After 3 decades in primary care medicine, I should be feeling a level of comfort with dealing with people, mostly seniors, in the declining phases of their lives.  With this kind of experience, there is a certain comfort that you have gleaned what is useful from your training, you have seen most things, and solved, as best as one can, most health problems, whether with a newer medicine, the right specialist, a better strategy to avoid toxic influences, or perhaps a better diet or exercise plan.  Regrettably, though, we have been taught only solutions, and we have been seduced into believing that every medical problem is solvable.  Yet at some level we know it isn’t true:  everyone stills dies, and no one is spared.  And worse, many of our seeming solutions have both overstated value, and understated risks, that can even shorten, not lengthen lives, and create more, not less troubling side effects.

In physician/author Atul Gawande’s provocative and insightful book, “Being Mortal” (2014), he states clearly that, while modern medicine has given us remarkable power and options to push back at most of the complex medical problems we face today, we physicians in medicine can do significant damage “…when we fail to acknowledge that such power is finite and always will be.” (p.259).  While people are indeed living longer and better than in any time in history, we are medicalizing aging and dying, to the point where both patients and doctors seem to believe that health care professionals have the omnipotence to solve these problems–or at least, push them off, seemingly indefinitely.  Perhaps this wouldn’t be so bad if medicine could increasingly deliver on these tall orders–fact is, though, there is harm in this denial: As Gawande suggests, “The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit…. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need.” (p.9)

Both families with aging relatives, and the doctors taking care of them need to have some tough conversations that both are preferring to avoid.  It is hard enough to face the facts of a life in its final stages, and more difficult to navigate the possibilities and availabilities of current treatments.  But it is hardest for both parties to speak in terms of what is most important to them at this stage of their lives–reflective of a need to shift from a quantitative need to maximize length of life, to a qualitative discussion, to get the most of every day left.  This conversation has to include whether or not a “Do Not Resuscitate” (DNR) order should be written, whether or not aggressive and risky therapies or surgeries should be considered, and whether these last days should be in a hospital, a hospice center, or a home, including an assisted living center.  And this conversation may need to be repeated and modified as circumstances change, as well as pro-actively, before the opportunity has passed for whatever reason.

If you have any of these concerns, talk openly and honestly with your family about your wishes, and talk to your primary care physician.  Too many people do not, and their last days are, too often, not what they would have wished for.  Consider reading Dr. Gawande’s insightful book.