Treatment after treatment, which made her sicker and sicker and sicker . Narrator and making peace with the end. In the last four weeks, ive been surrounded by family and friends. Some of the best days of my life, i must say. Narrator tonight on frontlinbeing mortal. Frontlinis made possible by contributions to your pbs station from viewers like you. Thank you. And by the corporation for public broadcasting. Major support for frontliis provided by the john d. And catherine t. Macarthur foundation, committed to building a more just, verdant and peaceful world. More information is available at macfound. Org. Additional support is provided by the park foundation, dedicated to heightening Public Awareness of critical issues. The john and Helen Glessner family trust, supporting trustworthy journalism that informs and inspires. The ford foundation, working with visionaries on the front lines of social change worldwide. At fordfoundation. Org. The wyncote foundation. And by the frontline journalism fund, with major support from jon and jo ann hagler, and Additional Support from chris and lisa kaneb. Support for being mortal is provided by the john and wauna harman foundation. sirens blaring atul gawande ive been a surgeon for more than a decade now. In medicine, your first fear as a doctor is that youre supposed to be able to fix a problem, and our anxieties include wanting to seem competent, and to us competent means i can fix this. In fact theres often a kind of implicit promise, im going to be able to fix this, im going to certainly give you the best shot you can have. Nobody could have given you a better shot. And then when things arent working, part of your anxiety is, was there something i missed, was there anything else i could have done . When i started out in my training in surgery, you discover that all the stuff you learned about in the books in medical school is really just a tiny little bit of what it means to be good at doing our jobs. Its not just about how smart you are anymore as a doctor, its about how you have to be able to work with teams, and how mistakes get made and how you handle them, and how you learn. Among the most uncomfortable difficulties was grappling with those cases where we couldnt solve the problem. The two big unfixables are aging and dying. You know theyre not. You cant fix those. Im a surgeon and im a writer. My writing has become the way that i can focus in and begin to understand the problems that most confuse me. One case in point was a piece i wrote called letting go about a woman named Sara Monopoli whom i helped take care of who was diagnosed with stage four lung cancer during the ninth month of her pregnancy at the age of 34. This was one of the most difficult circumstances. You have a young woman with a brand new baby. Of course everybody is fighting for every chance that shes got. She was young, shes enthusiastic, she wants to tackle this. You dont want to be the downer. So youre looking, youre grasping for a straw that says, well theres something here thats going to be beneficial. Stage four lung cancer, we know its not curable, but suppose shes the one that somehow gets cured. Maybe shes the one. And so therefore we should do all these things to her. Having any kind of discussion that would begin to say, look, you probably only have a few months to live. What do we do to make the best of that time, without giving up on the options that you have . That was a conversation i wasnt ready to have. I dont think any of us were. Gawande hey there. Dr. Gawande, how are you . Gawande how are you . Come on in. Gawande take me back to when shes pregnant, shes doing great, 39 weeks, your due date is coming, and . The collapsed lung would not allow for a csection. It was too dangerous to be opening her up with all that fluid build up, so sara had vivian basically pushing with one lung. It was so difficult, but she had the baby. You want to be part of that 15 that survives more than five years. You want to be part of that group so badly. And you say to yourself, why not us, you know . It wasnt about how can we have good days to the end . We didnt focus on that enough. Were trying to stabilize the situation and try to become a little. Spend a little bit of time as a family. But it was just. It was an impossible situation, impossible summer. I mean its just excruciating. Gawande when i came on the scene was when she got diagnosed with a second cancer. You know, in my mind what i was thinking was i wouldnt offer this surgery because the lung cancer is going to take her life. And yet i didnt feel i could say that to you all. I think we started talking about the experimental therapy that you all would like, or were hoping to get on for a trial with the lung cancer. And i remember saying something i sort of regret, which was, you know, maybe that experimental therapy will work for the thyroid cancer, too. I said that. And i know it was complete. Well, you had joined us in our sunny disposition, hoping for the best. Gawande i knew, i knew it was not going to. I mean i. In other words, the reason i regret it is because i knew it was a complete lie. I just was wanting something positive to say. I did not know it was an outright lie. You could lose your license for that, you know. Gawande i know. But, you know, i think. I dont think i was terribly equipped for having that conversation. Maybe you all werent. I dont think we were. Ive thought often about what did that cost us . What did. What did we miss out on . What did we forego by consistently pursuing treatment after treatment after treatment, which made her sicker and sicker and sicker . Gawande the very last week of her life she had brain radiation, she was planned for the experimental therapy the following monday. You woke up and she wasnt doing so well. On a friday. What happened then . So she woke up and was gasping for air and i tried to crank the oxygen up, i said, lets max this thing out, maybe we would get a bigger oxygen machine. We were so close to getting to the next potential fix. And she said, i cant do this. I cant do it at home. Im too scared. Im gasping for air and i cant cant do this. We should have started earlier with the effort to have quality time together. The chemo had made her so weak that she couldnt hold