I have been blogging about the 2014 Reith Lectures currently being given by Atul Gawande. This is Part 3, and is related to Gawande’s third talk entitled ’The Problem of Hubris.’ Part 2, which responds to the second lecture ‘The Century of the System,’ is here. Part 1, which responds to the first lecture ‘Why Doctors Fail,' is here.
In this weeks lecture Gawande again spent a lot of time recounting an illustrative case. This time it was about a family friend who had a recurrent cancer that ultimately proved untreatable. The purpose of the story is, first, to show the difficulty doctors have when dealing with patients whose conditions are terminal, second, to consider how healthcare professionals can help these patients to live well whilst dying and, third, to examine the connection between these two phenomena.
The difficulties medical professionals have when dealing with death and dying seems to provide the inspiration for the lecture's title - The Problem of Hubris. However, it seems a little ungenerous to think that individual doctors are reluctant to talk to patients about death and dying because they have an 'over-weaning confidence' in their ability to treat patients. After all the empirical evidence clearly augers against such presumptions. Rather, much like the rest of us, I think healthcare professionals find talking about death and dying difficulty and emotionally challenging. It is easier for them to retreat into their socially sanctioned roles and provide the patient with medical facts and information.
However, we can think of medical hubris when we consider the social institution as a whole. Our collective reticence to talk about death and dying means that it is easy for the system to provide treatment without really considering on the purpose of doing so. The presumption is that medical treatment is an unalloyed good. Yet studies consistently show that those who properly consider their prognosis and reflect on their outcomes they would prefer are more likely to plan for palliative and hospice care than pursue aggressive treatments and intensive interventions.
Interestingly those who receive hospice care and support often end up living longer, and doing so with an increased quality of life, than those who opt for (or are subject to) greater degrees of medical care. This is another example of medical hubris, one many of us share. It can be described using the idea of a 'ceiling of care,' a phrase I first encountered the other day. The most common example is the DNAR (Do Not Attempt Resuscitation). Patients who have agreed to a DNAR are agreeing to a care ceiling, a point at which they no longer wish to be treated.
The broader notion is useful when we wish to consider end-of-life care more generally. However far do we want medicine to go in its attempt to treat and cure us? Medical hubris prevents this question from being considered as it assumes medical care is the only option. However, just as terminal illness does not mean we cannot have quality of life or pursue particular end, the curative goal of medicine does not encompass the entirety of healthcare.
As Gawande's example illustrates, the end - the conclusion - of life can be meaningful. Death often robs us of such conclusions and, over the past 50 or so years, medicine has colluded with it by keeping those who are dying in hospitals. Both from the point of view of 'living well whilst dying' and financially, this is highly regrettable. In the audience exchange that followed the lecture, Gawande pointed out that if hospice care and palliative nursing was a new drug we would not be wondering how to pay for it, but demanding that its provision. Furthermore, when properly delivered, and when coupled with an honest discussion of prognosis, the patients own needs, wants and expectations, and the ceiling of care, such provisions work out cheaper than continuing to allowing medicine to structure how we die.