The End-of-Life War

Atul Gawande, excellent as always, tackles the difficult issues around end-of-life care, arguing that modern medicine has failed people facing the end of their lives. “The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task,” writes Gawande. “Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.” Expensive end-of-life care (and cancer treatment costs), of course, also contributes to runaway health-care costs.[%comments]


Death panels! *sarcasm*


this issue is mainly existential- if you have a living will, then the sovereign decision is made- however, people who are stricken by a disease may decide to go down fighting- the irony here is that the physician has a conflict of interest, and so is not necessarily qualified to make the ethical choice- probably best public policy is to educate the citizens- if healthcare is going broke and we don't want to increase expenditures, than we may advocate for living wills- of course, we could decide to build less bombs and churn out more chemo...


This is always a point that needs stressing if we are ever to make better consumptive choices in the medical arena, but what exactly is new here?

I was having these exact same discussion in an intro medical ethics class 15 years ago?

We spend so much of our medical resources on people who are going to die in the next few months and have a terrible quality of life. Healthcare is one arena where informed consent/markets do not work because people are manifestly irrational when it comes to the health of they/their loved ones. Should we spend 200,000 of societies money to keep grandma alive another 6 weeks? Sure!

David L

This is going to be the single most difficult and contentious healthcare-related political issue we face in coming years. Behind a veil of ignorance, I think most people would agree with this argument. But the fact is that people, when they're dying, will do almost anything for one more month, one more day. All rationale goes out the window when you're facing down the End. I truly hope that I can remain stoic when it's my time, but of course the odds of that are not good.


I respectfully disagree that medicine has "failed." I am a physician and agree that a number of physicians carry on attempts at fruitless care to an extreme, both for psychological (theirs) and financial reasons, but most of us have a pretty good idea when care is fruitless and even "stressful and painful" for the patient but many, many patients and families want "everything done," (especially because it usually costs them nothing). Also because we are encouraged to usually go along with the patient's and family's desires (and also because of attorneys) we spend a lot on unnecessary end of life care. Especially nowadays when patients are supposed to be our "partners" in health care decisions.


There is a particular type of pain that is common in people nearing their final day. It's called, inappropriately in my opinion, existential pain. There are no treatments for existential pain, there is only sedation, and even then it's not clear that it really helps. The practice of medicine often exacerbates this pain by failing to allow patients enough time to resolve some of the psychological and emotional roots of this pain and hopefully find peace.

Eric M. Jones

My father spent well over $250,000 of our tax dollars to prolong his life by three years of pain, incontinence, depression, constant pills and additional surgeries.

At least he provided training for new doctors....There must be a better way out of this life.


Doesn't the argument hinge as often as not on hope to beat the inevitable? At what point in the continuum do we decide that a person's chances are not good enough to continue treatment? How much is a life worth? The death panel joke is tired, but there is certainly room for it in the context of this discussion.

I'd rather target health care costs by restraining the ~30% insurance cut, tort issues, inflated provider salaries (even considering the great skill and importance of roles), and most importantly the unnecessary tests on relatively healthy people. Whomever seeks to legislate when one's chances are not good enough to deserve care should be ready to cope with the consequences.

I am a person who has put off an MRI on an ACL/MCL and double meniscus tear to try to rehab it (didn't work, obviously), seen my father pass after refusing care for a staph infection in his heart and brain, and recently had a ER visit with a very high fever for which the Tylenol they gave me (plain 500 mg Acetaminophen) cost insurance over $50 each. When considering this admittedly small sample, it seems that there are less controversial avenues for reform that should be pursued prior to blaming the dying for wanting to live. There are personal accountability avenues prior to end-of-life as well as preposterous costs built into the system that have no value to patient experience to name 2.



You know Custer is a crappy example of fighting to the bitter end, right?

Custer and his men were left to die while other troops stood by. The Little Big Horn is better example of a stop loss than a bitter-ender scenario.

Custer's actions might be a study in foolhardiness.

Custer's case is certainly a study in what happens when your enemy shows up with better rifles (you don't want to be the guy holding a Springfield when the guy riding against you has a Winchester).

But, at the end of the analysis, Custer's Last Stand was the result of Reno's decision to enact a stop loss.


The question is whether we are prolonging death, not prolonging life. I don't know anyone who wants to prolong their death. If the question is asked "Do you want us to do everything we can to prolong grandma's death?" Would everyone jump up and say "yes?" Everyone should have an advanced directive and medical professionals should be required to follow it, instead of caving to the family who hasn't had enough time to say goodbye. Just let me go, when it is my time. I hate the thought that my family members can elect to prolong my death. What I choose should be adhered to. But unfortunately, doctors often ask the family to be sure, putting them in a terribly uncomfortable role of "choosing" to end grandma's life, when grandma already chose for herself. So many facets to this problem.


The bottom line is that Nobody is getting out of here Alive.....
One thing that every single human being has in common is that we will all die someday. Knowing that, wouldn't it make more sense for us a a society to emphasize quality of life, rather than fighting the inevitable? I don't mean that we should not save lives, fight cancer, etc. What I mean is that in a terminal situation, with no hope at all for recovery, wouldn't it make more sense to enjoy the time you've got left, and come to terms with the reality and inevitibility of death? What is heroic about forcing someone to suffer uselessly for as long a period of time as we possibly can? Nothing.
It is fear of death, of the unknown, and also the reluctance on the part of loved ones to be selfless enough to do what is in the best interests of the person who is dying, rather than hang on as long as possible, regardless of the suffering caused by this.


Bubba Sixpack

My vote:

Let them have all the end of life "care" they want.

They or their heirs pay for it.