What matters in the end

“I learnt about a lot of things in medical school, but mortality wasn’t one of them. Although I was given a dry, leathery corpse to dissect in my first term, that was solely a way to learn about human anatomy. Our textbooks had almost nothing on aging or frailty or dying. How the process unfolds, how people experience the end of their lives, and how it affects those around them seemed beside the point. The way we saw it, and the way our professors saw it, the purpose of medical schooling was to teach how to save lives, not how to tend to their demise.”

That’s how Dr Atul Gawande begins his latest book, Being Mortal. And, coming from a surgeon, that about sums up the state of affairs nicely.

This book could not have come out at a more opportune time. This World Palliative Care Day, we are all talking about end-of-life care. And that “we” includes several seasoned critical care physicians. Perhaps, many of them would agree that the purpose of their education “was to teach how to save lives, not how to tend to their demise”.

In an editorial in the September issue of the Indian Journal of Critical Care Medicine, Dr R S Mani, senior pulmonologist, pleads that “good sense and humanity” should temper “technologically intensive medical care”. The “complete” physician, Dr Mani adds, “must empower patients to exercise their own will and to plan the last days of life according to their cherished values. Human life is imbued with the Spirit, and death, as with life, was intended to be meaningful.”

A passage from Being Mortal echoes the same sentiment. “People with serious illnesses have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others and achieving a sense that their life is complete. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The question therefore is not how we can afford this system’s expense. It is how we can build a health care system that will actually help people achieve what’s most important to them at the end of their lives.”

End-of-life care is not just about dollars or rupees. It is not about America or India. It is about humanity. It is about care. It is about being mortal and accepting it. It is, as the tagline of the book says, about “Medicine and What Matters in the End”.

Time we began to talk about the end. Thank you for your contribution to the conversation, Dr Gawande.

(Dr Atul Gawande is a surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women’s Hospital and is professor in both the Department of Health Policy and Management at the Harvard School of Public Health and the Department of Surgery at Harvard Medical School. He is Executive Director of Ariadne Labs, a joint centre for health systems innovation, and Chairman of Lifebox, a non-profit organization making surgery safer globally. Being Mortal is his fourth book.)

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