In “Letting Go,” an illuminating article on care for the dying, the surgeon and author Atul Gawande examines the choices that terminal patients and their families face at the end of life. Contrasting hospice with hospital care, he reports a remarkable finding:

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.

Reflecting on this finding, Dr. Gawande concludes that the “lesson seems almost Zen: you live longer only when you stop trying to live longer.”

“Almost Zen” is an approximation, akin to the modifier “Zen-like,” which often obscures what it purports to describe. But in associating this particular “lesson” with Zen practice, Dr. Gawande comes close to the mark. Shunryu Suzuki Roshi, author of Zen Mind, Beginner’s Mind, often admonished his students to have “no gaining idea” when practicing Zen meditation. Other teachers have done the same. Those Medicare patients who chose to forgo hospital treatment were indeed rejecting a gaining idea: that of a longer life at any cost. Ironically, by choosing hospice care, they not only improved the quality of their last days and avoided the debilitating side-effects of hospital treatments. They also lengthened their lives.

Yet it is one thing to know that you have a fatal illness and another to accept that you are dying. “I’d say only a quarter have accepted their fate when they come into hospice,” observes Sarah Creed, a hospice nurse quoted by Dr. Gawande. “Ninety-nine per cent understand that they are dying, but one hundred per cent hope they’re not. They still want to beat their disease.” Such hope is only human. Only a very cold observer would presume to judge it adversely. But to deny that one is dying, when that is in fact the case, is not a constructive way to prepare oneself or one’s loved ones for the inevitable. The Zen teacher Charlotte Joko Beck, who is nothing if not tough-minded, once proclaimed that to practice Zen, we have to “give up hope.” When that statement angered some of her students, she explained what she had meant:

Sounds terrible, doesn’t it? Actually, it’s not terrible at all. A life lived with no hope is a peaceful, joyous, compassionate life . . . . [W]e are usually living in vain hope for something or someone that will make my life easier, more pleasant. We spend most of our time trying to set life up in a way so that will be true; when, contrariwise, the joy of our life is just in totally doing and bearing what must be borne, in just doing what has to be done. It’s not even what has to be done; it’s there to be done so we do it.

Joko Beck’s tone is blunt, and her perspective may be difficult to accept. But that perspective accords with Dr. Gawande’s, insofar as it admonishes us to accept the harshest of realities and to act accordingly. Addressing the question of hope, Dr. Gawande recalls the example of Stephen Jay Gould, who survived a rare and lethal cancer for twenty years. “I think of Gould,” Dr. Gawande remarks, “every time I have a patient with terminal illness. There is almost always a long tail of possibility, however thin.” There is nothing wrong with looking for that tail, he acknowledges, “unless it means we have failed to prepare for the outcome that’s vastly more probable.” What is wrong is that “we have created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets . . . Hope is not a plan, but hope is our plan.” As a wiser alternative, he advocates open discussions, funded by medical insurance, between terminal patients, their families, and their doctors. Conducted with patience and candor, discussions of this kind can clarify what is most important to the dying person. And having had such discussions, people are “far more likely to die at peace and in control of their situation, and to spare their family anguish.”

* Atul Gawande, “Letting Go,” The New Yorker, July 26, 2010 (http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande).

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