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

TED 2012: Is Your Doctor a Member of a Pit Crew?

Atul Gawande is a rock star. From the moment I started to read his book The Checklist Manifesto until the last word, I was spellbound. Gawande writes fluidly, simply, and with great insight about issues in healthcare.  He speaks as engagingly as he writes.

Checklists have worked in other industries, like aviation and major construction, to reduce errors. The Checklist Manifesto is about importing those ideas into medicine.  And Gawande showed how it worked.  As a result of this work in his own hospital, Gawande was commissioned by WHO to devise a surgical checklist that could be implemented around the world.  

Here's the checklist:

The checklist was piloted in eight hospitals around the world, ranging from a rural hospital in Tanzania to world-class teaching hospitals in Toronto and Seattle. There's a knack to making such a good checklist - it had to be general enough to be applicable anywhere, it had to cover the most crucial items, and it couldn't be so long that no one would use it.  The result was a 19-item, 2-minute check list with 3 pause points.  You can see how obvious some of the steps are on the list above.   It's standard that antibiotics are given before an operation to reduce the probability of infection.  Really, now, would people forget such a simple step?  Introducing yourself to everyone on the team?  Give me a break.  Surely that would be obvious, especially in a situation where unambiguous communication might be life-or-death in an emergency that could arise.  Apparently these things are not that obvious: introduction of this checklist reduced complications by 35% and deaths by a whopping 47%.  47% reduction in deaths!! Not by fancy new technology, but by systematizing what everyone already knew was the right thing to do.

In today's TED talk, Gawande talked a bit about check lists, but mostly he talked about the culture and philosophy of medicine.  Medical culture was established back in the days when medical knowledge was sparse, specialists were few, and doctors practiced heroic medicine.  There were few treatments that had been proved effective, and doctors were often heading into uncharted waters and you had to be bold to try a procedure that might help. 

Today, the medical environment is completely different.  There are known treatments for most diagnoses - over 4,000 proven medical and surgical procedures and 6,000 drugs.  No one professional can know everything, and medical practitioners are now deeply segregated into their specialities.  It's all about working as a team, within a known, systematic framework.  But that's not how doctors have been trained.  Our system has trained cowboys.  What we need are pit crews!  We need to focus, not on individual heroics, but on values like team work, discipline and humility. 

Sitting on a hospital board, and thinking a lot about how innovation could take place in healthcare, it seems clear that individual components of the healthcare system can work very well, but the system overall is a mess.  Our hospital delivers fantastic care as a rehab hospital, but it is at the transition points between acute care and our hospital, and between our hospital and the home that the cracks in the system appear.  Ironically, as I've observed in businesses, fixing a broken system yields efficiency, effectiveness, customer satisfaction and cost savings.

Yet, because of cultural issues, Gawande says that adoption of the surgical check list has been slow and has had to struggle against the resistance of the autonomous, lone-hero vision of medicine.  Yet this simple change would save both lives and money.  The cost of adoption - namely training and engagement of staff - should be small compared to buying another sophisticated piece of medical technology.

Gawande's talk was totally inspiring to me, and I leapt to my feet in a standing ovation. I was somewhat surprised that only about 40% of the audience joined me.  I guess this kind of system thinking is not as sexy as some of the other talks we're hearing.

The Checklist Manifesto

A brief digression from TED to describe a great book I just finished called The Checklist Manifesto. Written by Boston doctor Atul Gawande, it describes the huge impact checklists can have in medicine. Checklists are common in other industries, such as aviation. Pilots adopted checklists when airplanes became so complicated that it was beyond the capacity of one human to remember every step required for flying. However, it is only recently that medicine, the profession with arguably the most complex tasks, have started to adopt checklists.

Johns Hopkins did some pioneering work on developing a check list to reduce the infection rate in central lines. This check list consisted of merely five steps - all no-brainers:

1. wash your hands with soap
2. clean the patient's skin with chlorhexdine antiseptic
3. put sterile drapes over the entire patient
4. wear a mask, hat, sterile gown and gloves
5. put sterile dressing over the insertion site once the line is in.
   

Simple and obvious, right? And yet steps were being skipped time and again. Who'd have thought that, a century and a half after Lister, surgeons and nurses would still need reminding to wash their hands?!? In early tests, this checklist astoundingly reduced central line infections from 11% to 0. This central line checklist has now spread to many hospitals with similar results, reducing infections in both the best and the worst hospitals.

Meanwhile, research was going on at University of Toronto and and Toronto General and at Kaiser in California on checklists for surgery. These experiments delivered equally stunning results. Gawande started to experiment with checklists. He used them in his own operating rooms, feeling out what worked and didn't work.

Then Gawande was approached by WHO to improve the safety of surgery around the world. After all, at least one million a year die in operations, just slightly more than from malaria. Gawande decided that the greatest contribution could be made by designing a surgery checklist. For a pilot, he chose hospitals as disparate as hospitals in high income countries in Toronto, Seattle, Aukland and London, and intensely busy hospitals in low and middle income countries, in Manila, Amman, New Delhi, and a rural hospital in Tanzania. These hospitals started introducing a two-minute, 19-step checklist. Comparisons of outcomes in the three months before and after introducing the checklist were astonishing. Major complications had dropped 36% and deaths 47%. Many highly sophisticated innovations in the OR have cost lots of money (an example might be robotic surgery) without a good return on that investment in terms of improved outcomes for large numbers of patients. Yet this simple, virtually free innovation seemed to make a huge difference.

Several lessons from this book will stick with me.

• The first step on the checklist is to require the surgical team to introduce themselves at the beginning of an operation. Typically, the group in an OR will not usually know each other very well, or at all. Gawande says the simple introduction goes a long way toward turning that collection of people into a team. Who'd have thought you could be undergoing an operation, something dangerous and unexpected could happen, and the team operating on you would have to communicate in this emergency without even knowing each other's names? This is part of a sea change in medicine from the accent on the individual hero doctor to the team.
• Put the checklist it in the hands of the circulating nurse and giving her or him the authority to stop the process if a step is skipped. Another aspect of making it a team sport.
• Keep the checklist as short as possible. If it's too long, practitioners will view it as a distraction from taking care of the patient, and will ignore it. As is so often the case with strategy, deciding what not to do or include is your most important decision.
• After these results, it seems almost criminal for a hospital not to adopt checklists. However, the constraint on adoption of innovation is the reluctance of people to change behaviour. Doctors are no different. As a public champion of checklist adoption, Gawande even admits to his own resistance initially to using the checklist he'd helped develop.
  
• If you want to succeed at innovation, start with a single, focused innovation. Once you have proof of concept you can expand beyond that initial niche. In the OR, for instance, there is scope for specialized checklists for all sorts of specialized operations, rather than just the general one to cover all surgery, Then, just like in aviation, you could develop a series of checklists which spring into action to guide actions in emergencies.
  
• It's a real innovation to look beyond your own industry for ideas that are transferable and transformative. Gawande talked to many people outside healthcare - in industries as diverse as construction and investing. His most important insights came from aviation, the pioneers in the use of checklists. Boeing spends huge amount of resources building checklists for the pilots who will fly their planes. He argues that Captain Sully, the 'Hero of the Hudson', was not being modest when he said it was the team that ensured the plane landed safely on the river. He was being dead right. And in the cockpit, the checklist for what to do upon losing engines after a bird hit was a key contributor to the pilot's ability to land the plane.

This book is a very quick and interesting read, sprinkled with delightful and relevant anecdotes that bring the material to life. It should be a must-read for anyone in healthcare, but it's hard to think of an industry that could not apply checklists.