Chocolate Ice Cream and Football

In a recent New Yorker article, "Letting Go," the surgeon Atul Gawande discusses the dilemma often faced by doctors, patients, and the patients' loved ones towards the end of a patient's life. Should aggressive therapies be followed even when the chances of extending the patient's life are slim, when the extension of life, even if successful, can be measured in a few weeks or months, and when the interventions will probably increase the patient's suffering? Or should doctors concentrate on keeping the patient comfortable and alert so as to improve the quality of whatever life remains?

The author recounts his conversation with Dr. Susan Block, a palliative care specialist at his hospital, who has had vast experience in helping patients negotiate end-of-life decisions. She tries to establish, in her conversations with patients, how they'd want to spend their time when there's little that can be done to prolong their life, and what they'd be willing to forfeit in order to obtain that quality of life. She gave a personal example.

Ten years ago, her father, Jack Block, a 74-year-old professor emeritus of psychology at Berkeley, was found to have a mass growing in his spinal cord. Without surgery to remove the mass, he was certain to become paralyzed from the neck down. Surgery, in contrast, entailed a 20% chance of paralysis. She spoke to him before the operation. "I need to understand," she told him, "how much you're willing to go through to have a shot at being alive and what level of being alive is tolerable to you." He told her, after an agonizing discussion, that he'd be willing to stay alive if he could eat chocolate ice cream and watch football on television. He'd be willing to suffer a lot, he told her, if he'd have a chance to do that.

After surgery, while still unconscious, he started bleeding in his spinal cord. He was already almost paralyzed and would remain so for many months if not forever. The surgeons gave his daughter three minutes to decide whether they should operate again. When they assured her that if her father lived he would be able to eat chocolate ice cream and watch football on television, she told them to go ahead. He lived another ten years, and although he was severely physically disabled, he wrote two books and many articles during the time he had left.

Not everyone would agree that the ability to eat chocolate ice cream and to watch football on television constitutes a tolerable level of being alive. Gawande reported, in an interview with Terry Gross on "Fresh Air," that his father told him that if that's all he'd be able to do, not to wake him up. Gawande thought that his father, also a surgeon, would probably want to exercise greater control over his life.

My daughter, a social worker in a palliative care unit of a Brooklyn hospital, stresses the importance of appointing a health care proxy, a person who can make medical decisions for the patient, as Susan Block did for her father, when the patient is no longer able to do so. But she adds that it's equally important that the proxy understand the patient's wishes. She overheard two sisters arguing violently about the course of action to be taken for their dying mother. One sister wanted every effort made to prolong her mother's life. The other shouted "Let my mother die!" My daughter agrees with Gawande's observation that some patients, who would prefer to die in peace, undergo painful and minimally useful procedures, solely to please their families.

Gawande's article prompted me to ask myself what I would want if I were in the position faced by Jack Block ten years ago, about to undergo a major operation that involved substantial risk of a degraded quality of life should I survive. I came to the conclusion that I'd want to be able to recognize my family and friends and to engage in meaningful communication with them and that I'd want to be able to understand written texts whether I read them myself or had them read to me. In short, I'd want to stay alive, even if I became severely physically disabled, if my mind remained intact. Chocolate ice cream and football on television would not by themselves provide sufficient incentive to live. If that were all I could do, I'd agree not only with Gawande's father but also with that chorus-girl pictured in a New Yorker cartoon published decades ago. As her elderly husband is being wheeled towards the emergency entrance of a hospital, she runs after him, her fur coat flying out behind her and her pearls jumping around her throat, shouting, "No extraordinary measures!"