Megan Tersteeg

Dr. Schur
Core 101
25 October 2017

“Our most cruel failure in how we treat the sick and the aged is the failure to recognize
that they have priorities beyond merely being safe and living longer; that the chance to shape
one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion
our institutions, our culture, and our conversations in ways that transform the possibilities for the
last chapters of everyone’s lives” (Gawande 243). Dr. Atul Gawande, an endocrine surgeon and
public health researcher, came to this conclusion after completing his research on how the
medical system fails at treating the elderly and how the system could be fixed. While primary
care physicians may argue that the system is too broken to be repaired, Dr. Gawande and
gerontologists have already begun to make improvements to repair patient care at the end of
life. In the American medical system today, doctors feel conflicted when faced with a patient that
cannot be “fixed” because they believe their job is to heal people’s illnesses. Because of this,
patients are given false hopes and cannot properly prepare for their death. Through studies
completed by Massachusetts General Hospital, Coping with Cancer Organization and
sociologist Nicholas Christakis, doctors believe that the American medical care can be improved
if doctors are trained to understand mortality and taught to have tough conversations with
patients at the end of life.
Medical schools all across the country teach students to identify, diagnose, and treat a
patient’s illness. They work hard to provide all the information to their students on how to treat
generally healthy, living people, but hardly explain how to treat a dying patient. In his book,
Being Mortal, Dr. Atul Gawande admits that medical school professors and students believe that
“the purpose of medical schooling was to teach how to save lives, not how to tend to their
demise” (1). Unfortunately, this means that the students are taught “almost nothing about aging
or frailty or dying” and are confused when confronted with a dying patient later on in their career
(1). When Gawande encountered his first reality of decline and mortality as a junior surgical
resident, it didn’t take long for him to “realize how unready [he] was to help” dying patients (3).
Gawande met Joseph Lazaroff, a sixty-year-old man with an incurable prostate cancer,
when we was working as an intern on the neurosurgical team. The medical team determined
that “the cancer couldn’t be cured, but hoped it could be treated” (3). Unfortunately, the radiation
treatment failed, so they offered him two options: “comfort care or surgery to remove the
growing tumor mass from his spine” (3). Even though the surgery provided minimal benefit,
Lazaroff choose this option because he didn’t want to stop trying. However, this left him with
countless other medical problems that ultimately led to his death fourteen days later, even
though the surgery was technically a success. “This is a modern tragedy, replayed millions of
times over. [...] Our every impulse is to fight, to die with chemo in our veins or a tube in our
throats or fresh sutures in our flesh. The fact that we may be shortening or worsening the time
we have left hardly seems to register. We imagine that we can wait until the doctors tell us that
there is nothing more they can do. But rarely there is nothing more the doctors can do” (173).
Because doctors avoid having important end of life conversations with patients, they are willing
to offer more treatments that will not actually improve their patient's conditions. Patients still
have a fighting mentality rather than facing the reality of their rapid descent toward death and
continue to choose the risky treatment over end of life care options.
Medical schools should teach doctors how to explain treatment options to patients as
they near the end of their life, so that they do not continue to choose more painful options that
avoid preparing them for death. When Dr. Gawande was in medical school, he read a paper
written by Ezekiel and Linda Emanuel, medical ethicists, who explained “the different kinds of
relationships that [doctors] can have with their patients”: paternalistic, informative, and
interpretive (200). The paternalistic style describes the “doctor knows best” model in which the
doctor decides the treatment for the patient. When presenting the options, they leave out
choices that they believe are unnecessary and tell the patient which option they should choose.
This type can be dangerous, since the patient has no say in the choice, yet tends to be a
common technique when dealing with vulnerable patients “that tend to do what they are told”
(200). The second style, informative, tends to be slightly more beneficial in medical care, but
can be confusing for the patient. Since the doctor thoroughly explains all the treatment options,
the patient gets to decide the course of action that is taken. Patients are sometimes
overwhelmed by all the options that they don’t know which treatment is the best and are
paralyzed with fear about making the wrong choice. “In truth, neither type is quite what people
desire. We want information and control, but we also want guidance” (201). Therefore, doctors
should utilize the third style, interpretive, when giving patients their treatment options. This style
combines the paternalistic and informative techniques to talk through the correct treatment for
the patient. An interpretive doctor understands the fears and needs of their patient and are able
to sit down with them to explain all their options and guide them through the decision process.
By asking the patient questions about their life goals and concerns, the doctors are able to
advise the patient to receive a certain treatment in order to satisfy their needs. Unfortunately,
most doctors view this style as “almost entirely theoretical” making it the least popular of the
three (201). If medical schools provided students opportunities to practice the interpretive style
in real life scenarios, it may be utilized more later in their careers. Patients would be more at
ease if doctors understood them individually and helped them through their treatment options
rather them either deciding or having it decided for them.
