Going Gently Into the Night

Going Gently Into the Night

A surgeon learns the lesson formulated by Cicely Saunders, the founder of hospice care: ‘Last days need not be lost days.’

By Paul McHugh in the Wall Street Journal

Of physicians, surgeons must be the most aware of how the limits of a mortal body restrict what they can do. In “Being Mortal” surgeon Atul Gawande describes learning how to extend those limits—and discovering how to respect them, in the case of terminal illness, in ways that neither he nor his patients anticipated.

The history of modern surgery began at the point of the scalpel, dealing with such straightforward matters as reducing blood loss or tissue damage at the surgical site. But the profession truly came of age when it identified as a surgical concern problems outside the site itself. In the mid-20th century, at Brigham and Women’s Hospital in Boston, Francis D. Moore, the hospital’s surgeon in chief, took a giant step forward by drawing attention to the body’s broad responses to surgery.

Moore documented a concatenation of alarm reactions to a surgical operation, alarms that took the form of post-operative metabolic and endocrine surges that needed vigorous countermeasures to keep them from overwhelming a patient with vascular collapse or multiple organ failure. Moore’s ability to identify and prescribe the right countermeasures increased patients’ chances of survival. It also made ever more radical surgical cures possible, bringing a vast range of illnesses and even organ transplantation under surgical control. From Moore’s contributions have emerged the full panoply of services that now sustain surgical achievements: intensive-care units, artificial kidneys, respirators, feeding and intravenous support teams.

Moore—called “Franny” by his friends—was a splendid Chicagoan who triumphed in academic Boston. He was passionate, optimistic, energetic, warm. Toward the end of his career, though, he began to wonder whether, with the advances he had helped make possible, doctors and patients had come to seek too much when facing terminal illness. He thought the surgical adage “a chance to cut is a chance to cure” was being pushed so far—with prolonged, futile efforts—that the lives of many patients with advanced disease had become unendurable. In a fashion seemingly uncharacteristic for this usually positive-thinking surgeon, Moore became a vocal champion of euthanasia.

In “Being Mortal,” Dr. Gawande does not discuss this historical context. But the author, a first-class academic surgeon at the very Boston hospital where Moore practiced decades ago, argues for the importance of palliative care for the terminally ill—especially the palliative services organized in a systematic fashion by hospice groups. He ardently believes that such services and treatments fall within the scope of the modern surgeon’s concern. Dr. Gawande can “cut and cure” with the best of them, but he has also come to “care and serve,” as he shows in a series of stories about patients who, in the course of his providing their surgical treatments, required palliative services.

One of Dr. Gawande’s most touching examples centers on the final weeks of his daughter’s piano teacher, who was suffering from terminal, untreatable leukemia. Dr. Gawande persuaded her to leave his hospital and try, with his support, hospice home care rather than passively await the future or seek “death with dignity.” With a combination of pain management and thoughtful physical assistance she regained energy and found the zeal, in the six weeks that followed, to give private lessons again. She also enjoyed a recital organized by her pupils, past and present, wherein they could all express their gratitude to her. Three days later she slipped into coma and passed away peacefully. With Dr. Gawande’s help this patient demonstrated what Cicely Saunders, the physician-nurse founder of hospice care in the 1950s, repeatedly asserted: “Last days need not be lost days.”

Dr. Gawande’s book is not of the kind that some doctors write, reminding us how grim the fact of death can be. Rather, Dr. Gawande shows how patients in the terminal phase of their illness can maintain important qualities of life with medico-surgical assistance. “Being Mortal” doesn’t gloss over what awaits us all, but it fixes our attention on the ways in which a patient’s wishes might be fulfilled—such as the wish for a peaceful, clear-headed valediction among loved ones. As Dr. Gawande chronicles, this effort requires thought and determination on the part of the doctor, the patient and members of the family.

He ends the book by describing how, in the process of striving to help his own physician-father during his terminal illness from a spinal malignancy, he still had much to learn. The kindness, skill, knowledge and refreshing candor of a nurse-practitioner from the Appalachian Community Hospice of Athens, Ohio, “blew me away,” he says. She managed Mr. Gawande’s father’s medications in a more systematic fashion than he could alone, and she helped him rise from bed and walk more securely. By smoothing out his pain relief she ended the periods of grogginess that had deranged his mind, and she brought about some recovery of his physical strength and his capacity to join in with his children and wife.

By making a forceful case for palliative care and hospice services—with their capacity to sustain life’s quality out to the end—“Being Mortal” provides a response to the presumptions of despair that fuel the euthanasia movement. One can’t help thinking that Franny Moore, for all his gifts, was not optimistic enough about all that medicine could accomplish. His followers have since extended the powers of the surgeon by making the tools that Moore gave them not the implements of a torturous process but rather the means of bringing life to a meaningful close.

Dr. McHugh, a professor of psychiatry at Johns Hopkins University, is the author of “Try to Remember: Psychiatry’s Clash Over Meaning, Memory, and Mind.”