COMMENTARY

Five Key Questions at the End of Life

Disclosures

January 21, 2015

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Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

My current favorite physician author is Atul Gawande. Gawande is a practicing general surgeon; a professor at Harvard; a Brooklyn-born, Ohio-raised ethnic Asian Indian-American, both of whose parents were physicians. He is also an acclaimed columnist for The New Yorker. His target audience is an informed public. He has a rare gift for being able to apply multicultural nuance, informed by scientific knowledge and clinical experience, to key issues of our time, with clearly deep emotion, best expressed through simple narrative. Quite a combo.

In October 2014, Gawande delivered the Fourth Annual Lecture of The Lundberg Institute in San Francisco, in association with the Commonwealth Club of California, to an appreciative, standing-room-only crowd. This presentation was a part of his book tour for Being Mortal: Medicine and What Matters in the End.[1]

In preparation for writing this book, Dr Gawande interviewed more than 200 people about their own experiences with aging or serious illness, or the experiences of a close family member. Thus, the book is not a scientific study, but it is supported by scores of relevant insightful anecdotes.

Of great interest, also in 2014, the Institute of Medicine (IOM) of the National Academy of Sciences published a major book, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.[2] Thirty eminent staff members and volunteers comprised the study and writing committee. The IOM book is 507 pages long, was informed by years of study and many hundreds of references, and includes many recommendations for dramatic and needed improvements.

These are two books with very different pedigrees yet remarkably similar findings and recommendations, which are all very different from common current American medical practices at the end of life. When a fatally ill person has exhausted the potential of scientifically based curative therapy and it becomes "just a matter of time" for "nature to take its course," Gawande recommends that each such patient be asked:

1. What is your understanding of your current health or condition?

2. If your current condition worsens, what are your goals?

3. What are your fears?

4. Are there any tradeoffs you are willing to make or not?

And later,

5. What would a good day be like?

Then, let the ensuing open discussion inform real shared medical decisions about the upcoming dying process.

If you want to get to know Atul Gawande better (and you should), read this wonderful Medscape One-on-One conversation with Medscape's editor-in-chief, Eric Topol, published in late 2013.

That's my opinion. I am Dr George Lundberg, at large for Medscape.

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