Atul Gawande on the Importance of Palliative Care

In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, chats with author and surgeon Atul Gawande, MD, MPH, about his New York Times bestselling book, Being Mortal: Medicine and What Matters in the End. The two also discuss their struggles navigating palliative care with their own aging relatives.

Gawande is assistant administrator for global health at the U.S. Agency for International Development.

Faust: Hello, it's Jeremy Faust, editor-in-chief of MedPage Today. Today, we are going to be joined by Dr. Atul Gawande.

Dr. Gawande is a surgeon, writer, and public health leader. He was founder of Ariadne Labs, a joint center for health systems innovation. He served as a member of the Biden Transition COVID-19 Advisory Board, and from 2018-2020, he was CEO of Haven, the joint venture of Amazon, Berkshire Hathaway, and JP Morgan Chase.

Dr. Gawande, thank you so much for joining us.

Gawande: Do I have to call you Dr. Faust now? <laugh>

Faust: You can call me Jeremy, if I can call you Atul.

Gawande: Okay, good. There we go. That'll be better.

Faust: Let me talk about two of your prior books; questions that actually came from readers. First, on Being Mortal. Since Being Mortal came out, do you feel that doctor and patient conversations have changed? Are they more honest? Are they more realistic? What's the feedback that you've gotten, both as an author and a physician?

Gawande: So, you know, the context when Being Mortal came out was that we'd come out of the arguments around the ACA [Affordable Care Act] and the idea that even paying doctors for their time to have conversations with people about their goals for end of life were 'death panels,' right? It had become a toxic subject, and victory one was reaching the place where it now feels as normal as motherhood and apple pie.

We can talk about the notion that people have goals in their life besides just surviving. That those priorities and goals in their life change over time and are different from person to person. That the most important thing that we have to do to learn what those goals are is ask people -- and we don't ask; 75% of the time, we don't ask.

Now, has the asking gone up? Has the quality of the conversation improved? Are we actually matching our treatment plans in healthcare to what people's goals are, and not just when they're at the end of life, but for any condition where they have a serious illness, impairment, chronic illness, and need to make choices in their life about what trade-offs need to be made; what minimum quality of life they would find acceptable; what their fears and hopes are for their treatments?

No, I'm not struck that there's been a dramatic change there. I think we have early adopters. I think palliative care has seen a real surge in applications and the skillset is moving into the curriculum in medicine. Our data continue to affirm that when these questions are asked, whether it's family members or clinicians that are having these discussions, people have better outcomes, but they've barely budged; they've barely budged.

And so the second part of the mission is -- Is it malpractice yet not to have these conversations that result in better outcomes, that result in less suffering, that actually lower our costs? No. It should be a scandal that we still don't have it as a routine part of what we do, that we're having a serious discussion about -- it doesn't matter whether it's chemotherapy, dialysis, surgery -- what are your goals besides living longer, and how do we optimize to make sure we can achieve as much of those goals as we realistically can?

Faust: In your own life, and I think about this in my own life, how do you manage this? Because it's really easy for someone to say, 'You know, I really want quality, not quantity of life,' or to say things that really reflect everything that you wrote in your book and that others have said. But then when the rubber meets the road, it's like, 'Oh, that's not for me. That's for someone else.'

I think of the example in the book of, I think, an elderly relative of yours who just wanted to be taking the bus everywhere, right? I was watching my dad, who's 75 and an elite athlete, in the gym yesterday, and he's working out so hard that even though he's got great health, I'm literally worried he's going to have a coronary. And I'm thinking, 'Dad, slow down. There's no need to do this,' but this is the way he wants to live.

At the same time, driving at night, not so popular when I bring up that maybe that shouldn't be done. How do you manage that in your own life?

Gawande: What you're describing is a need for the adult kids to change more than the adult parents to change, right? The adult parents are telling you the risk trade-offs that they are willing to make.

It's like having a conversation with my patient about whether they're going to wear a seat belt or not. We're going to have a discussion about the seat belt, about the smoking. We can say, 'Look, your larger goals in life are that you want to be there for your kid, you want to be there for a major career goal you have. Well, then the seat belt and the [not] smoking, they really are what you want to do, and I'm on the same side of the table with you. I'm with you on this.' A lot of the relationship between adult kids and elderly parents are in that conflict zone.

My mother has stage IV ovarian cancer. She had to make a decision when she was diagnosed while getting a biopsy of a lump, which turned out to be metastatic ovarian cancer. She woke up with a colostomy and a giant operation and a decision to make about chemotherapy. I was really unclear what she would opt for and whether I thought it was a good idea to go for chemotherapy or not.

She's 86 now, this was when she was 84. And she was really clear when we walked through -- 'What are your fears for the future? What are you willing to endure with your treatment? What are you not willing to endure?' The things I thought she'd be worried about, she wasn't worried about. What she was worried about was: 'I don't want to have falls and lose my apartment.' The chemotherapy had a toxicity of a neuropathy, and they described the possibility of having falls. And she had real worries about worsening anxiety or things around the side effects of steroids that are part of it.

The oncologist was able to fashion a pathway that said, 'Okay, we'll stop the chemotherapy when the neuropathy comes on, and we won't give you the standard steroid treatment. We're going to experiment. We're just going to give you Benadryl. We'll take a risk with some anaphylaxis.' And my mother was very happy to take that risk.

Did I feel good about it? I had to feel good about it and deal with that.

So, she got through it. She got through four of six cycles [of chemotherapy]. She had to stop earlier than the end [of treatment], but she kept her apartment. Everything went well. She's now in the fourth year of no evidence of disease with stage IV ovarian [cancer], and it's sort of stunning that she did as well as she did, because it was on her own terms.

I don't know what to say about the driving discussion, because now it's not just about their risks, it's about the risks of others. Those are really hard conversations. It was like the conversation I described in the book about my dad doing surgery with a brain tumor where his hand was being paralyzed, and his operating staff were enabling him to operate with a hand that wasn't able to tie knots anymore. That was not good. We really did have to have that hard discussion that was not about being allied around what he wanted to do.

That's part of this life.

Faust: And I think that it's really important for people in our profession, but also just people in the public, to hear us navigate this. It's super easy to say, 'Here's what you ought to do.' But I think that they benefit from hearing us go through this because it's so easy on paper, but as you just described, it's very difficult in life.

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