Monday 2 March 2015


Atul Gawande was invited to give the 2014 Reith Lectures. I took that as an opportunity to give him a bit of a slagging for implying that his idea of Checklists was equivalent to Moses bringing tablets of  The Law down from visiting with The Lord at the top of Mt Sinai. I don't think I'm the only one who puts Atul Gawande and Malcolm Gladwell in the same bin: brilliant, articulate, well-tanned, professionals who have gone viral with their accessible versions of complicated ideas. If you crank up your critical thinking muscle (or if you are an old sour-puss full of envy and begrudgery for the easy erudition of the G-brothers) you can find something a little superficial in their clear answers about things that have perplexed the great thinkers of our planet.

One of the episodes in the Reith Lecture series was about End of Life Issues, which you can hear on the BBC player: stay for the questions at the end - they are interesting. If you prefer to read, the whole episode is transcribed into an 11 page PDF. You know me, I've been jangling the end-of-life I - II - III - IV - V chain before on The Blob. A couple of weeks ago, we were given a copy of Gawande's book Being Mortal, and I finished it a couple of nights ago.  It's easy to read, in the same way as Henry Marsh's book about brain surgery, or any book by Gladwell. That doesn't necessarily man that it is easy reading. The book can be characterised as a handful of short stories which have been cunningly interleaved, so that each of the stories is inched forward in each chapter.  All of the stories have the same ending, and that's the ending that we can all anticipate in not more than 100 years and probably sooner.  The last sentences of the book record the death of Gawande's father, himself a surgeon who was destroyed by a tumour in his neck that invaded his brain and slowly strangled all his vital functions.
"I think he's stopped," I said.
We went to him. My mother took his hand. And we listened, each of us silent.
No more breathes came.
Gawande Sr. died in his own bed at home surrounded by his family, having 'put his affairs in order'. It reads like a good death, but he had spent several years a-dying submitting to an extraordinary range of interventions and only one of his many final carers is named. The others, having been deemed to have failed the old man in care, or honest assessment of odds, or unwillingness to accord him autonomy over his own life have been left anonymous.  If this is what can be expected for a fully-insured man of the profession, married to another doctor, father of another, who can network themselves to the very best care and advice that can be found in America, then you may reassess the odds of having a good death, in Kildare or Kiev or Krasnoyarsk. Gawande urges his readers to have the conversation early rather than when it is too late.  It is much easier for everyone, except the leading actor and only her when it gets too late, to not have the conversation and just carry on intervening with medical kit until the very last moment. Trying this and that; chemo or radiation; tubes in tubes out; shunts and stents; drugs and drugs and drugs. In the question session at the end of Reith III, Gawande asserts that, in the average lifetime, the most common week to undergo surgery is the last week, and in that week the most common day is the last day.  I urge you to get the book out of the library; if your parents are dead, you are next - there are options, it's just that you probably won't be presented with them.

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