Letting Go by Atul Gawande

ANNALS

Of

MEDICINE

LETTINGGO

WhatJhouldmedicinedowhen

it

can'ISilveY01i1'life?

BYAWLGAWANDE

S

a.raTh.omas.M.onopoI.

i.

was..preg-nant'withherfirstchildwhenherdoctorslearnedthatshewasgoingtodie.Itstartedwithacoughandapaininherback.ThenachestX-rayshowedthatherleftlunghadcol-lapsed,andherchestwasfilledwith

Huid.A

sampleof

thefluid

wasdrawnoffwithalongneedleandsent

for

test-ing.Insteadofaninfection,asevery-onehadexpected,itwaslungcancer,and

it

hadalreadyspreadtotheliningofherchest.Herpregnancywasthirty-nineweeksalong,andtheobstetricianwhohadorderedthetestbrokethenewstoherasshesatwithherhusbandandherparents.'TIleobstetriciandidn'tgetintotheprognosis-shewouldbringinanoncologistforthat-butSarawasstunned.Hermother,whohad

lost

herbestfriendtolLU1gcancer,

began

crying.Thedoctorswantedto

starttreat-

ment

rightaway,andthatmeantinduc-inglabortogetthebabyout.Forthemoment,though,Saraandher

hus-

band,

Rich,

satbythemselvesonaquietterrace

off

thelabor

floor.Irwas

awarmMonday

in

June,2007.Shetook

Rich's

hands,andtheytriedtoabsorbwhat

theyhad

heard.Monopoliwasthirty-

four.

Shehadneversmoked,orlivedwithanyonewhohad.Sheexercised.Sheate

well,

TIlediagnosiswasbewil-dering.

'This

is

goingtobe

O.J(.,"Rich

toldher."W!e'regoingtowork

throughthis.It'sgoing

tobe

hard,

yes.Butwe'llfigureitout.Wecanfindtherighttreatment."For

the

moment,though,theyhadababytothinkabout."SoSaraand

J

lookedateachother,"Rich

recalled,

"and

we

said,Wedon'thavecanceronTuesday.It'sacancer-freeday.

·Were

havingababy.

It's

exciting.Andwe'regoingto

enjoy

ourbaby.'

»

On

Tuesday,at

8:55

P.NL,

Vivian

Monopoli,

sevenpoundsnineounces,wasborn.Shehadwavybrownhair,

like

hermom,andshewasperfectlyhealthy.

.36THE

NEIlII

YO[IKER,AUGU5T2,2010

Thenextday,Saraunderwentbloodtestsandbodyscans.

Dr.

Paul

Mar-

coux,anoncologist,metwithherandherfamilytodiscussthefindings.Heexplainedthatshehadanon-small

cell

lungcancer

that

hadstarted

in

herleftlung.Nothingshehaddonehadbroughtthison.

More

thanfifteenpercentoflungcancers-morethanpeoplereal-izc-r-occurinnon-smokers.Herswasadvanced,havingmetastasizedtomul-tiplelymphnodesinherchestand

its

lining.Thecancerwasinoperable..But

there

werechemotherapyoptions,no-tablyarelativelynewdrugcalledTar-ceva,whichtargetsagenemutationcommonlyfoundinlungcancersoffemalenon-smokers.Eighty-fivepercentrespondto

this

drug,and,

Mar-

couxsaid,"someoftheseresponsescanbelong-term,"

Words

like"respond"and"long-term"provideareassuring

gloss

onadirereality.ThereisnocureforIlmgcanceratthisstage.Evenwithchemotherapy,

the

mediansurvivalisaboutayear.But

it

seemedharshandpointlesstoconfrontSaraandRichwiththisnow.Vivianwas

ina

bassinetbythebed.Theywereworkinghardto

be

optimistic.

