{"id":33511,"date":"2015-03-03T17:37:51","date_gmt":"2015-03-03T16:37:51","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=33511"},"modified":"2015-03-03T20:16:02","modified_gmt":"2015-03-03T19:16:02","slug":"saurabh-jha-war-on-death","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2015\/03\/03\/saurabh-jha-war-on-death\/","title":{"rendered":"Saurabh Jha: War on Death"},"content":{"rendered":"

\"Saurabh_Jha\"<\/a>Thomas Hobbes described life as pitifully \u201cnasty, brutish, and short.\u201d Thanks to the free market and the state, life is no longer a Hobbesian nightmare. But death has become nasty, brutish, and long.<\/p>\n

Surgeon and writer, Atul Gawande, explores the medicalization of ageing and death in Being Mortal<\/em><\/a>. Gawande points to a glaring deficiency in medical education. Taught to save lives and fight death, doctors don\u2019t bow out gracefully and say enough is enough. We\u2019re not taught about dying. We\u2019re taught about not dying.<\/p>\n

In our lexicon, life is a constant war against the Grim Reaper. We say inactivity kills<\/em>; screening saves<\/em> lives; an intervention reduces mortality<\/em> by 5 %\u2014an arithmetic impossibility as mortality for our species, barring select prophets, remains 100%. Words have precise meanings. Words also hide precise desires. It\u2019s not that we can\u2019t distinguish between a murderer and colorectal cancer; but by giving cancer moral agency\u2014we wage war<\/em> on cancer\u2014we imply that death is an anomaly that\u00a0must be fought.<\/p>\n

And we fight. We fight death in the hospices. We fight death in the hospitals. In many parts of the world, more people die in hospitals than in their homes. Some die, attached to a noradrenaline infusion, in the CAT scan\u2014the last pit stop of hope between the intensive care unit (ICU) and the morgue.<\/p>\n

It would be easy to blame doctors, their incentives and egotism and offer fixes\u2014such as fee for value, alignment of incentives, value to stakeholders, and other management speak. But Gawande doesn\u2019t take the easy path, instead exploring death compassionately.<\/p>\n

Gawande contrasts two cultures: the traditional east and the modern west. His grandfather, Sitaram Gawande, in a village in India lived fruitfully and died gracefully. He lived with extended family who supported him but didn\u2019t dictate how he should live. Sitaram checked the farmland every night on horseback even at an age when, according to Gawande, he might have been in a nursing home in the United States.<\/p>\n

I saw self-sufficiency in my grandfather as well. His family fretted about high blood pressure and his smoking. He would indulge them and then ignore them. He enjoyed their company but remained sovereign in his (bad) choices. I admired his chutzpah.<\/p>\n

Modernism\u2019s paradox is that strange calculus between independence and dependence. Individualism has oddly increased dependence. Dependence, that is, with the medical profession. But doctors did not cross this line willfully, even though many crossed happily. They were invited to fill a space that was occupied traditionally by religion, family, and community.<\/p>\n

For while the rise of the nuclear family has made many people more independent, it has also left them more lonely and insecure as well\u2014and left many people feeling guilty for ignoring their parents too. The guilt swells when a frail parent is in hospital. Physicians are caught between older\u00a0patients and their children. For some relatives, medical intervention shows that they truly care, the more aggressively they push for treatment the more evidence that they care. For the doctor, intervention is the path of least resistance.<\/p>\n

Zero paternalism hasn\u2019t helped. The doctor no longer knows best, although other cultures are different in this. My grandfather in India fractured his femur after a stroke. My relatives paid for his care as there is no Medicare in India. The CAT scan showed a large brain infarct. Fixing his femur was deemed pointless as meaningful recovery from the stroke was unlikely. After a couple of days of unconsciousness in the ICU, his physician asked my relatives to take him home saying, emphatically, that he needed his family and not an operation.<\/p>\n

The physician was paternalistic. He didn\u2019t dwell on what the family might have wanted. The family accepted his judgment. They had no choice. This would be unthinkable in the US. But my grandfather died in his home surrounded by his children and grandchildren, not in a CAT scan. Paternalism sent him home.<\/p>\n

