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Tuesday, January 28, 2014

Slow Medicine: Knocking on Heaven's Door

I recently read Knocking on Heaven's Door: The Path to a Better Way of Death by Katy Butler. Here is the Amazon page on the book. I thank one of my brothers for suggesting this book.

Butler, a journalist, gives us a no-holds-barred, yet compassionate, view of death and dying. Her main message is that, as we approach the end of life, health providers act too quickly, with invasive, expensive, and, usually, futile, procedures, and that patients, and especially families, need to watch out for that:
Dying is not an emergency. Emergency rooms, 911 systems, and intensive care units are all primed to prevent natural death. Engage them with caution. The most important sentences in this book  may be, "Can you refer me to hospice?" "I request comfort measures only," and "I am concerned about quality of life." (chapter 20)

Why is this? The reasons are well known, if seldom discussed in our public discourse. The main one, Butler believes, is that there are financial incentives for expensive procedures. Insurance companies, including the government, pay more for them. Specialists, for example the doctors who implant pacemakers, or do coronary bypass surgery, get paid several times more than family doctors or internists, who often give valuable advice, or listen, and care for the spirits of patients and families, supporting them when they need it most. Butler says that doctors may say that they don't make medical decisions based on the amount they, or the entities they work for, will be paid, and, perhaps, they also think that they don't. But, once the money is available, there is a natural, perhaps unconscious, tendency, to go for it. There doesn't seem to be much doubt that hospitals, although they render important services, are money-driven, and they get more from surgery and expensive devices than from comfort care, or going slow, to see if the patient can get better without such measures. Butler does not believe that the situation is going to change, unless the financial incentives are changed, and she is right.

It is also true that medical schools don't give much training aimed at backing off, and letting someone die in peace. EMS workers don't get much training of that type, either. Doctors and EMS workers try to save lives, as quickly as possible, and that's usually a good thing, but not always. It is often true that they bring people back from the brink of death who didn't want that, and had even specifically requested that they not be so "rescued." (Operations on the aged, unfortunately, often cause dementia that wasn't detectable before the operation.)

As Butler said:
"It did not once occur to us to say: 'You want to do major heart surgery on an eighty-four-year-old woman showing progressive dementia? What are you, nuts?
'" (quoting journalist Michael Wolff, about his mother. chapter 18)

Butler is an advocate for "Slow Medicine," taking a slower approach to doing things that may damage quality of life significantly. (Here's a review of another important book advocating Slow Medicine.)

Butler's own experience involved her father, living in New England, while she lived in the West, and her mother's care for her father, who had had a stroke, and suffered from dementia. One complication was that her father's pacemaker kept him going when he would otherwise have passed away, but it was nearly impossible to get anyone to turn it off.

She also points out that people who care for the dying at home don't get paid a lot, which is unfair. Butler suspects that part of the reason is that such caregivers are usually women. She has nothing but praise for such people. My own limited experience with them agrees. We probably didn't pay enough, and they were wonderful.

Butler is not a Christian. If anything, she is a Buddhist. But she understands that the circumstances surrounding death have changed, and gone away from the way things used to be:
After the mid-1950s, the attitudes of many doctors and patients shifted from faith in God and acceptance of death to faith in medicine and resistance of death. There was always something, no matter how ultimately futile, that a doctor or nurse could do. (Chapter 5) She points out that Christians, dying in the recent past, were most concerned about their relationship with God, and with other people, not about being kept alive, sort of, for another day or two.

A fine book, and it certainly made me think.

I have written on death-related subjects previously:

Here is a review of a book about the death of a Christian woman in the 1800's, Mrs. Hunter's Happy Death.

Here is a meditation on sudden dying, occasioned by the accidental death of a child in our small town.

Here is an essay on why sickness and death bother us so much.

Finally, here is an essay, in which I argue that God does not like human death.


Anonymous said...

I could not agree with this more. Health providers DO act too quickly, and the way they inform the family of their (often) invasive options is worded in terms that give false hope, or imply the repercussions are far less than they actually will be. I've come to learn that when a doctor says a procedure's side effects are not life threatening and usually tolerated well, what he really means is, it won't out and out kill you. It may ruin your life, but it won't kill you. It really is time to put faith in the afterlife back into our healthcare. Thanks for this post.

Martin LaBar said...

Thanks for your comment, Anonymous, whoever you are.