A"

Saraand

Rich

latertoldthesocialworkerwhowassenttoseethem,theydidnot

want

tofocusonsurvivalstatistics.Theywantedtofocuson"aggressivelymanag-

ing'this

diagnosis.Sarawasstartedonthe

Tarceva,

whichproducedanitchy,acne-like

fa-

cialrashandnumbingtiredness.Shealsounderwenta

surgicBJ

proceduretodrainthefluidaroundherlung;whenthe

Huid

keptcomingback,athoracicsurgeoneventuallyplacedasmall,per-manent

tubein

herchest,

which

shecoulddrainwheneverfluidaccumulatedandinterferedwithherbreathing.Threeweeks

after

thedelivery,shewasadmit-tedtothehospitalwithsevereshort-nessofbreathfromapulmonaryembo-lism-abloodclotinanarterytothe

aggre.uiveinteroentions+andbadatknowing'i.l)hento

flCUJ;

instead.onimprovingthedaystbatterminalpatientshavelift.

1W16rs,which

is

dangerousbutnot

un-

common

incancerpatients.Shewasstartedonabloodthinner.Thentestresultsshowedthathertumor

cells

didnothavethemutationthatTarcevatar-get~.

When

MarcouxtoldSaratbatthedrugwasn'tgoingtowork,shehadanalmostviolentphysicalreactiontothe

news,

boltingtothebathroominmid-discussionwithasuddenboutof

diarrhea,

Dr.Marcoux

ITeOIl1-

mendedadifferent,morestandard

chemotherapy,

withtwodrugscalledcar-

boplatin

and

paclitaxel,

Butthe

paclitaxel

triggeredan

extreme,nearlyover-

whelmingal.lergiere-sponse,

so

heswitchedhertoaregimenofcarbopla-tinplusgemcitabine.Re-sponserates,hesaid,werestill

voy

goodforpatientsonthistherapy.Shespenttheremainderofthe

S1.UU-

merathome,withVivianandher

hus-

bandandherparents,whohadmovedintohelp.Shelovedbeingamother.Be-tweenchemotherapy

cycles,

shebeganttyingtogether

life

backTheil,

ill

October,aCTscanshowedthatthetumordepositsinherleftlungandchestandlymphnodeshadgrownsubstantially.Thechemotherapyhadfailed.Shewasswitchedtoadrugcalledpemctrcxed,Studiesfoundthatitcouldproducemarkedlylongersur-vivalinsomepatients.Inreality,how-ever,onlyasmallpercentageofpatientsgainedverymuch.Onaverage,thedrugextendedsurvivalbyonlytwomonrhs=-fromeleven

months

tothir-teenmonths--andthatwasinpatientswho,unlikeSara,hadrespondedtofirst-linechemotherapy.Sheworkedhardtotaketheset-

backs

andsideeffectsinstride.Shewasupbeatbynature,andshemanagedtomaintainheroptimism.Littlebylittle,however,shegrewsickcr-e-incrcas-inglyexhaustedandshortofbreath.ByNovember,shedidn'thavethewindtowalkthelengthofthehallwayfromtheparkingg<U'agetoMarcoux'soffice;Richhadtopushherinawheelchair.AfewdaysbeforeThanksgiving,shehadanotherCTscan,whichshowedthatthepcmctrexed-e-hcrthirddrugregimen-wasn'tworking,either.Thelungcancerhadspread:fromtheleftchesttotheright;totheliver,tothelin-iugofherabdomen;andtoherspine.Timewasrunningout.

T

hisisthemomentinSan1Sstorythatposesafundamentalquestionforevelyonelivingintheemofmodernmedicine:

What

dowewantSaraandherdoctorstodonow?Or,toputitanother'''lay,ifyouweretheonewhohadmeta-staticcancer-s-or,forthatmatter,a

similarly

advancedcase

ofemphysema

orcon-gestiveheartfailme-whatwouldyouwantyomdoc-torstodo?

