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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.106 n.1 Pretoria Jan. 2016




Being mortal - Illness, medicine, and what matters in the end




Atul Gawande, a surgeon and professor at Harvard Medical School and a staff writer for the New Yorker, is the author of three previous books focusing on difficult issues doctors face.

In Being Mortal he takes a clear-eyed view of issues that have to be dealt with in an era when many people are living longer, often into debility, and when dying of old age is not a rarity. Gawande uses the stories of patients, friends and family to make important points. Modern medicine is primed to fix even what is unfixable: we mortals fear debility and death. In the attempt to extend life at all costs, unnecessary suffering is inflicted and personal finances and healthcare budgets are crippled. As Gawande says, 'We've been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being.'

In the chapter 'A better life', Gawande dis- cusses interesting studies where using simple measures - three square meals a day, reporting falls, adjusting medications - dramatically reduced the amount of time the elderly spent in hospital, so improving the quality of the last period of their lives. These interventions do not generate the revenue that actively treating patients does. The fields of gerontology and geriatric medicine in the USA are therefore unpopular, underfunded and understaffed.

Several clinical trials have shown that stopping treatment in cancer patients when previous lines of treatment have failed, together with the early institution of palliative care, results in their living a better quality and, more surprisingly, a longer life. That we do not often discuss this with our patients shows what happens when we confuse care with treatment.

The chapter titled 'Hard conversations' cuts to the heart of this. Here Gawande deals with those candid discussions that are difficult for both patient and caregiver but crucial to ensuring that illusions are removed and achievable goals are looked at realistically and compassionately. Excellent pointers are given in negotiating this crucial interaction.

Patient priorities are more than prolonging life and include avoiding suffering, mental alertness, improving relationships with family and friends, not being a burden, and feeling that their lives have not been a waste of time. 'Endings matter', says Gawande. The current system of high-tech medical care is failing our patients in meeting these needs, and the cost of this failure is enormous, financially and also in causing unnecessary suffering.

He movingly charts his own journey from being an 'informative' to an 'interpretive' doctor: from one who merely enumerates treatment options, often when this risks doing harm with little hope of benefit, to one who assists patients in managing the latter stages of their lives in a way that is meaningful to them. This interpretive approach requires spending the time to learn what the patient's goals are, understanding what risks and trade-offs they are prepared to accept in exchange for their independence, comfort and dignity, and then assisting them in realising this.

In the last chapter, titled 'Courage', Gawande looks at our personal responsibility in planning ahead for our inevitable ageing and death. It takes courage to confront this reality and to act on it. The reality is that if we do not do it, it will be left to others to take those decisions on our behalf, and with that the last vestige of our independence. It is up to us to ensure that our last days are more comfortable and meaningful. As this thought-provoking book shows, it is our dignity and humanity that matter in the end.

David Eedes

Clinical oncologist, Three Anchor Bay
Cape Town

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