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End of Life Medical Care

Medicine has triumphed in modern times, transforming birth, injury, and infectious disease from harrowing to manageable. But in the inevitable condition of aging and death, the goals of medicine seem too frequently to run counter to the interest of the human spirit. Hospitals isolate the dying, checking for vital signs long after the goals of cure have become moot. And life-ending physical conditions are most often treated as medical crises needing to be "fixed," instead of managed for quality of life when treatment has become futile. When are you most likely to have surgery? Two weeks before your death. So you get all of the pain and none of the benefit. We have to do better.

In his book, Being Mortal, Dr. Atul Gawande suggests an approach on the part of the medical profession that takes into consideration the implications of possible treatments, what the patient could likely experience, and the current desires of the patient. He acknowledges that, “Damage can be done when doctors fail to acknowledge that medical power is finite. With best intentions, doctors too often try to ensure health and survival when the goal really should be to enable well-being, and well-being is about the reasons one wishes to be alive.” 

There needs to be an honest dialogue between doctor and patient, seeking answers to the following questions:

“What is your understanding of the situation and its potential outcomes?”

“What are your fears and what are your hopes?”

“What are the trade-offs you are willing to make and not willing to make?”

And then, together, deciding,

“What is the course of action that best serves this understanding?”

While these might be considered “hard conversations” by some, they facilitate a mutual, consultative process that gives priority to the wishes, values, and desires of the patient as to what will make his or her remaining time fulfilling and complete.

The field of palliative care emerged over recent decades to bring this kind of thinking to the care of dying patients. Whatever can be offered, interventions and the risks and sacrifices they entail are justified only if they serve the larger aims of a person’s life. When this is forgotten, the suffering inflicted can be barbaric. When remembered, the good done can make an extraordinary difference in the remaining time of a patient’s life.