The

issuehasbecomepressing,in

recent

years,furreasonsofexpense.Thesoaringcostofhealthcareisthegreatestthreattothe

country's

long-termsol-vency,

and

the

terminally

ill

accountforalotofit.Twenty-fivepercentofallMedi-carespendingis

for

thefivepercentofpa-tientswhoarcintheirfinalyearoflife,andmostofthatmoneygoesforcareintheirlastcoupleofmonthswhichisoflittleapparentbenefit.Spcndingon

a

diseaselikecancertendsto

follow

aparticularpattern.

There

archighinitialcostsasthecanceristreated,andthen,ifallgoeswell,thesecoststaperoff.Medicalspendingfor

11

breast-cancer

survivor,for

instance,aver-agedanestimatedfifty-fourthousanddollarsin

2003,

thevastmajorityof

it

fortheinitialdiagnostictesting,surger}';<U1d,wherenecessalY,radiationandche-motherapy.

For

apatientwith

a

fatalver-sionofthedisease,though,thecostcurveisU'-shapcd,risingagaintowardtheend-toanaverageofsixty-threethou-sanddollarsduringthelastsixmonthsoflifewith<U)incurablebreastcancer.Ourmedicalsystemisexcellentattryingtostaveoffdeath

with

cight-thousand-dollar-a-month

chcrnotherapy,

three-thousand-dollar-a-dayintensivecare,five-thousand-dollar-an-hourSQrgelY,But,ultimately,deathcomes,andnooneisgoodatknowingwhcntostop.Thesubjectseemstoreachnationalawarenessmainlyasaquestionofwhoshould"win"whentheexpensivedeci-sionsaremade:theinsurersandthetax-payersfootingthebillorthcpatientbar-clingforhisorherlife.Budgethawksurgeustofacethefactthatwecan't

38Tl-IE.NEWYORKER,AUGUST2.2010

affordeverything.Demagoguesshoutaboutrationinganddeathpanels.Mar-ketpuristsblametheexistenceofinsur-ance:ifpatients

andfamilies

paidthebillsthemselves,thoseexpensivetherapieswould

all

comedowninprice.ButthC)fredebatingthewrongquestion.TI1efailure

of

omsystemofmedicalcareforpeoplefacingtheendof

their

life

runs

muchdeeper.Tosec

this,

youhavetogetcloseCI10ugh

to

grapplewiththewaydecisionsaboutcarearcactuallymade.Recently,whileseeingapatientinanintensive-careunitatmyhospital,

I

stoppedtotalkwiththecritical-carephy-sicianonduty,someone

r

dknownsincecollege."I'mrunningawarehouseforthedying,"shesaidbleakly.Out

of

thetenpatientsinherunit,shesaid,only

1'.'10

werelikelyto

leavethe

hospitalforanylengthoftime.Moretypicalwasanal-mosteighty-year-oldwomanattheendofherlife,withirreversiblecongestiveheart

failure,

who

was

in

theI.C.U.forthesecond

time

inthreeweeks,druggedtooblivionandtubedinmostnaturalorificesanda

few

artificialones.Orthe

seventy-year-old

withacancerthathadmetastasizedtoher

lungs

andbone,andafimgalpneumoniathatarisesonlyinthefinalphaseoftheillness.Shehadchosentot(lrgotreatment,butheroncol-ogistpushedhertochangehermind,andshewasputonaventilatorandantibiot-

ics.Anotherwoman,inhereigbties.with

end-stagerespiratoryandkidneyfailure,hadbeenintheunitfortwoweeks.Herhusbandhaddiedaftcr

a

longillness,withafeedingtubeandatracheotomy,andshehadmentionedthatshedidn'tW<U1to

die

thatway.

Buther

childrencouldn'tlethergo,andaskedtoproceedwiththeplacementofvariousdevices:apermanenttracheotomy,afeedingtube,andadialysiscatheter.Sonowshejustlaytheretetheredtoherpwnps,driftinginandoutofconsciousness.Almost

all

thesepatientshadknown,forsometime,thattheyhadaterminalcondition.Yetthey--alongwiththeirfamiliesanddoctors-wereunpreparedforthefinalstage.'Wearchavingmoreconversationnowaboutwhatpatientswantfortheendoftheirlife,

by