“Do Not Go Gentle Into That Good Night?”

Barbara Ehrenreich has never treaded gently with her writing. You may remember Nickled and Dimed (2001)—where Barbara went undercover and tried to pay her rent, car expenses, food, etc. on minimum wage? She couldn’t do it with two or three jobs. The cost of gas and maintaining an old beater to get her to and from low income housing to her job sites, which weren’t close, eventually sunk her. In Bait and Switch: The (Futile) Pursuit of the American Dream (2006) she exposed the challenges of white-collar unemployment, where job searching becomes a full-time job, as she underwent career coaching, personality testing, and image make overs.

I’ve also become a fan of her son, Ben Ehrenreich, clearly cut from the same cloth. His 2017 book, The Way to the Spring: Life and Death in Palestine, helped me understand the complexities of modern day Palestine.

Now at 77 years old, Barbara examines aging and our fixation in the US with youth and longevity and the perverse industries, including health care, which have arisen to preserve our lives. No one and nothing is sacred in Natural Causes. Barbara says she is “old enough to die” now, having survived breast cancer in her 50s. She will forgo colonoscopy, mammography, pap smears, blood tests and other testing that we, primary care physicians, routinely encourage. I listened to Natural Causes. It is easier for me to listen to nonfiction, especially this on target rant, as she takes on the Wellness and Mindfulness movements—over 500 mindfulness apps and money making opportunities, although some are free and I do recommend them to patients; Silicon Valley and Steve Jobs as “biohacks” trying to engineer immortality; and the fitness craze. And as I drove to and from my new job which is very much part of the medical industrial complex, I reflected on what is not working about health care.

Often the patient is not the center of patient-centered care. And the electronic health record has not make my life and my efforts to care for the patient much easier. However, it does help the bean counters and population health activities.On a more positive note, the  gives us some guidance about when to stop the preventive tests: Pap smears at 65y, Mammography at 74y, Colonscopy at 75y. Screening is most appropriate among adults who 1) are healthy enough to undergo treatment if cancer is detected and 2) do not have comorbid conditions that would significantly limit their life expectancy. Finally, the discussion of advanced directives is being encouraged, although not yet embraced.

Many of my new patients are elderly and are happy to consider what quality of life is for them. Several elderly patients have laughed and said, “I’m not sure what is so golden about these years.” It was a conversation I had with my Dad, who died Christmas 2016, at 92 years. In his final years we did a lot of talking about the decline in his quality of life because of his many losses: hearing, eye sight, physical strength. That was balanced with his desire to be around for Fran, my sister with Down syndrome, and my mom. With a reasonable surgeon, he chose not to undergo the surgery that might have saved him or been his final demise.

Those same challenges were evident when I visited my 94 year old aunt who struggles with numbness and burning in her fingers. For decades she taught and played the piano, organ and guitar. Now for the past few years, her fingers don’t work and they hurt. A devout Catholic nun, she sees this pain as her purgatory, to reap the benefits of heaven. Perhaps, but if that is true, we have a cruel god! However we make sense of the loss and suffering that is part of life and aging, my hope is to empower patients to think about what they want and what is important to them. They don’t have to accept the treatment we doctors offer, or often force on them, simply because we can. Chemo and radiation treatments, dialysis, fixing an aortic aneurysm in a 77 year old smoker who is wrapping up her cancer treatments are all options, but may not be the right ones at certain stages in life.

Barbara reminds us that we don’t have to die in pain, there is hospice and drugs.My hope is that we as doctors do a better job of policing what we offer and how we sell what we can do for and to patients. Unrealistic goals and false hopes are no favors simply because we are uncomfortable with talking with patients about the finiteness of life.

May we learn to be healers for all phases of life and have the honest conversations, avoid giving false hope, or as least be honest about the pros and cons of treatment choices. Sometimes doing nothing is a good option. And it isn’t doing nothing—there is lots to do with comfort care. With finite resources and time available to us all, the profession and our culture need to come to terms with the importance of quality and not the quantity of days lived. Perhaps it is now time to figure out how to go gently into our good night.