vivian. It was exhausting. And that was not. That was not a good outcome for. For the final, final months. Its not where we wanted to be. sniffles gawande in the last three months of her life, almost nothing wed done the radiation, the chemotherapy had likely done anything except make her worse. It may have shortened her life. What was interesting to me was how uncomfortable i was and how unable i was to deal well with her circumstances. It felt like a revelation in that here was a case which i could unpack enough to understand, why do we always go off the rails . It made me want to explore what other doctors were doing in these extremely difficult circumstances. And what i hoped was that maybe i might learn something that i should be doing differently. I work at the Brigham Womens hospital and the Dana Farber Cancer institute in boston. Theyre connected together across one street. Its here that my colleagues let me observe their experiences with patients facing the end of life. The struggles and the difficult choices. One was lakshmi nayak. Shes a specialist in cancer of the brain. And she has to have these end of life discussions with almost all of her patients. You picked a pretty tough field, right . So how many of your patients will you cure or help them have a better life . Its almost always fatal. We have, you know, each of us has an odd patient who survived for ten years or 15 years, but thats less than 5 of all of the patients that suffer from the most common malignant brain tumor. So yes, i dont get to tell people, im going to cure you. Gawande one of dr. Nayaks most challenging cases at the time was a man named bill brooks. He was 46 years old. Bill has brain cancer. That basically in his case has led to raised pressure in his head. But he feels really well. Bills sister had also died of a brain tumor, and that was what he was worried of the most. How do they look . They look delicious. chuckles they always look delicious. Everything is good for you, you eat anything. You know, were so lucky, we have each other, we have great families, we have great friends, we got great jobs, we live in a beautiful home, weve been lucky. And then, you know, all of a sudden, its like our world was turned upside down. Its a battle. You know, some people say dont listen to the numbers, and i always say, well that gives me something to shoot for. You know, if they tell you five years, lets go for six, seven, or ten. Thats good, you were right. Told you. So bills story from the very beginning has been challenging, because when i first saw him, i thought he had five to ten years. That changed. His symptoms started getting more aggressive. Gawande the headaches . The headaches. The not being able to lie down. I actually called mary. I said, we dont have much time, we probably have a few days to a month. And i told her she should take time off work. He started having pressure in his head. And we. Its okay. sniffles its okay. Paper towels, this is good. So. Dr. Nayak gets very um. She takes it very personal. She takes it very personally when she wants. Has to give us bad news. She basically just told us to get ready, and so, you know, of course you have your pity party. And then you kind of like dont give up hope. Its okay, sweetie. Gawande so after the phone call, dr. Nayak ordered a series of spinal taps to relieve the pressure in bills brain, and it worked. The pressure came down, he felt better, and they had new hope. But the disease was still progressing. You started having some pressure . Can i check a few things . Yeah, absolutely. Eyes wide open. What i was looking into your eyes was not the way your pupils reacted was, but to see what the pressure might be. And im worried that the disease will be growing. I think that its important for us even though it would be easier to sort of skip over this today. That we should talk about if things are not going as we hope, to just talk about worse Case Scenarios a little bit. And then best case scenario, too. What do you think . Best case, obviously, you know, well just continue what were doing if you think thats the right path. Gawande what made you jump in to say, best case, as well as worst case . I think that id scared them the first time. Gawande youre thinking back to when you talked about it before. Yeah. Gawande and you were worried that youd lose their confidence if you only talked about the bad side. Yeah and especially because he had been responding to treatment. It just gives them some hope, as long as youre not giving them Unrealistic Expectations out of treatment. Its worth a shot. Whats the third option . There is no third option. There has to be a third option. We do things together, we often are finishing each others sentences. If dr. Nayak had said, lets talk about worstCase Scenarios, then i would have said, and well talk about bestCase Scenarios. Have you thought at all as far as worseCase Scenarios go if you would want hospice at home or hospice at a facility or. . Do it at home. When we talked about hospice, i was reading marys body language that was sort of saying to me, dont go there. But given all the things that were going wrong, i felt like we had to do that. Have you thought about anything after the mri . My thought, and marys heard me say it a lot, is i want to see the next one to kind of see if its showing anything or not before i start to get worried or get too hopeful. Thank you. Thanks. Good to see you. Good to see you. Gawande it was amazing to see how my colleagues had these conversations. And it was teaching me what i might do better for my own patients. It turned out it also taught me how to do better for my dad. He got some bad news, back home in ohio. I remember i took notes in my journal around that time. Do you remember when dad first started to get pain in his neck . He had pain in his shoulder, and he thought that either playing too much tennis or just muscle. So when the result came, we were in a shock. Gawande hed gotten an mri. And as a surgeon he knew the results were not good. He emailed the images, i opened them up and its a huge mass and its concerning. He called me up and as were piecing it together over the phone, were kind of realizing this is right in the middle of the spinal cord. So the puzzle is how do you get