End of Life Thoughts

Our modern healthcare system fails people two ways:

• Senior residences and nursing homes focus on physical welfare, rather than striving for optimum quality of life. 
• As patients near end of life, physicians subject them to extreme but futile medical treatments.  

These ideas come together in Gawande's latest book Being Mortal. He lambastes nursing homes' focus on measuring the purely medical needs of their patients, like getting medications on schedule, but failing to care for their quality of life. Many activities that would provide stimulation for people's lives, could add risk to their health. Many residents in these homes would prefer to take these risks in return for a better life (by their own definition), but they are not given the choice.

Gawande also takes on the medical profession's obsession with intervention in late stages of life, interventions that can make the end of life agonizing for the patient. Yet studies have shown that, on average, these brutal measures don't extend life expectancy beyond that for people who choose palliative care.

Gawande advocates rethinking our entire system's approach to late-life end-of-life care, including a fleeting reference to assisted suicide.

This book brings together so many things I've been thinking about recently. Some time ago I wrote a review of How to Die in Oregon, a documentary about assisted suicide, one of the best documentaries I've seen at Hot Docs. It reinforced my support for assisted suicide options. And Canada's Supreme Court recently ruled that adult Canadians in grievous, unending pain have a right to end their own life with a doctor's help(details here). I've also written a glowing review of The Checklist Manifesto and of Atul Gawande's TED talk, which first made me a Gawande fan.

He's hit the ball out of the park again with this book. A must-read.
Links to past book reviews, with some of my favourites at the top:
Non Fiction:
The Innovator's Dilemma
The Wave: In Search of the Rogues, Freaks and Giants of the Ocean (my most viewed book review)
Curiosity (my second most viewed book review)
The Immortal Life of Henrietta Lacks 
The Checklist Manifesto
Uncharted
The Lean Start-up
The Upside of Irrationality
Thinking, Fast and Slow
Steve Jobs
Global Warring
Nudge

Fiction:
Americanah
Life After Life
A Possible Life (I love anything by Sebastien Faulks)
Mr. Penumbra's 24 Hour Bookstore
Major Pettigrew's Last Stand
Rules of Civility
The Taliban Cricket Club
The Vault
Before I Go To Sleep
A Son of the Circus
Still Alice
Faithful Place
Defending Jacob
The Strangler
The Help
The Housekeeper and the Professor


Some series I've liked:
Donna Leon's series about the Venetian detective Guido Brunelli: A Question of Belief
Canadian Peter Robinson's series about British detective Alan Banks: Before the Poison, Bad Boy
James Church books about a North Korean detective: A Corpse in the Koryo, Hidden Moon, Bamboo and Blood, The Man with the Baltic Stare
Gianrico Carofiglio's series about an Italian policeman: Involuntary Witness
Jo Nesbo's series about Norwegian detective Harry Hole: The Redeemer, The Redbreast, Nemesis
Alexander McCall Smith's series about the No. 1 Ladies' Detective Agency
Andrea Cammillieri's books about Sicilian Inspector Montalbano: The Shape of Water
Martin Walker's series about French local policeman Bruno, Chief of Police
Louise Penny's detective series set in the Eastern Townships of Quebec: Still Life
Jussi Adler-Olsen's series about Danish detective Carl Morck: The Keeper of Lost Causes
Ruth Rendell's books about Chief Inspector Reg Wexford
Arnald Indridsadon's books about Finnish detective Erlendur: Arctic Chill, Hypothermia and Outrage

Other books I've also liked:
The Spoiler
The Secret Race
The Blondes
San Miguel
The Better Angels of our Nature
Radioactive
The Believing Brain
Hellstrom's Hive
22 Britannia Road
The Imposter Bride
Murder as a Fine Art
Adapt
The Invisible Bridge
This Body of Death
Sustainable Energy - Without the Hot Air
Berlin Crossing
Gold
The Marriage Plot
The Paris Wife
The Forgotten Affairs of Youth
Turn of Mind
The Secret Speech
The Thousand Autumns of Jacob de Zoet
The Makioka Sisters
Russka
Suite Francaise
The Man from Beijing
Innocent
At Bertram's Hotel
Red April
You Are Not a Gadget
Five Smooth Stones
River of Gods
Nasty, Brutish and Short: The Quirks and Quarks guide to Animal Sex and Other Weird Behaviour
The Ghost
The Council of Dads
The Elements
Tribes
The Elephant, The Tiger and the Cellphone
McMafia
The Janissary Tree


