One writer that I have admired for some time is Atule Gawande. He writes for the New Yorker, runs a research lab on health care and was featured in a PBS Frontline documentary. I first learned of his work when I read “The Checklist Manifesto”. His latest publication is “Being Mortal: Medicine and What Matters in the End”, which stems from his time helping his dad through end-of-life experiences. He recently helped his mom in the process of finding an assistive living program. Both have revealed a new sensitivity on his part to the value of distinguishing and balancing Important To and Important For. Here’s an excerpt from an interview. See if you discover the person-centered-thinking aspect of his thoughts:
Can we rely on medicine and doctors to help patients focus on living as they choose? Gawande: I don’t think it’s going to come through medicine. I don’t think we’ll make it better because doctors require it to be better. It will be because patients and families realize there’s a better way to deal with the last days of our lives. That doesn’t mean you give up on getting the treatments you want; it means you look at the priorities that are most important to you. That’s what we have not followed through on.
What’s an example of discovering priorities? There are several stories in the film and book. One is about a woman who has been under treatment for two years for a cancer we know isn’t curable. We finally ask about what really matters to her, to make sure she gets to be able to do it if time runs out. We learn that she wants to take her grandchildren to Disney World — but by this time, it is too late. She dies just a few days later. If we had known and known soon enough how important this was to her, we could have ensured that it happened. It’s fundamentally about what patients want? A lot of these moments hinge on the fact that people do have priorities in addition to living longer. The most reliable way to know what those are is to ask, and we don’t ask. We ask less than a third of the time. It’s amazing, with the documentary, to have the camera in rooms, to see the conversations doctors, patents and families do have — and don’t have. Up until now, your Checklist Manifesto was probably your best-known work. That’s about the list you created to make sure surgeons followed a system to operate on the right limb, for instance, and to ensure communication on the surgical team. Is this new approach to end-of-life similar? I see it as completely similar. It’s really a series of questions that we need to be comfortable asking one another. It needs to be normal to ask these questions, especially when someone is faced with a serious illness, and especially when we know that we’re aging and becoming frail.
We need to know: 1. What is your understanding of where you are and of your illness? 2. Your fears or worries for the future 3. Your goals and priorities 4. What outcomes are unacceptable to you? What are you willing to sacrifice and not? And later, 5. What would a good day look like? Asking these allows everybody to understand what the goal really is — what are you really fighting for? It’s for a life that contains certain things. When I asked my dad these questions, he was very clear that he wanted a social life and he didn’t want aggressive treatment that would prevent him from being social. So if his tumor was going to make him a quadriplegic, he didn’t want to be on a ventilator or have a feeding tube.
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