Books: Knowing when to stop

American author Atul Gawande

Tough questions, including those around death and terminal illness, are tackled by surgeon and writer Atul Gawande in his latest book, writes David Larsen

"Death is the enemy. But the enemy has superior forces. In the end, it wins."

Atul Gawande is a surgeon, a writer, a researcher, and the chairman of a global non-profit organisation aimed at making surgery safer. He works for the World Health Organisation and was a health care adviser to Bill Clinton. Two of his four books have made the New York Times bestseller list in hardcover. He finds time for tennis. You could almost hate him.

Except you really couldn't. The man who comes through in his writing is kind, modest, fiercely committed to his patients' well-being, and strikingly open to learning the lessons that mistakes, our own or others', can teach us. In Better: A Surgeon's Notes On Performance, he recounts a conversation with an angry intensive care nurse:

"What is it with you doctors?" she said. "Don't you ever know when to stop?"

"She'd been caring for a man with lung cancer," he writes. "He had had one of his lungs removed ... surgery had left him unable to breath without a tracheostomy and a respirator ... Sepsis claimed his kidneys ... It had long ago become apparent that a life outside the hospital was not possible for this man. But neither the doctors nor his wife seemed capable of confronting this truth."

Gawande's writing frequently has a white-knuckle medical thriller quality. Visceral descriptions of what it's like to take a knife to someone for the first time ("skin is thick and springy"), of moments when routine surgery abruptly dives into disaster: "He lost almost his entire volume of blood into his abdomen in about 60 seconds and went into cardiac arrest. I made a huge slashing incision to open his chest and belly as fast and wide as I could. I took his heart in my hand."

But the harder and more distressing subject of his latest book, Being Mortal, is the one that first crops up in that conversation with the intensive care nurse: "How do you know when it's time to stop? When should doctors admit to their patients that there's nothing they can do?"

The default answer: never. "We want doctors to fight."

The problem, given modern medicine's constantly expanding reach, is that there's always another last-ditch thing to try.

Gawande tells several stories in Being Mortal that bring this into heartbreaking focus, and map out the progression by which his thinking on the subject changed. "We still fundamentally regard death as a failure of medicine. But some patients have problems that can't be fixed. There's a point at which we need to shift from the disease control process to understanding what people's goals and priorities are."

In the book, Gawande describes his own father's drawn-out fight with cancer. There's a key moment, where Gawande sits with his parents in an oncologist's office, and listens to her lay out eight or nine different chemotherapy options. "The only thing she did not discuss was doing nothing."

She tells his father that, with a little luck, he could be playing tennis again by the summer. His father at this point was borderline quadriplegic, and the tennis idea was by any definition a fantasy: in fact it amounted to a flat-out lie. The oncologist, clearly, could not bear to be in the position of having no hope to offer.

"I talk in the book about the 40 per cent of oncologists who acknowledge they've offered treatments they know will provide no benefit. And I also talk about the times I've done it myself. It's not because people are evil or bad at what they do. Out of sheer hopefulness you end up grasping for straws.

"Whereas you see expert palliative care doctors or hospice workers, who are able to talk about what patients can realistically expect in ways that make it very normal and comfortable and easy. That's still a set of skills I'm learning to master."

There is, it should be said, a great deal of good news in Being Mortal, as in Gawande's earlier books. All his work combines a sophisticated awareness that doctors and patients are just people, fallible and complicated, and a rigorous insistence that we can do better. One way he arrived at this view of the world, oddly enough, was through an activity he never set out to pursue - writing.

"When I got married, five out of my six groomsmen were writers. I'd never written anything but I'd always been attracted to people who were in the business of ideas. One of my friends, Jacob Weisberg, was editor of Slate, and they wanted to cover health-care issues, and Jacob asked me if I'd be interested."

A regular column at Slate led to a chance to write for The New Yorker, where he became a staff writer; Being Mortal grew out of two essays published in the magazine.

"I discovered the power of a great editor, which is that they're your writing coach. They're telling you, 'here's what you're doing well, do more of this, do less of that'. It's like getting trained on 30 gallbladders, with a surgeon standing across from you saying, 'here's what you're doing well, here's what you're not doing well, now stop it, damn it! And do the right thing!'

"Though it was a whole new experience again writing for The New Yorker. The first time I wrote a piece for them, I expected a two-month editing process. It was nine months. We went through 22 revisions. About 80 per cent of what I had originally written was chucked, I had to go and do extra investigating, I had to talk to more people. It was like being taught in one essay how to become a proper journalist. I would keep thinking it was going to finally end and we were going to publish it, but I had to acknowledge - every time the revisions happened, it would get better."

Atul Gawande will appear at the Auckland Writers Festival, Aotea Centre, May 13-17.