home with hospice care.
Overall, a very good book that
really takes a critical view of the current state of affairs for those in the
evening of their lives, and he has dealt with this subject as candidly as
possible. The core message of the book, if I have to sum it up in a single line
is that the individual should have a say in how they want to spend their last
living days and the medical community and family need to try and make that
possible as best as we can.