The positive and negative effects of the methods doctors use can be seen in almost
every case in the American medical system. When Dr. Gawande’s father, Atmaram Gawande,
started experiencing severe neck pain and tingling in his left arm, he decided to see his doctor.
After the MRI scans came back, they were all in shock. Atmaram was diagnosed with a massive
tumor in his spinal cord that looked inoperable to both him and Atul. Because they both were
surgeons, they knew that “spinal cord tumors are rare and few neurosurgeons have much
experience with them” (193). They decided to make appointments with two of the best
neurosurgeons: “one at the Cleveland Clinic” and “one at [Atul’s] hospital in Boston” (195).
Although both of these doctors offered a surgical option to remove part of the tumor and a
“procedure to expand the space for the tumor to grow”, they presented the options in two
completely different ways (196).
The doctor from Atul’s hospital urged Atmaram to operate right away because he feared
he would become quadriplegic in weeks. He pressed the information directly onto Atmaram
which made them worry about the situation even more. Additionally, the doctor had ruled out
chemotherapy and radiation since he believed that they were not nearly as effective as the
surgical option. “The facts were shot through with holes and uncertainties. The tumor was rare.
No clear predictions could be made. Making choices required somehow filling the gaps, and
what [Atmaram] filled them with was fear” (197). Because of his fear, Atmaram began asking the
doctor multitudes of questions about each step in the procedure. “[The neurosurgeon] was fine
answering the first couple. But after that he grew exasperated. He had the air of the renowned
professor he was- authoritative, self-certain, and busy with things to do” (197). He utilized the
paternalistic method and did not take the time to understand Atmaram’s concerns and needs. In
the end, the doctor gave him two options: if he wanted the procedure, “the neurosurgeon was
willing to help. If he didn’t, that was his choice” (197). Atmaram decided to visit the other
neurosurgeon in hopes that he would be able to address his concerns.
“The Cleveland Clinic neurosurgeon, Edward Benzel, exuded no less confidence. But he
recognized that [Atmaram’s] questions came from fear. So he took the time to answer them,
even the annoying ones. Along the way, he probed [Atmaram], too. He said that it sounded like
he was more worried about what the operation might do to him than what the tumor would”
(198). When making his plan for treatment, he took these concerns into account and sat down
with Atmaram and explain his options. Benzel believed that Atmaram could wait to do the
surgery until his symptoms worsened or he felt like he needed it since it was a slow growing
tumor. This doctor was able to address all of his patients concerns using the interpretive style
and shape his treatment plan to best fit Atmaram’s goals.
After some contemplation, Atmaram chose to continue under Benzel’s interpretive care.
Because Benzel did not push him to have the surgery right away, Atmaram continued doing
what he loved: “driving, playing tennis, doing surgery, and living life as he had been. [... Both]
he and his neurosurgeon knew what was coming. But they also knew what mattered to him and
left well enough alone” (199). Using the interpretive approach, doctors are able to address their
patients concerns in order to provide the best treatment. These treatments may not always be
ideal, but they enable the patient to live their life to the best of their ability. Even though the
interpretive view usually requires slightly more effort from the doctor's perspective, it helps
patients gain more trust in the treatment and allows them to be involved in their own health
decisions without being overwhelmed by the options available. If medical schools encouraged
their students to practice the interpretive method, American medicine might be able to increase
the number of cases like Atmaram and provide treatments that address patient concerns and fit
their lifestyle goals.
In order for doctor’s to determine a patient’s goals for treatment, they must be willing to
sit down with the patient and talk through four specific end of life questions. Having these
difficult conversations early in the patient’s medical care journey, allows doctors to know the
patient's concerns and address each one of them along the way. Medical professionals may
believe that this is too “far-fetched” to actually work in hospitals, but this system has already
worked in American Healthcare. In 1991, La Crosse, Michigan, “medical leaders headed a
systematic campaign to get medical people and patients to discuss end-of-life wishes. Within a
few years, it became routine for all patients admitted to a hospital, nursing home, or assisted
living facility to sit down with” a medical professional and complete a form with four “crucial
questions” (179).
1. Do you want to be resuscitated if your heart stop?
 2. Do you want aggressive treatments such as intubation and mechanical
ventilation?
3. Do you want antibiotics?
4. Do you want tube or intravenous feeding if you can’t eat on your own?
These questions allow doctors to understand patients end of life goals and make treatments that
reflect their wishes. Because of this understanding, elderly patients in La Crosse spend “half as
many days in the hospital” during their “last six months” as the national average (178). These
patients are able to die in the comfort of their own home because their doctors talked through
the end of life questions and knew when to stop aggressive treatments to accomplish those
goals.
Unfortunately, most American doctors do not feel prepared to have these conversations
with their patients. This results in excessive treatments “that actively inflicts harm on patients
rather than confronting the subject of mortality” (177). Millions of patients and doctors are not
ready to have these conversations, but without them, a patient may endure detrimental results.