Some books I didn't like very much:
A Perfect Heaven
Potsdam Station
The End of the Wasp Season
The Dark Room
Dead or Alive
A Vintage Affair
The Finkler Question
When the Devil Holds the Candle

Death with Dignity

As the Canadian Supreme Court hears the case for assisted suicide, it would be a good time to watch How To Die in Oregon. It would be particularly meaningful for Canadians, so many of whom are thinking deeply about these issues at the moment.

I saw this movie, which documents how assisted suicide works in Oregon, three years ago at Hot Docs (reviewed it here) and it remains one of the most powerful movies I've ever seen at Hot Docs. There are several ways to get this movie online.

How to Die in Oregon

Physician-assisted Suicide or Death with Dignity.  It's legal in Oregon. 

In the most thought-provoking movie I saw at Hot Docs,  How to Die in Oregon takes a hard look at the practice of physician-assisted suicide in Oregon.  And I mean a hard look.  The film opens with a man drinking the physician-prescribed deadly dose and the camera zooms in as he slips into a coma with his family around him.  A physician has prescribed the lethal dose; a volunteer mixes the Seconal into a glass of water; the patient drinks it himself.  The volunteer asks two confirming questions before handing over the drink.   "Are you sure you want to do this?  You know, you can change your mind." "Can you tell me what will be the result of drinking this mixture?"  Physician-assisted suicide is different from euthanasia in that the doctor does not administer a lethal dose; the patient has to be physically able to drink the liquid dose.

In the movie, we come to know Cody Curtis, an active, attractive, elegant, woman with a positive attitude, a caring husband and two children, who is suffering from terminal liver cancer.  She wanted to choose to die with dignity when the pain became intolerable.  Is it a sign of great moral courage to endure such pain in a hopeless situation when there is an alternative?  Clearly Cody didn't think so.  As Cody says near the end, "I don't ever want to have a night like that again".  

Doctors also face a tough dilemma when asked to prescribe a lethal dose for their patients.  Is this prescription at variance with their Hippocratic Oath or is it the ultimate good they can do their patients?  Cody's doctor was conflicted about this, but concluded that she owed it to her patient to give her freedom of choice.  

One of the reasons director Peter Richardson chose to focus the movie on Cody was because the doctor was willing to be included.  But he also included a statement by another doctor arguing vehemently that prescribing a lethal dose just couldn't qualify for doing no harm to a patient.  Opinions are fervently held on both sides of this question.  Richardson told us at the Q and A that he filmed 16 patients who had filled the lethal-dose prescription, but most did not use it.  Clearly just having the prescription in the drawer is comforting to many.

Cody postponed her original date when she was still feeling quite well;  she laughed about having to replace the the jewellery she had given away.  However, she knew the time had come in December.  Cody doesn't quite make Christmas as she'd hoped, but she does teach her son how to prepare the traditional Christmas squares.  When her husband asks where the cheque book is, she exclaims "I've been trying to tell him about that for 35 years!"  We watch through a lighted window as we hear the quiet conversation of Cody, her family, and her doctor as Cody achieves her peaceful end.

The movie followed the citizen-led push for a physician-assisted suicide law in Washington, led by a woman who has lost her husband in an ugly and painful death by brain cancer.  He did not have time after his diagnosis to establish residency in Oregon so he could not opt for physician-assisted suicide.  His wife pledged to him that she would fight for the law in Washington, and it ultimately passed by a significant majority.  Other states are considering adopting this law.  Laws for assisted suicide have been proposed more than once in Canada.

How To Die In Oregon won the Sundance Grand Jury Prize and was third in the People's Choice Awards at HotDocs (How good must those first two be!).  The movie was funded by HBO and will thus be available widely.  

What a strong movie.  Besides developing great affection and respect for Cody Curtis, and shedding some tears, I got thinking about end-of-life choices.  With the coming aging of our society, and the ability for medicine to keep us alive longer, this is a question that will be challenging many of us. 

 Would I want a 'get out of pain free' card, when faced with prolonged, futile suffering?  I would.  What do you think?