Paternalism is a good thing to shun and patient empowerment is a good thing to encourage. But even good things have side effects, and one side effect here is that physicians would rather intervene than risk being accused of undertreatment or paternalism.<\/p>\n

Culture explains a lot. Indians are fatalistic. The British used to be stoic. Americans are optimistic. India taught me reality. The NHS taught me limitations. But it was the US that showed me medicine\u2019s possibilities. Reality\u2014Limitations\u2014Possibilities. This is fodder for cognitive dissonance.\u00a0The “can do” spirit of Americans, that admirable and infectious optimism and hope, means they throw the kitchen sink to extend life. Hope drives medical care: it is a state of mind and can\u2019t be switched off by pressing a button.<\/p>\n

Gawande doesn\u2019t patronize the reader with sound bites and solutions. Being Mortal<\/em> is his best writing, by far. His treatment of death is transcendental and tirelessly reflective. His treatment of death\u2019s prequel, the nursing home, is searing. He indicts politely, but indict he does.<\/p>\n

The nursing home is a mirror for healthcare\u2019s warts: regulations that ground innovation, concerns about safety that defy common sense, and\u2014most depressingly\u2014an unwillingness to individualize. Nursing homes have become mirthless, soulless places where the elderly are literally dumped.<\/p>\n

Standardization may or may not be good for healthcare, but standardized care for older people\u00a0in nursing homes is bland. It doesn\u2019t have to be this way. Gawande describes how a maverick physician transformed the mood in a nursing home by bringing in birds and animals. Nuance, not six sigma, ails the human spirit in its twilight.<\/p>\n

Physicians can make ageing and dying less medical. Doctors are known to die differently<\/a>,\u00a0tending to use less medical care. What\u2019s good for the gander is not good for the goose. Why don\u2019t doctors prescribe thrift to others?<\/p>\n

But doctors, alone, can\u2019t beat culture. Modern society obsesses about not dying. Recently, an eminent physician, Ezekiel Emanuel, in an essay<\/a> wrote that he wouldn\u2019t seek medical care after 75. It was deeply personal writing that\u00a0somehow offended readers, including physicians<\/a>. Some interpreted from his writing that an unproductive life is a life not worth saving.<\/p>\n

This paranoia over nullifying the sanctity of an unproductive life reaches even the courts, as in the famous case of Terri Schiavo<\/a>, who was enterally fed in a persistent vegetative state for years despite her husband\u2019s objections. Even President Bush thought it important for her to be fed.<\/p>\n

Where demagogues rush, doctors fear to tread. Death\u2019s demagogues are bipartisan. Some warn that people are dying<\/em> because of toxins. Others caution that in socialized healthcare there will be death panels<\/em><\/a>\u2014mythical committees that\u00a0deny life saving treatments to save costs. But costs aren\u2019t trivial. Nearly a third of healthcare spending<\/a> happens in the last six months of patients\u2019 lives\u2014costs that may break apart US healthcare.<\/p>\n

Dying is a vexing problem for the medical profession. The “can do” blends with the “won\u2019t give up,” which is difficult to give up. As long as we give health an infinite value we will demonize death. In the age of plenty it is not easy to lighten up about life. But to live a little we must risk dying a little. If we die to live, we will live solely to not die. Which would be an overmedicalized life, and a dull one.<\/p>\n

Saurabh Jha<\/strong>\u00a0is an assistant professor of radiology at the University of Pennsylvania School of Medicine. Follow him on Twitter\u00a0@RogueRad<\/a>\u00a0<\/em><\/p>\n

Views expressed are solely of the author and do not represent views of the institution.<\/p>\n

Competing interests:<\/strong> I declare that I have read and understood BMJ policy on declaration of interests and I would like to declare the following:\u00a0I have received a speaker’s fee from Toshiba.<\/p>\n","protected":false},"excerpt":{"rendered":"

Thomas Hobbes described life as pitifully \u201cnasty, brutish, and short.\u201d Thanks to the free market and the state, life is no longer a Hobbesian nightmare. But death has become nasty, […]<\/p>\n

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