Tuesday, June 9, 2015

Have You Read "Being Mortal" by Atul Gawande? Part 1


The full title of this popular book by Boston surgeon and New Yorker magazine contributor, Atul Gawande, is Being Mortal and What Matters in the End.

It focuses on the ways in which traditional medicine neglects or actually harms the quality of life of people in the later stages of a terminal illness.  He would like to reposition medicine as being in the business not of extending life, but of elevating well-being.

His book has been called "urgently needed" and "courageous."

And it is both -- but it doesn't go far enough.  It has a hole in the center.

Being Mortal still puts the focus on the relationship between the doctor and the patient and ways in which the doctor can be more relational, more focused on what really matters to the patient.  Gawande recommends that doctors dealing with very sick people ask them basic palliative care questions like these:
  • What is your understanding of your situation?
  • What are your worries for the future?
  • What are your goals?
  • What trade-offs are you willing to make to achieve your goals?
  • What is unacceptable to you?
  • What would a good day look like?
All good questions.  And questions that will shift the conversation from doctor dictating treatment or presenting a laundry list of treatment options and leaving it to the patient to decide, to a conversation about meaning and hope.

So what's the hole?

The life partner is largely missing from Gawande's approach to helping the patient reclaim her final phase.

Yes he does write about his mother's presence during his father's approach towards death.  But she's a presence, a caring and frightened sidebar, not a critical part of the treatment equation.  And the relationship between them, their couple-ness, is not addressed.

What if, in addition to asking his father, he asked his mother the basic palliative care questions?  What if he helped his mother and father talk to each other about their goals, and trade-offs, and hopes?  What if he helped them decide together what they needed as individuals, and as a couple -- a couple who has moved through almost the entirety of their lives together?

I am not suggesting that Dr. Gawande merely shift his perspective to include the needs of the well partner.  My guess is that, in his practice, he already does this.   I am suggesting something else.

I see the life partners as an intertwined system, a system that mediates each person's life experiences.  The partners sway together to their unique, intimate, relational music.  When one steps, the other counterbalances.  How they move through the final phases of one partner's illness, as a meshed system, will be one of the most important determining factors of how the ill partner passes, and how the well partner survives.

Whether the couple relationship is beneficial or detrimental, it has impact.  I propose that shifting the focus from extending life to elevating well-being must incorporate the patient's most intimate relationship into the treatment process.

More on this in Part 2.

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