With the advent of the DVD, moviemakers have offered viewers the option to watch alternate endings of their favorite movies. A “director’s cut” lets us choose one ending over another, according to our preferences.
Atul Gawande’s book, “Being Mortal,” allows individuals in declining health or with a terminal illness to consider alternate endings to their own lives. PBS’ Frontline produced an hour-long episode about Gawande’s approach.
For the aging, a typical ending includes a decline in mobility, mental function and control over the most basic elements of life.
The most common questions along this path include: When shall we move Mom to a nursing home? Which one shall we use?
Neither the surrounding family nor the new nursing home resident finds the path hopeful or healing. Inevitably, the quality of life declines.
“This is the consequence of a society that faces the final pause of the human life cycle by trying not to think about it,” Gawande writes.
Gawande, a surgeon by training, explains why the traditional path rarely leads to a satisfying quality of life and then outlines simple steps that have proven to enhance life for aging people who need extended care.
He describes more attractive alternate endings.
After discussing possible solutions for elder care, Gawande turns to similar factors surrounding the care of the terminally ill.
As a physician, he admits that he and other doctors have a very difficult time admitting when a patient has reached a stage when science and medicine cannot cure them.
Not knowing any other way to treat the problem, physicians often keep pouring more and more medical treatment on a fire that will not be put out.
Chemo to the last minute or debilitating surgeries with little hope of changing the outcome are not always the answer.
Gawande suggests that medical professionals learn to recognize watershed moments and learn to have conversations with their patients. He offers three questions to guide these discussions:
- How do you understand your condition?
- When we know the time is short, what are your goals?
- What tradeoffs are you willing to make to reach those goals?
The first question provides a context for the patient and physician to be honest about the prognosis. The second question helps the treatment team know what is important to the patient.
Does the grandparent want to take grandchildren to Disney World one last time? Does the music teacher want to continue giving lessons as long as possible? Does the sports fan want to watch one more season of football?
Knowing these goals allows caregivers to suggest the best ways to accomplish them. And, finally, when the situation is terminal, there are always tradeoffs.
Does the patient choose pain over lucidity or lucidity over pain? What other tradeoffs are acceptable? Each case is unique, so it is important to know.
Above all, Gawande encourages conversations that include caregivers, patients and family.
These honest discussions are critical to discovering the best endings – the ones with the highest quality of life and the deepest satisfaction for the patient.
We must get over our fear of mortality and our denial of death if we want to encourage the fullest life to the very end of mortality.
The fact that Gawande illustrates many of his points with examples from his own father’s decline and death gives him great credibility.
I’ve sought out people in the health care profession who have read this book and I’ve encouraged others to read it, even giving away a few copies to people I think could carry this discussion forward on a local level.
Hospice workers are very pleased these conversations are going mainstream.
Other ministers have commented on how helpful it is to have the rubric of Gawande’s questions in discussing these matters with church members who feel the pressure to make decisions in critical moments.
Ministers and caregivers who regularly encounter aging patients or those in terminal circumstances will find this book helpful and encouraging.
“At least two kinds of courage are required in aging and sickness,” Gawande asserts, “the first is the courage to confront the reality of mortality – the courage to seek out what it is to be feared and what is to be hoped … But even more daunting is the courage to act on the truth we find.”
I believe Gawande’s approach offers a watershed concept that encourages healthy conversations about quality of life.
Ministers and caregivers who regularly encounter aging patients or those in terminal circumstances will find this book helpful and encouraging. Hopefully, it will become an important influence on the end-of-life care they provide.
Editor’s note: In a two-part Skype interview, David Hull, former pastor of First Baptist Church in Huntsville, Alabama, discusses lessons learned from the death and dying process of his father, noted Baptist leader William Hull. Part one is available here; part two is available here.