this out . Were two surgeons looking at a mass, its like two carpenters looking at a house. You know, youre not saying, ah yeah we cant fix this. But, you know, at the end of that conversation, yeah, im, im thinking this could. This could be a life threatening problem. It was hard for us, as a family, to talk about this. And thats despite three of us being doctors. In fact, talking with anyone near the end of life about their decisions is so difficult that there are actually physicians who specialize in the process. Theyre called Palliative Care physicians, people like Kathy Selvaggi, who works at the dana farber. Her technique is as much about listening as it is about talking. What would be on your checklist for what i should make sure i do when im doing it next time . First of all, i think its important that you ask what their understanding is of their disease. I think that is first and foremost, because oftentimes what we say as physicians is not what the patient hears. And if there are things that you want to do, lets think about what they are and can we get them accomplished . Gawande you know, people have priorities besides just living longer. Yes. Gawande you got to ask what those priorities are. And then you got to tune the treatment to those priorities. Exactly. And if we dont ask, and if we dont have these discussions, we dont know. Hello, im dr. Selvaggi, im kathy. Gawande dr. Selvaggi works with doctors throughout the hospital to help with their hardest patient conversations. So how are you feeling . A little better than i was when first came in here the other day. Gawande aymen elfiky was one of those doctors, hes an oncologist who, like me, grapples with reaching good decisions with his patients about dying. Hed been caring for a patient named Norma Babineau for two years. He said that during that time he had tried to broach how dire her prognosis was, but he had not been successful let me start by giving you both an overview where were at now. Because the cancer has developed a more aggressive course to it, right . Its a more resistant type. This is where the tough discussions, uh, come up. The disease, we knew, has been acting up. Right now, in this state, the treatment would hurt you more than help you. Thats just a fact. And you would not get the benefit of it. Is there a time, you think, a timeline, or. . We could be talking about three to four months. We can be longer, it can certainly be shorter if the pace picks up. Theres miracles that can happen in between. Its a question you had to ask, and i dont want you to dwell on that. If i were going to bet on somebody doing better, it would be. I would be betting on you to do better than that timeline. Our goal is, for whatever time is left, is to make it the best quality that we can. But i need to take the baby to. To where . To walt disney. To do walt disney. Yeah, im going to take her for christmas. We got to find the right medicine to get me better so i can take my trips. Gawande so the really hard part, i find, in these situations is, you know itll come to this point, when do you help them understand that . Whats going through your mind, though, whats it feel like to you . That i wish i could do better. Gawande still feels like a little bit of a failure for us, doesnt it . Its very much a failure, and its hard. Gawande even though you knew from the beginning you werent going to be able to. You. You werent curing this problem. Right. Its just a fight mentality that perhaps goes back to training in med school and just the way we are wired and were not trained for that other mode. Thats where we have to take our cues. Gawande Palliative Care doctors like Kathy Selvaggi are different. Theyre teaching us there might be a better way in these circumstances. You know i think, i think its hard to hear sometimes the timeline. But i think its also important to have a sense because if there are things that you want to say or do or people that you want to see, it helps you to find that time a little better. I think she knew that she was getting sicker and weaker. One of the goals was to try and get her home with hospice services. But the medications and the things that were requiring, its just not going to happen. Gawande forget disney world, were not even knowing whether we can leave the hospital. Exactly. Gawande so we didnt do that before last monday. Feels really late in the game, you know . Um, it does feel a little bit late in the game. We, you know, were all sort of taught that in order to make a difference in our patients lives, we have to be doing something. We have to be operating, we have to be giving them a medication, we have to be radiating, we have to be giving chemotherapy. In some ways i think the medicine is the easy part. Its all of this other stuff thats much harder to deal with. How are you . Good, how are you . I wanted to talk with you about. Um, i know the other day, norma, we talked about, um, where to go from here. You may need more and more iv or intravenous medications to control your symptoms, and im worried that were not going to be able to do that at home. What do you think about that . Yeah, i think its coming close. When you say coming close, that were coming near the end . Yes. Yeah. I worry about the same thing. And what well do is well. Well keep you here and well take care of you here. Okay . Yeah. All right, norma. All right. Well see you a little later, okay . Okay. And ill get, um. Why dont i clear this out for you . Gawande Kathy Selvaggi had helped norma understand that she was dying. Still norma had little time to say her goodbyes. She died ten days later. These are really important conversations that should not be waiting the last week of someones life, between patients, families, doctors, other Healthcare Providers involved in the care of that patient. Gawande theres no natural moment to have these conversations, except when a crises comes, and thats too late. So i began trying to start earlier talking with my patients and even my dad. I remember my parents visiting. My dad and my mom and i had sat in my living room and i had the conversation, which was, what are the fears that you have, what are the goals that you have, and you know, he cried and my mom cried. And i cried. He wanted to be able to be soc