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This is a very good list of questions that a good doctor should ask every patient, from Angelo Volandes, an internist at Massachusetts General Hospital:
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The list of questions is short, but actually answering them probably isn't. These are questions that get at some very fundamental decisions about what makes life worth living — and at what point a patient might decide to stop fighting a disease.
But as Volandes, who also founded a group dedicated to advanced end-of-life planning, argues, they are absolutely necessary questions to answer — even when you're perfectly healthy.
"The best time is when the patient is feeling great, when they have their wits about them, and not critically ill," Volandes recently told HealthLeaders. "This is not a one-time conversation. Doctors should be having these routinely. At a minimum, with anyone over 65, with a critical illness. [Otherwise] it's depriving them of having their wishes honored. We are so compartmentalized that we think we have to pass it off to the oncologist or cardiologist. No, this is a fundamental part of your job."
There's a beautiful story that Atul Gawande tells in his new book, Being Mortal: Medicine and What Matters in the End, that really helps underscore how crucial these types of questions are. It's about a man named Jack Block. At 74, he had to decide whether to undergo a surgery to remove a mass growing on his neck. The procedure ran a 20 percent chance of paralyzing him from the neck down — but without it, the growth would definitely leave him unable to move his legs or arms.
This is the moment, Gawande argues, that there had to be some version of the six questions conversation. Gawande interviews Block's daughter, Susan, who is a palliative-care specialist. And even though this is her line of work, she tells him that the conversation about this surgery was "really uncomfortable:"
We had this quite agonizing conversation where he said — and this totally shocked me — ‘Well, if I’m able to eat chocolate ice cream and watch football on TV, then I’m willing to stay alive. I’m willing to go through a lot of pain if I have a shot at that.’
Susan says this wasn't the answer she expected; she didn't even remember her father watching football. But just hearing what mattered — knowing what Jack would consider a life worth living — ended up guiding all further decisions. When Susan's father developed spinal bleeding, she asked the surgeons: will he be able to watch football and eat ice cream? The answer was yes. They kept going with treatment until the answer was no.
"Few people have these conversations, and there is good reason for anyone to dread them," Gawande writes. "They can unleash difficult emotions. People can become angry or overwhelmed. Handled poorly, the conversations can cost a person’s trust. Handled well, they can take real time."
But these conversations could be the starting point for a health-care system that cares just as well for patients who will heal as those who will not. They're the place where autonomy gets defined for each patient: whether a life worth living means one where they are able to see friends, or drive their car, or eat chocolate ice cream, or the millions of other things they may hold dear. Those conversations don't happen now. And as long as that's the case, all of our autonomy, as we inevitably grow old and become more dependent, is at risk.