Sara Monopoli “was just thirty-four and pregnant with her first child when the doctors learned
that she was going to die. [...] An x-ray showed that her left lung had collapsed and her chest
was filled with fluid” (149). Tests indicated that “instead of an infection, as everyone had
expected, it was lung cancer, and it had already spread into the lining of her chest” (150). Sara
and her husband were shocked, but kept an optimistic attitude toward her diagnosis. Even
though the cancer was inoperable, they wanted to focus on “aggressively managing” the
diagnosis and do whatever they could to stop it (151). Her doctors treated her with three
different types of chemotherapy, but none of them improved her condition. When discussing her
treatment options, her doctor, Marcoux, “told them that, at some point, “supportive care” was an
option to think about. But, he went on, there were also experiment therapies” that did not have
high success rates (152). Sara decided to try the experimental treatments which again proved to
be ineffective. Eventually, she also developed thyroid cancer and worked hard to fight back.
Marcoux “even raised the possibility that an experimental therapy could work against both he
cancers, which was sheer fantasy. Discussing fantasy was easier than discussing what was
happening before [his] eyes” (169). Because he did not take the opportunity to discuss Sara’s
end of life goals, “neither she nor her family was prepared” when the end approached (172). Her
family was stunned at her rapid decline since Marcoux did not take the time to truthfully discuss
Sara’s prognosis and continuously filled them with unreasonable hope.
According to a study completed by Nicholas Christakis, a sociologist, Marcoux is not the
only doctor avoiding end of life conversations. “More than 40 percent of oncologists admit to
offering treatments that they believe are unlikely to work. [...] Doctors worry far more about
being overly pessimistic than they do about being overly optimistic” (168). While optimism can
be beneficial, a doctor must learn to identify when end of life conversations need to be made so
that there is no ambiguity when death comes. Medical professionals, like Dr. Atul Gawande,
have become aware of the importance of these conversations and started implementing them in
patient care.
When Atmaram’s conditioned worsened, Atul knew it was time to discuss his father’s
advanced directive. He asked each question one-by-one to ensure he understood his father’s
wishes. Although “those question were among the hardest [he’d] asked in his life”, he and his
family felt “relief” and “clarity” after the conversation (213). They felt like they were prepared to
take the next steps because they knew Atmaram’s wishes and made the right medical decisions
for him. As his father got closer and closer to death, Atul was able to bring up the idea of
hospice to his family. His father was willing to receive end of life care since they had discussed
this goals and fears at the end of life and he knew that hospice would offer the best chance to
achieve them. The hospice nurse, Margaret Cohn, took two hours to talk through important
questions with Atmaram in order to understand his wishes. Because of this conversation, she
was able to adjust treatments and medications during his hospice care to satisfy his needs.
Atmaram was able to live longer than his family and doctors expected which allowed him to see
his son's graduation from Ohio University. Although he was wheelchair bound, he was
determined to walk across the basketball court and walk up the twenty concrete stairs to sit with
his family. As Atul helped him to his seat, he concluded: “Here is what a different kind of care- a
different kind of medicine- makes possible. Here is what having a hard conversation can do”
(230). In the end, Atmaram was able to die peacefully without pain in the comfort of his own
home. His family was able to say their goodbyes as he took his last breaths. Having the difficult
conversations with loved ones may be unthinkable at the time, but the benefits a family receives
from the talk can be clearly felt as heath declines and death ensues.
“Dying and death confront every new doctor and nurse. The first times, some cry. Some
shutdown. Some hardly notice” (7). When medical professionals enter the medical field, they
imagine all the cases they will solve not about the deaths they will witness. They are not
prepared to face what they see as “failure” and are unable to handle the problem. However,
“death, of course, is not a failure. Death is normal” (8). Doctors tend to “know these truths
abstractly”, but don’t understand them “concretely” (8). If medical schools start to implement
courses that teach students the three modes of doctors and how to have end of life
conversations earlier, medical professionals would be able to guide their patients through the
tough decisions at the end of life and prepare them for their death. Studies, like the
Massachusetts General Hospital, show that “those who see a palliative care specialist stop
chemo therapy sooner, enter hospice far earlier, experience less suffering at the end of their
lives, and live 25 percent longer” (177). In the same vein, the Coping with Cancer Organization’s
study also showed that “terminally ill cancer patients” that were given aggressive treatment like
“mechanical ventilation” had “substantially worse quality of life in their last week than those who
received no such intervention. And six months after their death, their caregivers were three
times as likely to suffer major depression” (155). These studies should indicate that the
American health system should change their practices and begin to teach doctors how to utilize
the interpretive approach in medical school as well as encourage them to have difficult
conversations about end of life care before their conditions worsen. These two changes will
improve patient’s end of life care drastically because both the doctors and patients would know
the correct treatments to use near death to accomplish the patient’s final goals.