Daily Archives: August 4, 2010

Ponce de Leon, M.D.

In the history of mankind, one thing has remained constant: we all die. Sure, life expectancies have lengthened, different illnesses now take us out much later in life, but at the end of the day, the probability of death equals 1. Another constant, flowing from the first, is that we generally wish to avoid death. Hence, the search for the elusive fountain of youth, whose waters, when consumed, are said to restore health and lead to incredible longetivity–if not eternal life. The Spanish explorer Ponce de Leon claimed to have found the spot somewhere near St. Augustine. Perhaps that’s why so many senior citizens seem to gravitate to Florida.

Of course, most of us know the fountain of youth to be a myth, but that doesn’t mean we’ve given up on the dream. Instead, we’ve turned from the miraculous to the scientific, trusting medicine to help us live forever. Again, deep down, we know that it can’t possibly work forever, that we’re just delaying the inevitable, but our goal often becomes to see just how long we can make that delay last. Unfortunately, we often sacrifice quality at the feet of quantity–living more days that aren’t worth living. But that’s a subjective determination that varies for each individual and their own circumstances. There’s much to be considered here, but most of us don’t consider these sorts of things in advance, because, frankly, who wants to think about such morbid things? It goes against the very fiber of our being.

Mainstream physician-author Atul Gawande touches on this end-of-life decision-making in his latest piece for The New Yorker magazine. It’s a heavy article–one that, if you let it sink into the water table of your soul, will have a profound impact on you. When I read it, I was initially disheartened–the stories it contains are sad–but then I realized that denial is even more worthless and far less constructive. I urge you to read it and to give serious thought to its implications. Ask yourself the hard questions. Share your answers with friends and family, or better yet, prepare a living will.

The takeaway is that it’s a balancing act. Continuing to seek more and more medical treatment will eventually rob you of the life it promises to provide. Gawande writes,

“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 is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can’t eat: there’s always something.” 

We all want more days, but we want those days to be good. Strangely, as Gawande reports,

“hospice care seemed to extend survival for some patients….The lesson seems almost Zen: you live longer only when you stop trying to live longer.” 

Sometimes fighting is called for, but at other times, radical acceptance seems to be more beneficial.

“The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.”

There’s another aspect to all of this, which is that all of this chasing of the wind is expensive. Medically speaking, the last year is usually one of–if not the most–expensive years of a person’s life. To the extent that we are pouring resources down the drain, an approach that shifts to focus on quality rather than quantity of life might also reduce health care spending–of course, now is the time to cue Sarah Palin’s “death panel” rhetoric. This could produce savings for the Medicare program, but as Don Taylor and Amy Abernethy point out, reduced spending on end-of-life care alone will not be sufficient to make Medicare financially viable for the long-term.

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Posted by on August 4, 2010 in Uncategorized

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