|Published 7 October 2014.|
Surgeon, teacher, speaker and author Atul Gawande fashions a book about the difficulties many people face in their last months of life.
Advances in medicine have given people a myriad of options in how to address serious illness, particularly cancer.
When should patients work with medical professionals to intervene and when should patients refrain?
In other words, should people aggressively pursue every avenue for extending life despite the low probability of success and without considering the hardship that chemotherapy, radiation, and surgery might create?
Other questions posed by the book: When should patients pursue less aggressive treatment options? And when should they switch from life-saving care to comfort care?
It's extremely difficult to make these choices. Even Guwande's own father, also a doctor (a urologist) struggles to decide how to respond to a serious illness that starts with tingling in his left arm.
Guwande and his parents stumbled through the process of choosing the kind and timing of various medical interventions. His father journey as doctor-turned-patient made me very aware of how agonizing the questions of managing the last years of one's life can be. Even the experts don't have clarity on this issue of late-life health care.
Gawande deftly weaves together research, treatment models, statistics, anecdotes, and meditations on the topic of how to respond to life-threatening illness or injuries. Not only does the book describe the path Guwande's father takes, Guwande shares stories about his wife's grandmother, their daughter's piano teacher and several patients in Guwande's surgical practice.
One of the most salient elements of the book is Guwande's description of three models for the doctor-patient relationship: paternalistic, informational and guided choice.
The patient is passive in the paternalistic model with the doctor making all the treatment choices. In the informational model, the doctor provides all the technical information and asks the patient to choose the course of action. This model often overwhelms patients because they are not experts and they are usually emotionally overwhelmed by their illness or injury.
The guided model encourages the doctor to ask the patient's about preferred outcomes and preferred quality of life: "What is most important to you?" Then the doctor uses his or her expertise to choose a path that works with the patient's desires in mind.
For example, if the difference between aggressive treatment and palliative care might only result in a life extension of a few months, the patient might forego the surgery or chemo or radiation. If the person would rather risk being a quadriplegic than die without surgery, he or she would choose the surgery.
Ultimately, Guwande invites readers to consider these questions now, before serious health complications make conversations more difficult to hold. Several of his anecdotes show family members having gut-wrenching discussions but ending up being grateful for the guidance they provided when the patient was unable to articulate their wishes--mid crisis.
A powerful book written with an amazing balance of expertise and sensitivity.
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