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A better life, even if it's a shorter life

By Jonathan J. Ariel - posted Friday, 9 January 2015


Australia's aged care policies are being overhauled, with a crucial aspect, the Commonwealth Home Support Program, beginning on 1 July. This program will hopefully encourage older Australians to remain independent in their own homes for longer.

Let's hope so.

What better time then to consider how other jurisdictions are wrestling with an ageing demographic?

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Enter Atul Gawande.

This gentleman practices general and endocrine surgery at Boston's Brigham and Women's Hospital and is professor in both the Department of Health Policy and Management at the Harvard School of Public Health, as well as the Department of Surgery at Harvard Medical School.

At least that's what his website states.

But you wouldn't know it from peeking at the cover of his latest tome: Being Mortal, in the event that you're lucky enough to pick up a copy at your local bookstore.

The book's cover is devoid of post-nominal letters and as it carries just one simple endorsement, you could be forgiven for thinking the book was penned by someone far less clinically qualified and not quite a Rhodes Scholar.

Gawande's thesis is stark. It is as simple for the ill to understand as it is disconcerting to many physicians: eventually people die and regardless how healthy and fit they are, en route to the grave most will suffer indignities, endure pain and possibly lose their minds. And much, much of this can be avoided.

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For too long Western societies held (and continue to hold) that both old age and death are medical problems in search of medical solutions. But the fact is while many consider these as "problems", they are certainly not medical "problems". In fact, they are not problems at all. They are experiences.

Gawande shares excerpts from several patients' lives, that start with a person's pre-illness vitality and independence and - regardless of the length of the medical intervention or technologies used to prolong life - terminates with a person's death. A death where dependence on strangers or drugs or both has elbowed out hitherto known independence. Gawande holds up his own father's long battle with a slow growing spinal cord lesion as one example.

He also takes aim at the West's biggest single biggest source of unnecessary yet orchestrated, impersonal and structured diminution of patients' quality of life: the innovation of elder care accommodation whose residents, while often disabled or drugged to their corneas are nearly always subjected to the "Three Plagues" – boredom, helplessness and loneliness.

He contrasts this with the management of the old and the sick in undeveloped economies such as India, where families and not nameless, faceless and cold institutions are responsible for looking after the old and the infirm in a shared, multigenerational manner. Not only is the Third World's way of doing things cheaper, many old folk also live longer and live better than in the First World.

Most Americans - and plausibly, Australians - imagine that they will live in good health until someday down the track they would suddenly out of the blue, drop dead.

But in truth, regardless of how we expire, be it following a fatal disease or a chronic disease or as a result the expected breaking down of our bodies over time (commonly called "old age"), very, very rarely do we die quickly.

While surveying elder accommodation, Gawande notes that while superficially they vary widely in how they look and what they offer, they are one in their overwhelming objective: to appeal to the residents' children, not the residents themselves, by repeatedly emphasising their commitment to "safety", often at the expense of allowing the residents to live lives they want. It's as though the nursing homes understand that children put a priority on how far away Mum 'n Dad's funerals will be held rather than asking "what quality of life do Mum 'n Dad want to be able to enjoy at Shady Pines"?

Gawande's stories including those of his mid 70s father, an Athens, Ohio urologist Atmaram Gawadne, as well as that of a 34 year old Sara Monopoli, demonstrate that modern death is often excruciating and lengthy, irrespective of a person's age. In both of these cases, death followed a painful struggle against cancers, Gawadne's being spinal and Monopoli's being lung.

In all such cases, most of the old and infirm as well as their families deceive themselves into thinking that the timing of their exit from this life is under their control, and while they have to a greater or lesser extent managed to live a dignified life, they will somehow be allowed to pass away in a dignified manner.

Gregory House, M.D.,the misanthropic fictional diagnostician from the highly acclaimed TV series House M.D., touched on the same widely held hallucinations of an easy death.

Onerous treatments continue even when objectively they are pointless and only generate more suffering. Why? Three reasons: patients are hard wired not to give up hope; patients' families are idealistic about their medical goals and the real kicker is that often, doctors themselves fear to be perceived by patients as giving up too soon.

Gawande is an exceptional communicator.

His goals of bringing end of life matters to the attention of the public are noble, worthy and timely. But he's up against formidable enemies: dying patients (and their families) that regardless of the facts will not accept defeat; physicians' (at times irrational) loyalty to their patients and Big Med, whose focus remains to grow its customer base (i.e. occupied nursing home beds) at all costs, even if the cost is the constant pain their customers have to "live" with.

After all, from Big Med's standpoint, dead patients don't need accommodation or medical consultations.

And of course, the dead don't get prescriptions filled, do they?

BEING MORTAL (H/B)

Medicine and What Matters in the End

By Atul Gawande

288p Profile Books, London $26 (online)

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Being Mortal: Medicine and What Matters in the End by Atul Gawande (Profile Books, London) $26 (online)



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About the Author

Jonathan J. Ariel is an economist and financial analyst. He holds a MBA from the Australian Graduate School of Management. He can be contacted at jonathan@chinamail.com.

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